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 Chapter 54: Thread lift

Shohreh Ghasemi 1 (BDS, MS oral Surgery ) , Mark Stevens2 ( DDS, MD ,OMFS ,Pediatric oral
maxillofacial surgery),facial plastic surgery ,Samir AboulHosn 3 (MD,OMFS,PHD)
1. Oral Surgery, UIC (Barcelona, Spain), educational alumni of state department of USA.
2. Chairman of the department of oral maxillofacial university of Augusta, Atlanta, USA
3. Professor of UIC (Barcelona, Spain), chief of oral maxillofacial Unit, Plato hospital, Barcelona
Corresponded Author: Shohreh Ghasemi.email:shooshoo_gh@yahoo.com.
Tel: 001-954-3762412. 0034-664338317
Abstract : the use of bidirectional suture or barbed threads is a minimal invasive technique for facial
rejuvenation ,capable of making the middle and lower thirds of the face firmer ,this method is not
comparable of conventional facelift .with the development in aesthetic medicine and technology ,it is
simple ,less invasive and rapid recovery ,it can meet the requirement of patient with minimal invasive
facial rejuvenation and the optimum result will reach by combination therapy .
Key words: Aging face, facelift, minimal invasive surgery, rejuvenation, thread, silhouette
Introduction
Senescence or biological aging is the gradual deterioration of functional Characteristics . Senescence
can also be referred to as cellular senescence of the whole organism . Cellular senescence leads to
decline the biological functions and decrease ability organism of the adopt to metabolic stress.
Aging of the face is a Three-Dimensional, (3-D) process which affects all tissue bone, muscles, adipose
tissue and skin. This 3-D aging process is multifactorial .the primary factors, are due to gravity , the laxity
and ptosis of subcutaneous tissues ,decrease collagen and hyaluronic acid , atrophy in combination with
migration and hypertrophy of adipose tissues and bone reabsorption. Moreover there is an overall lack in
elasticity .1,8
The bone and cartilaginous structures become more visible as the skin and subcutaneous tissues thin; the
texture of the skin is altered and convexities turn into concavities. This contributes to a depression in the
temporal, perioral and orbital areas; in addition, the nose, eyelids, lips and cheeks migrate inferiorly with
accompanied loss of bone. The result is seen by retraction of the chin and the lower third of the face .other
overt signs of aging are the appearance of wrinkles, sagging skin, skin pigment changes and modifications
in face proportions. Fat characterized the shape of the face and is responsible for the youthful appearance.
There is a marked facial outline shape change as we age this transformation is especially seen when
comparison of a young woman face taking an inverted isosceles triangle shape and turning it into more
trapezoid with time..9, 10.
The other signs of the aging, is hair color, with aging the hair follicle make less melanin ,this is the cause
of gray hair ,scalp hair often start graying at the temple and extends to the top of the scalp. Hair strands
become smaller and leave less pigment ,so the thick ,coarse hair of the young adult gradually alter to thin
,fine light colored hair many hair follicles stop producing new hair .2.9
Therefore, to counteract these facial changes, one must develop global rejuvenation plan based on a three-
dimensional approach .this approach is based on combination of many rejuvenating products. Material
and procedures. This can be accomplished use with the customized administration of botulinum toxin,
hyaluronic acid, and carefully placed bidirectional suspension sutures. Although there are common areas
 Chapter 54: Thread lift

to all faces as it relates to the process of aging, each patient will have their own subjective perception of
their aging face .2, 10 (figure 54.1)

Figure54.1; Aging
AGING OF THE FACE
In a young face this compartmentalization of the fat is not visible because of the widespread and well-
balanced distribution of the superficial and deep fat.as we age the fat tissue is redistributed ,the face loses
its fullness and “fat bags” begins to appear as a distinct and separate compartments .Simultaneously ,the
underlying bony structures and prominence become clearly visible ,the malar fat pad covers the malar
bony prominence in younger face .overtime these fat pads tends to slide inferiorly, revealing the inferior
orbital rim contributing to the formation of deeper nasolabial fold.14,16
For these individual, a thread lift may be a good alternative to more invasive procedures thread lifts have
emerged recently because of the high costs. Long recovery time of the standard face lift or rhytidectomy
.thread lift costs less and require less downtime .some surgeons promote the thread lift as a “lunch time
lift “or “weekend face lift”.it can be performed in about approximately one hour.6,17.20.3.7..
Thread lift amongst the spectrum of procedures for non-surgical facial rejuvenation
Today a wide variety of minimal surgical procedures and modalities for facial rejuvenation are available
the following are now wide spread: a.)Botulinum toxin. b.)Fillers c).Radio frequency d).Meso therapy
e)cosmetic camouflaging The thread lift provides an actual milder lift, and is a semi-invasive procedure
and it has milder result but less costly with less postoperative recovery ,less down time .11.19

Dynamic of thread lift

Barbs along the thread act as cogs to grasp, lift and suspend the facial muscle. The barbs open like an
umbrella to form a support structure that lifts the sagging tissue. (.19.13). This creates tension in the thread,
and the tension lifts the skin tissue. Collagen formation occurs around the threads and their cogs or barbs,
producing an increasing collagen bundles type 1, and 3.(17.19)
Classification of thread based on Direction:
A large number of worldwide companies have their own patents as to not only the design of the threads,
but also the minor variations of method of deploying them., there are two types of barbed threads which
are available. These are:
a. Bi-directional threads, with no anchoring points, inserted within a hollow needle and placed in
such a manner that the thread cannot move either way because of the two-way direction of barbs
 Chapter 54: Thread lift

fixing it nicely. Examples are the APTOS threads, silhouette soft (Europe), Instalift (USA) . Mint
Lift (Hans Biomed Company- South Korea), spring thread (France), Happy lift (promo Italia .)
b. Uni - directional barbed threads, which are anchored at a higher level fixation point. Examples
are Surdev sutures(Bulgaria), Silhouette lift (USA),Nova threads (USA, Korea)

figure54.3: variation of thread

Classification based on biomaterial:
a. Poly Dioxane (PDO): are popular in aesthetic clinics in Korea ,that are absorbable between six to
twelve months
b. Poly –lactic acid sutures(PLLA) : bidirectional cone that has used in orthopedics rods and screws
for bone fracture ,they are absorbable, acting on the deeper layers of the skin to produce collagen(
silhouette soft or Instalift ),spring thread
c. Poly Carproamide sutures: Serdev sutures that are absorbable in three years , and that were
used for face and body lifting.8.,10

Candidates for thread lift

Best candidates
Ideal candidates for thread lifts include people with minimal signs of ageing. Women between the ages 35
and 45 who have minimal sagging in jawline, or deep nasolabial fold. Thread lift candidates include those
who have had some relapse from a previous procedure such as a facelift or neck lift.
Ideal patients are also those who understand and accept the possibility of the risks and complications, the
ideal patients must understand the limitations of these threads, have realistic expectations.

Poor candidates
Poor candidates are those patients who have excessively sagging skin, advanced age and show very
limited improvement. patients who are obese, have heavy or, rugged skin will show little or no
improvement .Threads are strictly contraindication when patients have prior facial implants, and
permanent filler such as PMMA and silicone and or other non -absorbable filler.
The exclusion candidates are also who has multiple skin allergic reactions or infections, immunologically
compromising diseases like cancer/ HIV etc., systemic diseases like diabetes, tuberculosis, etc.

Universal technique for double needle thread lift:

Preoperative markings:
 Chapter 54: Thread lift

*before positioning the suture, it is better to stimulate the desired result with the stretching of the face
with finger, this will help the physician to insert in correct position and good evaluation of the patient.*
1) insertion point: make a 5 point straight line 5 to 7 mm, apart from the upper portion of auricular helix
insertion (temporal area), the hair should be separated and trapped to not exposed to the approach area .at
this point you can estimate that how many threads you need .the number of threads depends on the
severity of skin laxity or sagging, usually up to four.
2) exit point: it depends on how many threads you need for insertion and also it to be able to direct the
tensile force in lowest part of the face (the first point 1-1.5 cm of nasolabial fold midpoint and 1.5 cm
from the labial Commissure, for the second point, it is necessary to draw a line and there should be 0.5 -1
cm apart from the first thread.
The midpoint or entry point must be equal distance from the two exit points .local anesthesia (2%
lidocaine hydrochloride with epinephrine hemi tartrate 1:200,000 ratio at the needle insertion and exit
point .after the disinfection of the face ,the clinician will need to create an entry point with 18G needle to
facilitate the insertion of threads with cone or barbed and to introduce the yarn and tunneling technique as
well as protect the tissue integrity. the first needle (23 G thread in Silhouette or 21 G needle in mint )was
inserted vertically and perpendicular to the face and then 5 to 7 mm with a reasonable degree the needle
will be pulled to the layer of subcutaneous tissue depth ,(in Asian that has much more thicker skin the
needle should be inserted deeper) .when reaching the exit point ,the needle or cannula is partially and
proximally removed . one it reached to the adipose tissue ,the needle will be converted to 90’ and parallel
to the skin was inserted we should pass the whole or the cones(4,6,8) to the exit point .then from the entry
point the rest of needle should be inserted by the same technique .then the suture needle cut and the tissue
is compressed till to reach the desirable ,we should upstand the patient at the frontal view ,check the
symmetry of the face and then cut the suture that has protruded from the skin of the patient .for cutting the
end of the suture ,it is better to press lightly and then cut to avoid any residual cone or node or barb to be
remained superficially that can lead to infection or tangle under the skin .
 Chapter 54: Thread lift

We have two possible techniques for the thread insertion, straight or acute line angle, the straight angle is
suitable for malar region,

Figure 54.3: silhouette lift (Non absorbable), that is off label in Middle East, but still in Europe and USA
are demonstrating in patients.
 Chapter 54: Thread lift

Figure 54.4: mint lift thread (easy double needle) figure 54.5: mint lift
(before&after)

Figure 54.6. Silhouette soft (8 cones) for eye brow : as it is illustrated, the thread were not cut.

Complications:
1. Technical errors:
A: creation of hollow or dimpling at the entry point this usually resolved between the first and third
weeks, if the deformity remains the residual thread is pulled out the of superficial skin attachment point ,
or with the sub sectioning with needle 18G(.figure 54.7.c)
B: Pain and edema is a common experience: the use of NSAID helps reduced the pain and edema,
 Chapter 54: Thread lift

a: b: figure54.7 (side effect ) c:

C: skin crease and irregularities: it will be disappeared in one to three weeks , if it still present, a low
pressure massage can help to release suspension of the cones or barbs under the superficial
skin.(figure54.7.a)
Unforeseeable reaction:
A: Ecchymosis or hematoma: that will be disappeared in 14 days, ice pack for 24 hour is an essential and
arnica tablets or cream will help to relieve from it. (figure54.7.b)
B: infection is usually due to the poor disinfection, or poor approach of medical and esthetic history of
the patient, and due to the block of the cone or barb from the entry and exit point .the antibiotic therapy
oral and topically are important in the prevention of infections.
Post up instructions: Antibiotic both orally and topically are administrated for six to seven days,
NSAID are administrated to minimize pain and swelling after the thread lift is recommended, that no
further facial procedure be performed .procedure such as ,lasers,IPL, are contra-indicated massage for 15
days ,and (RF ) for six months, physical or vigorous exercise should be limited , sleep sure occur in
supine position ,.dental treatment should also be avoided for at least 15 days . 9.11.17.18.
Conclusion : the personalized treatment ,that can be performed in all portions of the face ,the case
selection for this treatment is the most important ,the PLLA is famous and well known for production of
collagen type 1,3 . The result will be maximized over three month, thread lifts can last for 12-18 months.
The optimum result can be obtained when combination therapy like Botox, HA injection or mesotherapy
is used in combination with thread lift to improve facial esthetics.
References
1. Sulamanidze, Ma, SulamanidzeGM, flabby skin, aging, new approachII, congress on esthetic and
restorative surgery, Moscow, 1985.
2. Wu.W barbed sutures in facial rejuvenation. Esthetic surj 2004,24,6.
3. Khrustaleva, Irina MD; Khrustaleva, Galina MD; Borovikova, Anna MD; Tamarov, Alexey MD;
Borovikov, Alexei MDPlastic and Reconstructive Surgery – Global Open: June 2016 - Volume 4 - Issue 6
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4. Successful Treatment of Thread-Lifting Complication From APTOS Sutures Using a Simple MACS
Lift and Fat Grafting ,Article in Aesthetic Plastic Surgery 36(6) · October 2012 .
5. Newer technologies give thread lifting a lift, Lisette Hilton, Jan 14, 2019.
6. What you need to know about thread lifts, Kevin Tehrani, New York, NY ,American society of plastic
surgery
 Chapter 54: Thread lift

7. Facial Rejuvenation with Absorbable and Barbed Thread Lift: Case Series with Mint Lift™ Samira
Yarak and Juliano Augusto Ribeiro de Carvalho , August 11 2017
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