Thread work

Thread lifts are gaining in popularity again, whether marketed as “Scar-less Lifts” or “Puppet Facelifts”, they are courting attention and controversy in equal measure. Given recent media coverage, one could be forgiven for thinking that threads are a new device, but they have been evolving over the last decade and in fact they have been around much longer than that.

The first thread lifts were pioneered in Europe using threads made from tendons, nylon and gold in the 1970s; this was then followed by the use of prolene and the creation of the “anti-ptosis” or APTOS® (barbed) threads in the late 1990s. As the millennium turned, more and more brands appeared, however controversy was not far behind this new treatment trend. So what’s caused the sudden media frenzy in the last 12 months, which has led to the increased industry promotion and marketing of thread products in our home market?The simple answer is that we probably have Korea to thank for much of the recent revived interest in the technique. A sudden increase in the promotion and use of polydioxanone (PDO) threads is indeed traceable to the country that is rapidly growing as a global influence in the cosmetic surgery marketplace, and where cosmetic surgery is a typical gift when graduating from high-school. The threads themselves have certainly improved in the last 10 years, the techniques modified and optimised, but the controversy very much remains. Do thread lifts produce tangible, lasting results? Is patient satisfaction above average? Do the potential risks outweigh the benefits? Plus, the most hotly debated concern of all: just who should, and more importantly, who should ‘not’ be performing thread lifts?

WHAT IS THREAD LIFTING? Thread lifting is a procedure which involves elevating different parts of the face (and body) using specially designed threads or suture material, manufactured from different compounds (polymers, composites etc.) without having to make surgical incisions or excise skin, as per the classical face-lift or rhytidectomy. Threads are inserted using needles or cannulas and may need to be anchored, pulled taut or simply placed in patterns. Thread lifts are also referred to as suture lifts or suspension face-lifts. As well as their use in face-lifting procedures, it’s worth noting that as thread lifting techniques and products have developed so have novel indications for their use, some of which are not on the face. Threads are now being used for lifting and tightening effects in the breasts, buttocks, knees, hands and neck. Similarly, not all facial applications are for a simple cosmetic lifting result in the jawline or jowl area; the procedure is also being utilised for cheek repositioning and correction of asymmetries (e.g. lifting post-stroke), for mild upper eyelid ptosis, and for brow lifting.

BARBED, COGGED, CONED, SCREWED OR JUST PLAIN SMOOTH? As we have mentioned, threads or sutures are inserted using needles and cannulas, with some requiring anchoring, others being free-floating or self-supporting by “hitching” themselves into the tissues once pulled taut, and others being laid in a matrix or scaffold structure to produce a lift through increased collagen formation following a foreign body reaction. At a basic level, threads can be divided into two groups: barbed (including cogged, coned or screwed) or non-barbed (smooth) threads. The use of barbed, cogged, coned or screwed threads is generally considered to be more technically challenging, requiring additional training and skill. The barbed threads themselves also come in a variety of “flavours” to suit a targeted result, as follows:

• Uni-directional or bi-directional threads, depending on whether the cogs or barbs are orientated in only one direction or in opposite directions, with a smooth region in the middle which allows for a change of the thread’s direction to affect the vectors that cause bunching;
• Convergent or divergent threads, depending on whether the barbs or cogs are orientated towards each other or in opposite directions with reference to the middle of the thread.
• The “aggressive” nature or shape of the barb – how much they stick out, what form they take and their size, also determine their anchoring ability. The screwed thread consists of a central thread which has one or two other threads winding around its outside in a screw thread pattern along the length of the thread. The coned thread has small conical shaped sections evenly distributed along the length of the thread, which are secured in place along its length by small knots in the thread; these cones act as anchors

Smooth threads traditionally followed the concept of simple suturing as used by surgeons to “stitch up”. This began to be adapted as a thread lift concept by anchoring or securing a smooth thread in one place, pulling the thread taut (thus creating a lift) and anchoring it at the other end. Sometimes, this is done in conjunction with looping the suture material within the tissue for added lift. Smooth threads are designed to create lift predominantly through a foreign body reaction, rather than by pulling the tissues tightly, and this is increased using targeted pattern placement of multiple threads. With the development of PDO threads, the application of smooth sutures has become considerably easier. Choosing whether you are in the barbed or smooth camp, depends not only on what you are trying to achieve with your patients, but also very much on personal preference in terms of technique and what you feel comfortable with.

PATIENT SELECTION As with many procedures performed in aesthetic medicine, everyone can do them, but not everyone can do them well. From the patient’s perspective the correct choice of practitioner, who is using the correct choice of thread type and who is scrutinising both their anatomy and expectations is the only recipe that will produce an outcome that is satisfactory to both patient and practitioner. Dr Niroshan Sivathasan emphasises that good and appropriate patient selection is “the” critical factor in the decision to go ahead with a thread lift procedure. This is especially paramount with regard to managing their expectations of the results that any cosmetic procedure, including a thread lift, can achieve for them. Some patients have either inadequate skin-laxity or too much laxity, which would not make the intended procedure beneficial and effective for them. He adds that surgical dexterity helps, as does the use of botulinum toxin (to paralyse muscles that may cause the threads to migrate during the early period) a few weeks before the insertion of threads. Ultimately, patients must understand that a thread lift is not a surgical facelift and thus it will not produce the same results. According to Dr Sivathasan, the ideal patient for a thread lift is aged from the late 30s to the late 40s, (typically would be classified as Baker I or Baker II with regard to the descent and deterioration of the ageing face), and who are prepared to follow the post-operative regimen (mainly with regard to taping). Cost must certainly be considered when advising a patient, as in part, this element allows comparison with other modalities which are used to effect similar outcomes. Obese patients, those who are immunocompromised, and those taking blood-thinners are not candidates.

RESULTS AND LONGEVITY Threads have been subject to much controversy, particularly with regard to their efficacy. One of the biggest criticisms you will hear when you ask medics about thread lifts is that the results and the longevity of any correction are satisfactory to poor. This is of course a very subjective area as one must consider what you are comparing the longevity of thread lifts to in order to come up with an opinion on how good they are. When compared to the longevity of results from temporary cosmetic injectables such as dermal fillers and botulinum toxins, the thread lift results do last longer. However, typically, and certainly what is borne out in many clinical papers, is that thread lift longevity and efficacy has been compared with surgical face-lifts. So, are we simply all expecting too much of thread lifts. After all this approach is not a surgical lift (and does not involve repositioning and/or removing droopy and excessive soft tissues), so expecting it to last 10+ years like a face-lift is a tad ambitious.

COMPLICATIONS There are multiple potential complications reported from thread lift procedures, not all of which are possible with all types of threads or thread material. However, as the techniques and products have been developed and refined over the last decade, so the incidence of complications (and the variety of them) has decreased in the most part. Some believe that the risk of complications and infections is increased for barbed threads over smooth options, although others disagree depending on thread composition and size, irrespective of barbs etc. Similarly barbed threads tend to require both an entry and exit point, whereas some of the smooth options which are not anchored only require an entry point, thus reducing the risk of potential infection. Dr Sivathasan states that when counselling patients for adverse events, it is easiest to divide them into “early” and “late”. Transient issues with swelling and bruising are, of course, expected. Bleeding along the course of the insertion line where the needle is placed for delivery of barbed threads may also be seen, as well as more significant injuries to vessels and nerves, leading to transient paraesthesias (‘pins and needles’ sensation). Thread breakage, thread migration (slippage), or threads poking back out from their insertion holes, as well as skin dimpling or puckering at anchor/entry points are not uncommon. Scarring and epidermal inclusion cysts (implantation of epidermal elements into the dermis which creates a particular scar tissue) have been reported, as has thread visibility especially around the brows and forehead. Dr Sivathasan stresses that finer, clear threads must be used in these areas, and also noted that some types of thread provoke more bio-stimulation which may, paradoxically, become the enemy – this is a key concern of his. In terms of the correction being attempted through thread lifting, there is the problem of both hypo and hypercorrection with the procedure, as well as asymmetrical results. In some cases, threads can be removed, but additional trauma is likely to result with barbed types. Asymmetries can often be more easily corrected. There is also small potential for partial facial paralysis, which is, ironically, something which threads are being used to cosmetically correct from the stand-point of aesthetic improvements to the face. Damage to major salivary glands has been reported, too. One type of complication, mostly referred to with the use of gold threads and other smooth sutures, and certainly known as a complication in body lifting techniques where tissues are heavier, is the wonderfully named “cheesewiring”. This “cutting” action of the thread can cause trauma to the underlying tissues during the course of the post procedure period, as well as weakening the effect of the original lift. Of course not all complications are of a damaging nature in terms of the integrity of the facial structures, some undesirable outcomes simply come down to aesthetics and the ideals of beauty. One mistake, which was most commonly seen in Russia and Eastern Europe with the introduction of Korean threads to these cosmetic hungry markets, was the lack of thought or respect given to the differing faces of differing races and ethnicities. It is also worth noting that most insurance companies offering medical indemnity cover to aesthetic practitioners will insure across the board for thread lifts, with little differentiation, and certainly no specific reference to brands or CE marked products only.

WHO SHOULD BE PERFORMING THREAD LIFTS? This is a question which polarises opinion within the industry. The Consulting Room recently carried out a survey, which looked at the controversies surrounding appropriate thread lifting practitioners. We found that of those who responded 92% felt surgeons should be allowed to perform the treatment, with 74% also agreeing with (cosmetic) doctors being permitted. The numbers then dropped rapidly with only 34% agreeing with advanced nurses (INPs), 26% with dentists, 15% with nurses and 2% with beauty therapists. As we have seen, the majority believe that thread lift procedures should only be performed by surgeons and physicians. This is generally advocated due in part to the skill needed to carry out the procedure, but also, and more significantly to the ability and medical knowledge possessed to be able to deal with any complications which may occur. The understanding and appreciation of the anatomy and varying planes of the facial tissues is something which those who have trained as surgeons and cosmetic physicians possess more so than other medical and non-medical disciplines. Whatever you choose to do, the importance of adequate medical indemnity cover and patient records, including good clinical photography will ensure that you have all your evidence, no matter how efficacious or long-lasting your results are with thread lifts.  

Lorna Jackson has been editor of The Consulting Room™, the UK’s largest aesthetic information website, since 2003. She has become an industry commentator on a number of different areas related to the aesthetic industry, collating and evaluating statistics, plus researching, investigating and writing feature articles, blogs, newsletters and reports for The Consulting Room™ and various consumer and trade publications. Lorna was recently awarded Journalist of the Year at the MyFaceMyBody Awards 2014.

Dr Niroshan Sivathasan has published over 30 articles and is a reviewer and editorial committee-member for various medical journals. He is completing a higher fellowship at present. He has a particular interest in aesthetics and works in cosmetic and restorative surgery in Sydney, where he is also the Medical Director of DHI Australia. He is, additionally, a senior trainer for injectables, and is the lead cosmetic physician at centres in London and Sydney.