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Surgery and Cosmetics

Anthony Benedetto, DO

Thread Lifts

Anthony Benedetto

Wednesday, January 03, 2007

Noninvasive and minimally invasive cosmetic procedures have become one of the most sought-after types of self-enhancement measures for people in all age groups who are seeking additional ways to improve their appearance and body image. Included in the panoply of procedures for facial rejuvenation are Botox (Allergan Inc., Irvine, California) injections, various laser treatments, and now the minimally invasive thread lift.

This revolutionary procedure counteracts the forces of gravity and chronological aging by lifting and suspending sagging facial soft tissue and skin in a quick and expeditious fashion. Marlen Sulamanidze, MD, from the former Soviet Republic of Georgia, originally developed the barbed threads for the thread lift technique by personally devising a way to physically notch the commonly used surgical suture material, 2-0 polypropylene (Prolene™, Johnson & Johnson, New Brunswick, New Jersey) along its length with a scalpel and dissecting microscope. His original Aptos (anti-ptosis) threads had cogged or barbed projections along the length of the threads in two opposing directions commencing from the center.

Thread lifts can be used for lifting sagging soft tissue and skin of the face, including the forehead and brow, cheeks and midface, jaw line and jowls, and submental area and neck. Because of its minimally invasive nature, thread lifts can be performed entirely under local anesthesia in an ambulatory setting. However, some surgeons still prefer the use of light sedation for this procedure. There are even current studies looking at the feasibility of using similar but larger gauge threads to lift breasts, buttocks, and other parts of the body by this less invasive manner.

Aptos Threads and Contour Threads

Aptos threads were originally distributed in North, Central, and South America as the Feather Lift procedure and threads, but they were never approved by the U.S. Food and Drug Administration (FDA). Aptos threads still are manufactured and distributed worldwide in sterile packages in which the blue, cogged 2-0 polypropylene thread is preloaded into a hollow cannula with a sharp, cutting point at its distal end. Its proximal end is open to the patent cannula that contains the barbed thread, making it convenient to reload another barbed thread into the same cannula if necessary. Aptos threads are designed to be implanted into the lower dermal, subcutaneous plane. Once in place, the cannula is withdrawn but the thread remains at the site of implantation, secured and firmly attached to the surrounding soft tissue. The barbed threads are left free floating in tissue, but remain in place by virtue of the moorings of their barbs that attach to the soft tissue while suspended in it.

Since their introduction, Aptos threads have been modified in many different ways by different individuals in various countries. In the United States, unfortunately, the original Aptos threads have yet to be FDA-approved. However, in January, 2005, Contour Threads™ (Surgical Specialties, Reading, Pennsylvania) were approved by the FDA. Similarly produced, Contour Threads are made of clear 2-0 polypropylene with unidirectional barbs or cogs placed in a helical configuration, located only in the center one third of the thread. These barbed threads are then swaged onto the back end of a narrow, solid trocar with a sharp needle tip at its front end. The proximal ends of the Contour Threads are swaged onto a 26 mm ½ circle taper needles. Contour Threads are made to be placed into the plane of the subcutaneous tissue by advancing the trocar with its attached thread through the tissue, which is then cut from its implanting trocar. Once situated properly and the soft tissue suspended at the desired level, the threads can be sutured into the fascia of the scalp, temple, or mastoid area with its needle, depending on what area of the face is being lifted. Unlike the free-floating Aptos threads, Contour Threads are anchored in place proximally, which theoretically should result in higher lifting and more secure suspension, maximizing the threads' holding strength and producing longer-lasting lifts.

Articulus Threads

Surgical Specialties recently released another type of cogged thread, the Articulus™. This innovative barbed thread consists of clear polypropylene suture material that is swaged at either end onto two 7 inch straight taper-cut needles. Where the thread is attached to the straight needles, there are no barbs for 10 cm. However, in the center of this thread there are two opposing unidirectional sections of barbs 15 cm long that are separated by a narrow gap of nonbarbed, smooth thread of 5 cm.

With one of its two needles, the Articulus barbed thread is inserted proximally either behind the hair line or behind the ears through the skin and into the fascia. This needle is then advanced to its intended location and pushed through the skin where the needle then is cut away from the thread, leaving portions of nonbarbed thread exposed. Adjacent to the first insertion point, the second needle is inserted through the skin and fascia in the same manner but parallel to the first. The inserted Articulus thread now can be manipulated from either the looped proximal end that is in the fascia or the two exposed distal ends on the face to contour and lift the sagging skin to the satisfaction of both the patient and physician.

Silhouette Suture and Feather Lift

Another variation on the thread lift that's soon to be released, pending FDA approval, is the Silhouette Suture (K.M.I., Corona, California) and the new Feather Lift technique. Unlike other suspension sutures that possess cogs and barbs, the Silhouette Suture is manufactured with tiny transparent "cones," small umbrella-like attachments, spaced evenly apart along the length of a thin (3-0 polypropylene) colored thread. Since the integrity of the polypropylene thread is not compromised by the incisional notching of the barbs, the Silhouette thread can be manufactured with a narrower diameter yet still possess a higher tensile strength than the other types of barbed threads that are made of 2-0 polypropylene.

Once inserted into the soft tissue of the face, these smooth cones become attached and fixed in place in the soft tissue with the new collagen deposition that surrounds them, suspending the skin without the prickling sensation of barbs, according to the manufacturer.

Implantation and Recovery

The insertion of the Aptos free-floating threads, as well as all the other types of threads, requires strict sterile technique during implantation. Aptos threads usually can be implanted with minimal surgical intervention. Consequently, there is minimal postoperative morbidity, pain, edema, or ecchymosis. Within less than 10 days, the patient is completely recovered.

This is not necessarily the situation when Contour Threads are used. Since more incisional surgery is required to insert and anchor the threads into the fascia, the patient experiences a bit longer postoperative recovery time by about 1 or 2 weeks after the Contour Threads are implanted.

Postoperative recuperative time is not yet completely defined for the Silhouette Feather Lift technique.

Advantages and Disadvantages

There are many advantages to facial rejuvenation by suture suspension with a thread lift technique. In addition to the cost savings when compared to a traditional, invasive, full face rhytidectomy, the results are immediate, the postoperative morbidity is negligible, and recovery time is short, depending on the threads used. Ordinarily, overcorrection is necessary to achieve and maintain the results expected by both the physician and patient. This overcorrection commonly relaxes within 3-5 days postoperatively. This excessive tightening of the skin also can be manifested as a puckering and folding of redundant skin proximally in the temples and posterior neck. This corrugation of skin is more intense when Contour Threads are used, because of the greater amount of tightening that can be achieved when the threads are sutured into the fascia. Whichever thread is used, the redundant, pleated skin eventually relaxes and flattens out spontaneously within 2 or 3 weeks.

Disadvantages to a thread lift depend on which product is used. Sterile surgical technique, preoperative precautions to avoid unnecessary bleeding and hematoma formation, and prophylaxis against infection should be taken regardless of the type of thread lift procedure used. Also, postoperatively the patient should be instructed on how not to disturb the implanted threads by not manipulating the treated areas vigorously during daily activities (e.g. face washing and make-up application) and by sleeping in an elevated position for 1-2 weeks. Otherwise, the threads can potentially break, migrate, and extrude through the skin. Although this is seen more frequently with Aptos threads, the potential for similar outcomes is present with Contour Threads. Extrusion of the free ends of the knot at the site of fascia tying is what more commonly occurs when Contour Threads are implanted. The extruded thread tips can be easily cut and shortened with minimal effort. Proponents and users of any of the thread lift techniques say these side effects will become less common as the sutures are improved and as studies determine the best ways to place them.

Skepticism

There is currently some skepticism about thread lifts. The main concerns are:

  1. The thread may be seen through the skin. The thread may be seen or felt through the skin if it was implanted too high in the dermis. When correctly placed, threads are rarely noticeable.
  2. The thread can extrude. If the patient has excessive facial movements, especially early in the postoperative period, there can be a rupture of the thread, causing it to travel and extrude at a distant location from where it was implanted. If this happens, it can be easily removed. If the rupture and extrusion occur after at least 1 month postoperatively, most if not all of the correction and redraping of the soft tissue will remain without the need to reimplant additional threads.
  3. It may last only 6 months. The duration of the results depend on the type of patient selected and the amount and extent of the soft tissue to be lifted and draped. Every patient is different, and the results are predicated on the appropriateness and selection of the patient.

Some of those who perform traditional invasive surgical face lifts with its high price tag have said that any new procedure like the thread lift should be predicated on a good 10 years' worth of laboratory work with animal models and clinical studies before it is widely adopted. Proponents of the thread lift have remarked that the thread lift reminds them of how the technique of liposuction evolved. In the beginning, liposuction contradicted everything that was known and practiced about how to remove fat at the time and everyone was saying it was dangerous, nonsensical, and untested. But now it is one of the most popular cosmetic operations performed. Most consider thread lifts similarly and predict that the technique may turn out to be exactly the same as liposuction did: a good concept and procedure in evolution that will find its place in the armamentarium of many physicians.

Conclusion

Success with thread lifting or any other cosmetic procedure depends on proper patient selection and the preoperative preparation of the patient. Most patients seeking a thread lift do not want that "pulled-tight 'scared' look" that can be produced by a traditional surgical face lift, along with the extended recovery time and the telltale scars. Traditional rhytidectomies can last 5-10 years but are complicated by poor technique, postoperative infections, and patients who smoke tobacco and are poor scar and keloid formers.

Likewise, the thread lift procedure also is technique dependent and can be complicated by improper placement of threads and other avoidable and occasionally unpredictable circumstances. However, the usual duration of a well-executed thread lift can last 2-3 years and possibly longer for less than one third the price and none of the postoperative morbidity of a full-face surgical rhytidectomy. Improper technique with any procedure will produce complications and untoward results. Moreover, just like with any other procedure, cosmetic or therapeutic, results can be variable and a physician stands a better chance of maintaining a satisfied and happy patient if the physician properly informs the patient preoperatively about all aspects of the procedure. It is extremely important for the success of the procedure and patient-physician relationship that the patient knows and understands what (and what not) to expect.

Also, as with many other cosmetic procedures, thread lifts can and should be used in conjunction with other rejuvenation procedures, such as Botox, fillers, lasers, liposuction, and whatever else the physician can do to enhance a patient's appearance and self-esteem.

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