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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 4  |  Page : 219-223

New combinations of threads with surgical methods for facial rejuvenationnew combinations of threads with surgical methods for facial rejuvenation


Private Practice, Istanbul, Turkey

Date of Submission23-Dec-2019
Date of Acceptance23-Sep-2019
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Naci Celik
Tesvikiye Street, Number: 17/8, Nisantasi, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_81_19

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  Abstract 


Background: Surgical rejuvenation of the face is popular in esthetic surgery. Thread-lift techniques became more popularized in recent years. On the other hand, most of the plastic surgeons still prefer classical surgical face-lift methods because of the superiority of the results. Materials and Methods: Between March 2018 and June 2019, 14 patients were operated with a combination of threads and other surgical methods including fat injection, blepharoplasty, subcutaneous radiofrequency with Cool Atmospheric Plasma J-plasma, and gliding temporal lift with surgical net for facial rejuvenation. For thread lifting, a relatively new type of nonabsorbable suture that is made of polyester and silicone is used in this study. Results: All patients healed uneventfully. One patient had a temporary weakness of buccal branch of the facial nerve. Discussion: It is obvious that the esthetical results of classical face-lift methods are far more superior than those of thread-lift methods. On the other hand, the complications of threads are less likely and easily manageable. Besides, more and more patients request doctors to do thread lifts. Conclusion: The author thinks that more plastic surgeons should contemplate to introduce the threads into their practice since many other nonplastic surgeons offer thread lift as a substitute for face-lift. This is a myth. However, we cannot deny the growing number of patients who are looking for an easier and scar-free way of face-lift with a less downtime. These types of combinations, revealed in this study, allow plastic surgeons to achieve better results compared with the thread lifts alone while reducing the complications and offering a faster healing period than the classical face-lift methods.

Keywords: Face-lift, face-lift combinations, facial rejuvenation, J-plasma, thread lift


How to cite this article:
Celik N. New combinations of threads with surgical methods for facial rejuvenationnew combinations of threads with surgical methods for facial rejuvenation. Turk J Plast Surg 2020;28:219-23

How to cite this URL:
Celik N. New combinations of threads with surgical methods for facial rejuvenationnew combinations of threads with surgical methods for facial rejuvenation. Turk J Plast Surg [serial online] 2020 [cited 2020 Oct 28];28:219-23. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/4/219/296474




  Introduction Top


Thread-lift techniques promise fast healing, minimal complication, minimal scarring, and lesser cost compared with a standard face-lift operation. It is known among patients as “lunch break lift” and considered as a minimally invasive alternative to a face-lift. Because of the complications of the nonabsorbable threads and unpredictable results of absorbable threads,[1] the author of this article stopped using threads in 2005 after using for a short period. However, since 2005, more and more doctors, especially dermatologists and practitioners who deal with antiaging and medical esthetics, keep promoting this technique as an alternative to face-lift. The more popularized among people, the more complications raised due to the technique.[2],[3] Most of the plastic surgeons remained distant to thread-lift techniques because of the quantifiable risk of adverse events and patient discomfort.[4] However, the author was introduced with a new type of nonabsorbable suture (Spring Thread®, 1st SurgiConcept 96 Rue de pont Rompu 59200 Tourcoing, France) in February 2016. It is a biocompatible composite material made of polyester core on which is molded a medical grade silicone envelope. Its elasticity provides a spring effect that compensates the creep of classic threads. After using those nonabsorbable threads with the classical method, the author realized the power of those threads and designed a new way of facial rejuvenation with less incision scars and less risk of classical face-lift complications but a more powerful effective lifting with better long-term results. This technique combines the efficiency of “surgical procedures” with the easiness of the “minimally invasive thread-lift techniques.” This type of combination of threads with other facial antiaging procedures of the face has been described before.[5]


  Materials and Methods Top


The combination method for the face-lift depends on the patients' need and customized accordingly. Not every step is performed in all patients.

  1. Forehead lift or eyebrow lift is performed with the hemostatic net method described by Auersvald and Auersvald.[6] The elevated part of the eyebrow, usually lateral, is also supported with a thread
  2. Upper blepharoplasty is performed in the classical way
  3. Lower blepharoplasty is performed with pinch technique
  4. Midface-lift is performed with silicone threads
  5. Lower face-lift is performed with silicone threads
  6. Neck lift is performed with silicone threads and Cool Atmospheric Plasma (CAP) J-plasma (Renuvion®)
  7. Volume loss is replaced with fat injection
  8. Redundant skin is excised if only necessary.


The author designed this technique after using thread-lift technique in 66 patients between March 2016 and June 2018. Between June 2018 and March 2019, thread lift was performed in 54 patients. Of these 54 patients, only 1 male and 13 female patients who normally would be considered not for the thread lift but for a regular face-lift were included in this study.

The mean age of patients is 40.5 (between 29 and 63).

Four regions in the face and neck area are designated for practical reasons:

  1. Eyebrow, forehead, and temple (upper face)
  2. Cheek (midface)
  3. Mandible contour (lower face)
  4. Submental area and neck.


Steps of technique

  1. The patients are informed about the procedures. The risks and complications due to these operations are explained. It is also distinctly underlined that this procedure is not “a coffee break face-lift”
  2. Patients' desires and needs are considered in order to select the types of operations and the amount of threads that will be used
  3. Patients are photographed and consent forms are taken
  4. Preoperative blood tests are done in the hospital at the morning of operation day, and patients are evaluated by an anesthesiologist
  5. If needed, neck lift is the first part of operation. To achieve a neck lift, submental and neck area is suctioned with a 2-mm cannula (if liposuction is needed) or just tunneled subcutaneously after tumescent solution injected. Renuvion® is used for internal tightening. The thermal precision found in Renuvion® has some advantages over laser or temperature-controlled radiofrequency. The device–tissue interface is selectively treated by the high-energy microplasma. Subdermal region thus the microcirculation is not affected with this radiofrequency method.[7] Thread lift of the neck is not done at this stage
  6. If fat injection is to be performed, the second step of the operation is liposuction. Aspirated fat is prepared for fat grafting, microfat grafting, or nanofat grafting according to patients' needs
  7. Fat injection is performed. A small amount of fat is always spared until the end of the operation in case of need
  8. Scar-free gliding brow lift is the preferred method of the author for the upper face and brow area. It is a subcutaneous dissection which starts from the hairline and goes down to the eyebrows. Elevated skin is advanced to the scalp, and it is fixed with 4.0 prolene sutures (hemostatic net) to the underlying tissue.[6] A silicone thread is always used for the fixation of the eyebrows before hemostatic net is applied. Prolene sutures are to be removed 48–72 h after the operation
  9. If an upper blepharoplasty is to be performed, it is performed at this stage
  10. Threads are placed for the midface and lower face-lift. Threads should never be located superficially. It is easy to understand the level of thread during the placement. If it is too superficial, there will be indentations at the skin when the needle is advanced or pulled. In this situation, the needle should be pulled back and readvanced in the correct, a little bit deeper level. They are placed from up to down at one side of the face. Thread quantity and direction and the position of entrance and exit points are patient dependent. Next, the same maneuvers are repeated on the other side of the face. In closed technique, threads were inserted through a stab incision. If open technique is to be performed, a 2-cm incision is made at the temporal area. A pair of silicone threads is used in the neck area for the creation of cervicomental angle in this stage. The author prefers an interlock in the midline of the neck in order to elevate the hanging neck skin. This thread is placed in a more superficial level compared to the other threads which are used in the midface. A controlled indentation over the neck skin helps to create a nice cervicomental angle. [Figure 1] explains different thread placement techniques
  11. If it is an open technique, the incisions are sutured back after threads are anchored to the temporal fascia with 2.0 PDS suture
  12. The threads are pulled from the scalp exit holes while the face skin is moved softly over the facial part of the thread to the entrance points. An overcorrection or overlift is never done
  13. After the face is lifted, all threads are cut by paying attention to not to leave any part of the thread coming through the exit points on the face or scalp
  14. Any immediate asymmetries or pits at the exit points are corrected by a simple finger massage. A subcision is rarely needed to correct any skin depressions.
  15. Lower eyelid pinch blepharoplasty is performed as the next stage
  16. If needed extra fat or hyaluronic acid, injections can be performed while paying attention to inserted threads
  17. In some patients, a skin fold in front of the ear due to skin laxity of the patient can be seen after thread lifting. These skin folds are removed just like a face-lift or minimal access cranial suspension lift skin excision.[8],[9] This excision should be performed without any face-lift flap dissection, and there should be no tension in wound edges. Skin is closed with 5.0 Vicryl and 6.0 prolene sutures. The author prefers open method if redundant skin excision is part of the operation plan. On the other hand, classical way of thread placement through stab incisions does not prevent this maneuver as the threads placed deep enough
  18. An elastic facemask is put for a few days in order to support the threads.
Figure 1: Threads can be introduced in many styles. Blue thread is the author's preference for eyebrow elevation. For midface lift, a temporal incision can be used and threads can be fixed to the temporal fascia. One or two pairs can be introduced (green). Another method is to introduce the threads through stab incisions. This is more versatile in terms of positioning threads. However, it needs more threads as one half of the thread is used for elevation and the other for fixation (purple). For the submental region, a loop is performed in the midline (gray)

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  Results Top


All patients healed uneventfully. [Table 1] shows the number of patients and treated areas. The number of threads used was between two and five pairs (mean: 3.4). One patient had a temporary weakness of the buccal branch of the facial nerve, which healed spontaneously in 2 weeks. All 12 patients who had brow lift complained numbness at the subcutaneous dissection area on the forehead, which resolved in 2 months. All seven patients who had neck lift with CAP-J plasma complained tightness of the skin and difficulty in neck hyperextension. Those complaints were also resolved in 4 weeks. [Figure 2], [Figure 3], [Figure 4], [Figure 5] show the postprocedural esthetic results of four patients.
Table 1: Number of patients and treated areas

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Figure 2: (a and b) Preoperative pictures of a 58-year-old woman. (c and d) Postoperative 7 months. Gliding temporal lift, upper blepharoplasty, lower pinch blepharoplasty, fat injection, Renuvion® for submental area and mandible contour after liposuction, one thread for eyebrow, two threads for the cheek, and one thread for the submental region. Threads were placed by percutaneous technique. No skin excision was performed

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Figure 3: (a and b) Preoperative pictures of a 42-year-old woman. (c) Postoperative 5 days. (d and e) Postoperative 9 months. Gliding temporal lift, upper blepharoplasty, fat injection, Renuvion® for submental area after liposuction, one thread for eyebrow, two threads for the cheek, and one thread for the submental region. Threads were placed by percutaneous technique and no skin excision was performed

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Figure 4: (a and b) Preoperative pictures of a 31-year-old woman.(c and d) Postoperative 16 months. Only one thread was placed through temporal incision for the cheek. Another thread was placed along the contour of the mandible. Redundant skin excision was performed in front of the ear. Concomitant upper lip reduction was done

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Figure 5: (a-c) Preoperative pictures of a 54-year-old man. (d-f) Postoperative 19 months. Two pairs of threads were inserted through temporal incision for midface and for jowls. Another one is used at the neck after neck liposuction. The patient also received fat injection for the face. Redundant skin around the ear was removed

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  Discussion Top


The first sutures used for face-lift were originally developed by Ruff in 1992 and independently by Sulamanidze in 1996. Ruff's suture was clear, unidirectional, barbed, and made of polypropylene, whereas Sulamanidze's suture was blue, bidirectional, barbed, and made of polypropylene.[10]

Since then, many companies from different countries developed both absorbable and nonabsorbable threads with different physical and mechanical characteristics.

In 2008, Villa et al. published a review article concerning the use of thread-lift sutures. They concluded that the technique was still in its infancy. However, they also presumed that it had the potential to become a useful and effective procedure as further innovations were made.[11] Eleven years after this article, Gülbitti et al. published a literature review based on a PubMed search of the articles about thread lift published since 2006.[12] This article determines the real scientific current state of the art on the use of thread-lift sutures. The study reveals that, interestingly, there are only 12 articles, of which 7 of them were published after Villa et al.'s review after excluding duplicates, articles about open procedures, review articles, case reports, and letters to the editor as well as reports dealing with nonbarbed sutures. Gülbitti et al. conclude that, within the past decade, little or no substantial evidence has been added to the peer-reviewed literature to support the promising statement about thread-lift sutures made by Villa et al. in 2008. They also conclude that thread-lift technique has a limited direct lift effect with short longevity, while the use of thread-lift sutures in combination with an open procedure may be promising.

The aim of this technique is to reduce the complications of the classical face-lift techniques. It also aims to reduce the face-lift scars. There is no dissection of the face-lift flaps, which results in damage of the circulation of the skin. The experience of the doctor reduces the complications of the face-lift, but flap dissection will be always harmful for the circulation of the skin, which results in an older look of the skin after face-lift.

The advantages of this technique are as follows:

  1. No skin dissection prevents devascularization of the skin and results in with an intact skin quality after the procedure
  2. No skin dissection and skin or superficial musculoaponeurotic system (SMAS) elevation decreases the common face-lift complications such as nerve damage or hematoma
  3. Redundant skin excision anterior and posterior to ears are performed in <20% of the patients, and it heals superior compared to classical excision because of the less tension and unimpaired skin circulation
  4. Postoperative healing period is shorter with a lesser amount of edema and bruises
  5. It is a semi-undoable operation. To remove threads is simple if the patient does not like the lift effect
  6. An extra pair of threads can be inserted under local anesthesia, if needed
  7. Learning curve is easy.


Every technique in this article was described previously, but the combination of all is new, and there are differences as well:

  1. Fixation of the lateral eyebrow with thread after gliding brow lift: It is an extra prevention of recurrence of brow ptosis
  2. Insertion of silicone threads deep: It is like a SMAS plication without skin dissection. Besides, deep positioning of the threads prevents skin irregularities.
  3. Using of Renuvion® and silicone thread lift together at the neck and submental area: This maneuver is very effective to create a nice cervicomental angle.


There are some situations that may prevent the use of threads. These include:

  1. Uncontrolled diabetes
  2. Immunodeficiency or autoimmune disorders
  3. Immunosuppressive treatment
  4. Active infection
  5. Bleeding disorders
  6. Keloid tendency
  7. Previous permanent or semi-permanent filler injections in the treatment zones. This type of fillers, including silicone, methacrylate, or cross-linked polyacrylamide, will create a capsule around the filler. Damage to this capsule during the insertion of threads may yield a grave inflammatory reaction.



  Conclusion Top


In conclusion, the author believes that any kind of face-lift, including thread lifts, should be performed by plastic surgeons who are capable of combining different techniques and capable of overcoming the complications. Thread-lift methods should be considered as a reliable and an effective method for facial rejuvenation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sapountzis S, Kim JH, Li TS, Rashid A, Cruz PC, Hwang YS. Successful treatment of thread-lifting complication from APTOS sutures using a simple MACS lift and fat grafting. Aesthetic Plast Surg 2012;36:1307-10.  Back to cited text no. 1
    
2.
Goldan O, Bank J, Regev E, Haik J, Winkler E. Epidermoid inclusion cysts After APTOS thread insertion: Case report with clinicopathologic correlates. Aesthetic Plast Surg 2008;32:147-8.  Back to cited text no. 2
    
3.
Winkler E, Goldan O, Regev E, Mendes D, Orenstein A, Haik J. Stensen duct rupture (sialocele) and other complications of the APTOS thread technique. Plast Reconstr Surg 2006;118:1468-71.  Back to cited text no. 3
    
4.
Abraham RF, DeFatta RJ, Williams EF 3rd. Thread-lift for facial rejuvenation: Assessment of long-term results. Arch Facial Plast Surg 2009;11:178-83.  Back to cited text no. 4
    
5.
Sulamanidze M, Sulamanidze G. APTOS suture lifting methods: 10 years of experience. Clin Plast Surg 2009;36:281-306, viii.  Back to cited text no. 5
    
6.
Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: An efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthetic Plast Surg 2014;38:1-9.  Back to cited text no. 6
    
7.
Gentile RD. Cool Atmospheric Plasma (J-Plasma) and new options for facial contouring and skin rejuvenation of the heavy face and neck. Facial Plast Surg 2018;34:66-74.  Back to cited text no. 7
    
8.
Marten TJ. High SMAS facelift: Combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg 2008;35:569-603, vi-vii.  Back to cited text no. 8
    
9.
Tonnard PL, Verpaele A, Gaia S. Optimising results from minimal access cranial suspension lifting (MACS-lift). Aesthetic Plast Surg 2005;29:213-20.  Back to cited text no. 9
    
10.
Garvey PB, Ricciardelli EJ, Gampper T. Outcomes in threadlift for facial rejuvenation. Ann Plast Surg 2009;62:482-5.  Back to cited text no. 10
    
11.
Villa MT, White LE, Alam M, Yoo SS, Walton RL. Barbed sutures: A review of the literature. Plast Reconstr Surg 2008;121:102e-8e.  Back to cited text no. 11
    
12.
Gülbitti HA, Colebunders B, Pirayesh A, Bertossi D, van der Lei B. Thread-Lift Sutures: Still in the Lift? A Systematic Review of the Literature. Plast Reconstr Surg 2018;141:341e-7e.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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