There is great demand from patients for non-surgical or minimally invasive surgical aesthetic procedures that can lift the face and neck. With the promise of a non-surgical rhytidectomy or facelift, thread lifts have become a popular treatment.
Absorbable materials, such as polydioxanone (PDO) and polylactic acid (PLA), are common thread materials. In the author's experience, using such threads, they can provide shorter term improvement (6–12 months) and are mostly suitable for a younger patient with faces that are not too heavy. This is due not only to the nature of the threads, which lose their tensile strength within months (depending on the material), but also the techniques used for their placement. All techniques used in the temporary (dissolvable) threads employ minimal or no anchoring. This leads to less obvious lifting, compared to those that are anchored. Part of the reason as to why those techniques do not provide anchoring is that those threads lack sufficient length. In this article, three case studies will be shared that demonstrate the use of silicone-based permanent threads that achieve, in the author's experience, a greater and longer-lasting lift. This is due to the permanent nature of the threads (nylon core and silicone-barbed coating), as well as their length, which allows the use of anchoring techniques for better results and longevity. The author must emphasise that, despite the threads being permanent, the results never are, and they are not marketed as such. No cosmetic procedure brings permanent results.
Comparing permanent threads to absorbable threads
Absorbable threads rely upon short-term, bio-stimulation of the tissue to accelerate fibrosis rather than suspend the tissue. They are unable to offer any lasting lift to the skin, as they rapidly lose tensile strength. For example, PDO retains only 50% of its original tensile strength at 4 weeks (Weitzul et al, 2005), while PLA sutures retain 50% of their original tensile in 6-8 weeks (Gilding and Reed, 1979).
The aim of permanent threads is to reinforce the loose connective tissue that has become slack to lift and give mechanical suspension to the tissue. The permanent thread becomes part of the extracellular matrix, providing long-term structural support for the tissue. They can encapsulate in a similar way to breast implants and become well-embedded into the soft tissues.
Structure of the thread
The author's preferred permanent suspension thread is Spring Thread®, which is a 300mm long polyester thread, upon which are moulded, silicone cogs (Spring Thread, 2021). These completely biocompatible materials have been used in surgery for over 50 years. As they are inert, they are not identified as a foreign body that needs removal; therefore, any risk of inflammatory reaction is low.
Case study 1
A 52-year-old woman presented to clinic who felt that her skin was becoming lax in the lower face, her nasolabial fold was too severe and her jowls were beginning to droop. She did not want a surgical procedure and general anaesthetic but wanted long-lasting results. So, Spring Thread was chosen as an ideal treatment.
A total of three threads were used for each side of the face. The patient was seen again at 1 week, and no corrections were necessary. The patient was very happy with the results and felt that it had refreshed her and restored her confidence. The procedure improved facial contours, the cervicom and ibularangle, reduction of jowls and improved jawline definition. Additionally, the patient also reported that her crow's feet expression lines had greatly diminished. Due to the subcutaneous tissue being lifted, it provided greater padding, thickening the tissue in the area, and so, they became less prominent.
The needles are 150mm long and blunt-ended, which avoids trauma. Although they are strong, they are also flexible, which allows them to navigate facial contours more effectively.
Spring Thread has a high number of cogs along the thread (28 per cm), which allows for tension to be distributed along its whole length. The cogs are rounded to reduce trauma and point in four directions, which gives strong adhesion to the tissue. For several months following the procedure, fibrosis occurs along the length of the thread, which strongly fixes the thread, and it becomes part of the tissue (Spring Thread, 2021).
The cogs are also bi-directional. At the centre point of the thread, they change direction, and this enhances the fixation and suspension. The upper strand of the thread fixates within the subgaleal space between galea and pericranium, where there is very little space between the structures, while the lower strand lifts and suspends the mobile facial tissue.
Unusually for a thread, Spring Thread possesses similar elasticity to the skin (around 20%), which means that it expands and contracts with facial movement (Spring Thread, 2021). The tissue is dynamically stabilised, and it is more comfortable for the patient than a rigid thread. It leads to natural-looking results, as the face can move.
Case study 2
Techniques
Non-surgical
The straight laying technique is a simple procedure that takes less than 1 hour to perform (Figure 1).
Unless a thread has a fixation point, it cannot offer a sustained lift. The upper part of the Spring Thread exits from the scalp area, which is relatively immobile. There is very little space between the structures here, which provides strong fixation, while the lower part of the thread gives mechanical suspension to the mobile facial tissue area.
Case study 3
The more length of thread is used for anchoring, the better and longer lasting the results are. The author tries to use most of the barbed part of the thread, which sometimes means having to exit and enter again through the same point. Sometimes, this is easier to achieve with separate longer needles, but, because of the natural curve of the scalp, there is always a limit as to how far one can reach with one needle insertion.
Effective overall results for the non-surgical laying last for over 2 years (Foumenteze et al, 2010), after which, they gradually diminish through natural ageing, at which point, patients can return and have further threads installed if they wish (Guillo, 2016).
Surgical
There are a variety of surgical techniques that can be used for thread lifts, varying from the so-called FY technique described by Guilo (2016) to mini facelifts that involve skin excision. The advantage of using these threads in mini facelift techniques is that the procedure will require minimal undermining and will result in a short scar. The useful thing about this thread is that it is very versatile. It can be adapted to different needs, and new techniques can be created. There are no strict rules. The thread can also be used unilaterally for facial symmetry restoration after facial nerve injuries.
The FY technique uses ‘scales’ suspension, where one side suspends the other. To achieve that, both sides are passed through the scalp and exit into a mid-point (or slightly off-centre point to avoid mid-parting scaring), the same way as an Alice band.
The ideal patient candidate for these and all threads in general is someone who has a moderate amount of subcutaneous fat. This provides a good place for the threads to be placed, without the danger of them being too superficial or too deep. If the patient has very little subcutaneous fat, there is a danger that they may be visible, as they will only be covered by the skin. To avoid this, some practitioners may pass them too deep and injure the underlying structures. However, if the face is volumised prior to the thread lift—either by fat transfer or, if there not enough fat, by dermal filler—then this subcutaneous place is enlarged, and the procedure becomes possible even for patients with very slim faces. If the face is too heavy, more threads are needed to provide a good lifting effect. If there is excess fat accumulation in the neck and submental area, liposuction can be performed prior to the thread lift in to achieve a better jawline definition. A radiofrequency-based skin tightening device can also be used (the author uses FaceTite/NeckTite by Inmode) to help contract the skin and avoid the patient being left with too much excess skin after the liposuction. So, in theory, every patient can be suitable for the procedure. Some will be outright suitable, while others have to be made suited, either by volumising those with slim faces or debulking those with fuller faces before the thread lift is performed. If there is too much excess skin, this can either be excised during the procedure, or skin tightening devices can be used to reduce the excess.
Safety of permanent sutures
Some practitioners can be hesitant about using permanent products, perhaps as they may believe that they can cause long-term problems, although the literature suggests that this is not necessarily the case. A multi-centric study of 110 patients showed that serious complications from permanent sutures were uncommon (Foumenteze et al, 2010). The main post-operative complication can be short-term, low-level pain at the skull or temples, where the thread crosses over the temporal artery. Painkillers are prescribed for this. Mild bruising and oedema are common and temporary.
The main complications that can occur with permanent threads can be too superficial implantation, which is due to poor technique or infection and can happen with any type of thread. In the case of infection, it is possible to remove the thread (Guillo et al, 2012).
Removing the thread entails injecting local anaesthesia along the thread path and using a small lancet to open up the skin at the original entry point. A hooked tool is used to catch the thread and pull it out, while gently massaging the skin to release the cogs (Guillo et al, 2012).
Another complication can be due to poor patient selection, which can lead to inadequate results. In the author's experience, permanent threads are suitable for patients with mild-to-moderate facial/neck sagging, a lack of excessively wrinkled skin and without overly heavy tissue. Patients who do not need or want surgical lifting are typical, as well as those who have had surgical lifting in the past and want a follow-up treatment.
Conclusion
Spring Thread silicone threads can be ideal for patients who do not quite need or want surgical lifting, as well as those who have had surgical lifting in the past and want follow-up treatment. The straight laying procedure can be performed under local anaesthetic with short downtime and is well tolerated by patients. The thread provides substantial lift, with natural-looking results, and the longevity of the result is 2–3 years, which can be further extended. The risk profile is similar to absorbable threads, and the two standout factors in favour of Spring Thread are the longevity of the result and the amount of lift achieved.