The Thread-Lift Technique of Cervico-Facial Lifting

David A. F. Ellis, Lorne Segall, and Kristina Zakhary

The first rhytidectomy procedures, reported as early as 1901, consisted of only elevation and redraping of the facial skin.¹ Since then, the concept of the cervico-facial rhytidectomy has evolved and improved. With the definition of the superficial musculoaponeurotic system (SMAS) in 1976 by Mitz and Peyronie and the increased understanding of facial anatomy and the pathophysiology of aging came an increased sophistication and complication of facelift surgery technique.² Cervico-facial rhytidectomy procedures began to involve larger incisions and more extensive soft tissue dissection.³

Recently, the pendulum has swung back, and patients have begun to seek minimally invasive approaches for cervico-facial rejuvenation, with more rapid healing and less risk of morbidity.^4–7 In fact, in the United States, the number of traditional plastic surgeries declined by 5% over the past 5 years, whereas minimally invasive cosmetic procedures increased by 53%, according to a report from the American Society of Plastic Surgeons.⁴ Some patients would even readily accept a more subtle result in exchange for a rapid recovery and return to normal activities. This demand has prompted surgeons to develop techniques that can be performed in an outpatient setting and can achieve equally successful results with less aggressive procedures, smaller skin incisions, and shorter recovery times.^5–7 The ideal cervico-facial lifting procedure combines safety, minimal morbidity, and high patient satisfaction.⁸

Soft tissue suspension with barbed cables or sutures is a novel, minimally invasive technique for correction of face and neck involutional aging changes.⁹ These sutures were popularized by Sulamanidze in the late 1990s and termed Aptos (“antiptosis”) sutures or threads, but the patent is held by Ruff who concurrently developed these barbed threads in the early 1990s and named them Contour threads.^10–12

The barbed polypropylene sutures must be inserted in the subdermal SMAS plane to elevate the brow, midface jowls, and neck and be fixed to the deeper fixed structures.⁹ This provides an effective, relatively atraumatic method of correcting the facial soft tissue ptosis associated with aging. The suspension cables simplify the facial lifting procedures by shortening surgical incisions and eliminating the need for extensive undermining and surgical manipulation of the SMAS. This simplistic barbed suture suspension procedure can be performed under local anesthesia, through needle insertion into the subcutaneous tissue, and lifting with vectors of superoposterior suspension.¹³ This reduces operative time, the need for intravenous anesthesia, postoperative recovery time, as well as the various risks of rhytidectomy complications including hematoma, flap necrosis, infection, nerve damage, and scarring.¹⁴ The major benefits to the patient over the more traditional face- and neck lifting procedures include the lack of extensive tissue undermining and trauma and a lack of significant patient morbidity. The procedure is conservative and time-sparing, requiring less than an hour to perform, and allowing most patients to return to work immediately or within a few days.¹⁵

♦ The Aptos Thread

The Aptos thread (Kolster Methods, Anaheim, CA) was popularized by Sulamanidze in the late 1990s. The term Aptos is derived from the Greek words anti and ptosis.¹⁰ The Aptos thread suspension is based on the concept that the skin can be lifted and held in a suspended position with barbs alone without affecting the underlying muscle or bone. It is essentially a 2-0 polypropylene, nylon suture with barbed projections in opposite directions that adheres to the dermis (Fig. 8.1).¹¹ The proximal side of an Aptos thread has barbs that extend forward in the direction of its movement through the tissue, and the distal side has barbs extending in the opposite direction, against the direction of the suture’s movement through the tissue. The bidirectional design of the suture barbs enables the suture to travel one way within the soft tissue and prevents the suture from moving in the opposite direction. This provides a uniform and symmetric gathering of the soft tissues, with the suture remaining fixed in a specific position, uplifting the soft tissue and creating a new facial contour.10^,¹¹

Fig. 8.1 Aptos suture with bidirectional barbs.

♦ The Contour Thread

Another device, the barbed Contour thread (Surgical Specialties Corp, Reading, PA), developed by Dr. Gregory Ruff who holds the patent, evolved in concept over the early 1990s. In 1995, the Contour thread received U.S. Food and Drug Administration approval in the United States for lifting of cheek, jowl, and brow.¹² Using the model of the porcupine quill, Ruff designed a multibarbed, unidirectional monofilament suture that maintains a grasp on soft tissue through an even, spiral distribution of barbs on each quill. The Contour thread is essentially a 25-cm 2-0 polypropylene barbed suture that is wedged onto a 7-inch straight needle with a tapered cutting tip on one end to facilitate suture passage through tissues. On the opposite end of the Contour thread is a 26-mm, 0.5 circle tapered needle, used for suture fixation (Fig. 8.2).¹⁴ The Contour suture differs from the Aptos thread in that it has unidirectional barbs and is necessarily anchored superiorly to a fixed structure. More recently, double-armed Contour threads are available, which no longer need to be sutured to soft tissue or fascia for proximal support.

♦ A Physiologic Basis for Thread Lifting

In an attempt to clarify the mechanism of tissue ptosis correction by the barbed sutures, Sulamanidze and co-workers performed an experimental study of the tissue morphologic changes in response to implantation of barbed polypropylene sutures.¹⁶ Histopathologic studies were performed in which barbed polypropylene sutures were inserted subdermally in rats and compared with nonbarbed polypropylene suture in control rats. The tissues were examined with special stains for collagen, fibroblasts, and vascular response, with serial skin biopsies taken regularly for up to 6 months. A difference was noted between the barbed suture and its control, in that the smooth nonbarbed polypropylene suture elicited minimal or no vascular, inflammatory, fibroblastic, or collagen response. The barbed suture, in contrast, demonstrated an early inflammatory response followed by a vascular proliferation and fibroblastic reaction, which created a collagen cuff with laterally extending bands around the barbs. It was concluded that this collagen cuff accounted for the maintenance of the grip of the barbs to the subdermal tissues and the correction of soft tissue ptosis. It was also postulated that cervico-facial immobilization after suspension cable placement was necessary in order to allow initiation and early maturation of the collagen response.¹⁶ Further studies were performed to evaluate the tensile strength of the barbed sutures, which demonstrated that they can maintain greater tensile strength measured in pounds per square inch (4 to 5 lb/in²).¹⁷ These results form the basis for the scientific principle behind the clinical results seen with the barbed suspension cables.

Fig. 8.2 Contour suture with unidirectional barbs.

♦ Indication for the Thread-Lift Procedure

The correction of cervico-facial ptosis with only cable suspension sutures is indicated in select patients who were reluctant to undergo traditional face and neck lift procedures.
The thread-lift procedure can be used as an adjunct to SMAS imbrication in patients undergoing cervico-facial rhytidectomy.

♦ Head and Neck Sites Amenable to Thread Lifting

Nasolabial (lip-cheek) groove
Melomental groove
Lateral eyebrow
Platysmal bands in the neck

♦ Patient Selection

The ideal patient is either a younger person who does not have a full face with heavy soft tissues, many rhytides, and much redundant skin, or a facelift patient whose surgical result may be enhanced or further supported by the placement of these subdermal suspension cables. Patients with excessive skin redundancy and heavy, ptotic facial and/or neck soft tissue are not suitable candidates for the cable suspension technique as the sole procedure due to poor longevity of results and a higher risk for complications. These patients would most likely be best treated by other cervico-facial rejuvenation modalities, such as more traditional facelifting procedure and/or laser skin resurfacing techniques.