Introduction
Thread lift procedures have gained attention in cosmetic medicine and popular culture as a minimally invasive alternative to rhytidectomy. The use of thread lifting has grown in recent years, with the procedure dubbed by many as the “lunchtime facelift.” Although different techniques of thread lifting exist, the fundamental concept involves the passage of sutures beneath the skin to lift sagging tissue and promote new collagen formation through a reactive healing response. The combination of these two effects leads to a natural, subtle enhancement with gradual improvement over time.
The advantages of thread lift procedures as compared to more invasive alternatives include smaller incisions, a shortened recovery time, and the avoidance of complications associated with traditional surgery. Thread lifting also possesses unique benefits over other minimally invasive techniques. Ablative and nonablative laser resurfacing can dramatically improve the skin’s surface, but neither treats the subcutaneous tissues, and both may cause prolonged downtime. Filler correction of volume loss, when done tastefully and artfully, plays an important role in treating cosmetic patients; however, even in the most adept hands, faces are prone to over-volumization, which can lead to a swollen appearance.
Thread lift procedures were initially conducted with smooth sutures and have since evolved to incorporate barbed sutures. In the latter technique, the thread is studded with small, outwardly radiating projections, which anchor into the subcutaneous tissue and upwardly suspend the skin. These barbed sutures are well- studied for use in the forehead, middle and lower thirds of the face, and the neck. In addition, off-label applications in the décolletage, buttocks, and knee areas have been reported.
Thread lift sutures come in two varieties: absorbable and non-absorbable. Permanent, non-absorbable threads were initially approved for the correction of facial ptosis, whereas absorbable threads were historically used to suture incisions. , The use of non-absorbable threads for cosmetic applications has diminished significantly over the last decade due to a high degree of reported adverse effects and low satisfaction rate. Conversely, absorbable sutures have become more popular due to their improved tolerability and physician understanding that these threads act as fibroblast stimulators rather than tissue lifting devices. The fibroblast stimulating properties of Polydioxanone Threads have also been demonstrated in treatment of stubborn atrophic scars by the authors of this chapter.
In this chapter, we will first discuss patient selection, the authors’ technique, site-specific procedural pearls, and potential complications. A literature review of various cosmetic threads will be discussed in the latter half of the chapter, as there is currently a paucity of comprehensive data regarding the long-term safety, efficacy, and durability of cosmetic procedures performed with sutures. This section will aim to address this knowledge gap and provide the clinician with an informed overview of modern thread lifts.
Patient selection
Proper patient selection is crucial to ensuring the success of any surgical procedure, and the same applies to thread lifting. Facial thread lifts are best suited for patients with early or moderate aging changes without significant photodamage, laxity, or loss of elasticity. Low body mass index, minimal fullness of the soft tissues, and strong underlying bony projections are also desirable features to consider when selecting patients. Ideal candidates for neck thread lifts should have redundant skin that can be easily displaced by posterolateral force, while also having enough fat to ensure that the threads are not visible after placement.
In the author HK’s experience, female patients between the ages of 35 and 60 with relatively thin faces and mild to moderate sagging best encompass the above selection criteria. Male patients, even if they possess the aforementioned features, do not exhibit the same success rate due to physiologically thicker skin compared to their female counterparts.
Patients with inflexible schedules are also well-suited for this minimally invasive procedure, as the lifting benefits are enjoyed with little required downtime. Additionally, the ability of this treatment to be performed in-office renders this therapy as a safe alternative for patients unable to undergo more invasive surgical procedures; however, it is important to note that a traditional surgical facelift is still the more appropriate option for patients who do not possess the characteristics described in the first two paragraphs.
In addition to identifying suitable candidates, managing patient expectations is also important to optimize results. This includes counseling patients that these sutures are primarily used as biostimulators of collagen production rather than lifters of soft tissue. As such, the author HK routinely advises the patient during the consultation appointment that the thread lift treatment should be viewed in a similar fashion to the soft tissue injectable filler Sculptra. The conversation frequently progresses as follows: In one instance a liquid [Sculptra] is injected and, in the other, a suture is placed under the skin in order to stimulate focused collagen production. Both bio-stimulators will demonstrate subtle immediate lift and volumization; however, as collagen manufacturing increases with time, tissue elevation and volume correction will be more readily appreciable. It is also important to note that the body continuously breaks down collagen as we age. Therefore, it is reasonable to expect that either of these procedures need to be repeated every 1 to 2 years to ensure optimal outcomes. This crucial aspect of the patient interaction reinforces the idea that the results may not be immediate and, furthermore, maintenance treatments will likely be required in the future. It is important to note that the success rate of thread lifting is highly dependent on the experience of the surgeon as well as the specific region of the face treated. For instance, the outcomes of the brow and neck treatments are generally much less impressive than the outcome of mid face.
Authors preferred sutures
Silhouette instalift
These proprietary threads are composed of poly-L-lactic acid (PLLA) and glycolide polymer, two biodegradable substances that stimulate the production of collagen. These compounds are woven together to form a single suture that is enhanced by the placement of small cones and knots along its length. This unique structure maximally lifts the targeted area while simultaneously provoking a wide-scale increase in collagen production to prolong the results of the procedure.
Silhouette InstaLift advantages: the relatively thin caliber of the sutures allows for rapid absorption and is less likely to cause postoperative pain and nodule formation. Additionally, it’s longer length offers more flexibility than other threads.
Silhouette InstaLift disadvantages: the needle is inserted from the mid-cheek area, which results in visible entry points for 3 weeks. Puckering of the insertion points may also occur, since both threads enter at the same incision site and dermal tissue may become trapped between the two needles. Furthermore, the thinness of the thread increases its tendency to break, which is problematic given the high cost of this particular suture.
EuroThreads (NovaThreads)
EuroThreads sutures contain a different absorbable compound called polydioxanone (PDO). The malleability of this polymer allows it to be packaged in a variety of formulations, including smooth, barbed, and twisted. Smooth threads are best suited for the correction of decreased skin elasticity, barbed threads are excellent for subtle elevation, and twisted threads are optimized to restore lost volume.
EuroThreads advantages: these larger-caliber sutures are less likely to break and have insertion points that can be hidden in the hairline. EuroThreads are also less expensive than Silhouette InstaLift.
EuroThreads disadvantages: EuroThreads have higher rates of post-operative pain and nodule formation compared to Silhouette InstaLift.
Procedure (Silhouette InstaLift)
Each Silhouette InstaLift suture consists of a single thread with bidirectional cones and needles at both ends. Insertion of the suture requires one central entry point followed by two exit points located roughly 4 to 5 cm away along the desired treatment vectors ( Fig. 9.1 ). An 18-gauge needle is used to create the central insertion port. The first Silhouette InstaLift needle is then inserted vertically 5 mm into the entry point to reach the subcutaneous fat. This precise depth is marked by a black line on the needle. Thereafter, the needle angle is flattened to become parallel to the skin surface and is advanced toward one of the exit points. Once the exit site is reached, the needle is sharply externalized and pulled to set the cones in place ( Fig. 9.2 ). To complete this aspect of the procedure safely, the author HK recommends using a needle cap to help prevent a sharps-related injury while still producing adequate counter tension.
This procedure is then repeated with the second needle head, but in the opposite direction. It is of utmost importance to ensure that the exact same entry point is used for both needle heads to avoid skin trapping and long-term puckering at the insertion site (see 
and ).
Procedure (EuroThreads) [NovaThread]
Entry sites for EuroThreads sutures should be located in areas that can be easily hidden (e.g., within the hair line). Following anesthesia as described above, the entry point is made using a 16- or 18-gauge needle. The EuroThreads, which is attached to a cannula, is then passed through the entry point and into the subcutaneous tissue. To advance the thread from the insertion site, firm tension is placed on the distal portion of the suture, and the tissue is advanced over the thread up to the entry point. The suture movement is directed toward the pre-marked anchoring site, which is selected based on the treatment area. Further details describing appropriate entry and exit sites for different facial regions are described in the below sections.
During the advancement process, the patient and surgeon may hear clicking sounds as the suture intercalates with the tissue. Sutures should be placed in straight lines within the subcutaneous plane, with the vector directed perpendicular to the target plane. Straight vectors provide the highest tensile strength, whereas arcuate or angulated placement of threads can result in uneven lifting.
Prior to removing the cannula, the most distal tip is firmly pressed with the non-dominant hand. The driving hand then turns the cannula 180 degrees clockwise, followed by 180 degrees counterclockwise. The cannula is then removed, and the visible remnants of the suture at the entry site are cut to skin level (see 
).
Brow lift
Lifting the brow requires two threads per side, with each thread originating from the hair line. The medial suture is aligned with the medial 1/3 of the brow and advanced in a straight line to the inferior brow area. The lateral suture is aligned with the middle 1/3 of the brow and advanced in a straight line to the inferior brow area ( Fig. 9.3 ). The authors prefer barbed EuroThreads for optimal lift.
Authors’ technique
Preparation
Thread lift procedures are sterile procedures and treatment areas should be prepped accordingly (Author HK prefers Hibiclens). The number of sutures that should be prepared in anticipation of the procedure varies according to the area and desired amount of lift. Entry points for each thread type vary; however, the anesthetic procedure remains the same: 1% lidocaine with epinephrine is injected into the skin and subcutaneous layer using a 30-gauge needle. No anesthetic is required along the length of the projected thread pathway, as the threads should not cause pain as they travel in the subcutaneous plane. Use of anesthesia in this region is discouraged, as it may distort the tissue and mask pain sensation, which can be an important indicator that the thread is in the wrong plane.
Mid-facelift
Lifting the mid-face requires three threads per side, with each thread originating from the superior temple within a hair-bearing area (see Fig. 9.3 ). The most superior thread is advanced lateral to the orbital rim to 5 mm past the nasolabial fold. The endpoint of the middle suture lies between the oral commissure and the mandibular rim, where jowl hooding is maximal. Finally, the most inferior suture travels vertically from the temple to 1 cm past the angle of the mandible (see Fig. 9.3 ). The placement of these sutures varies according to the patient’s laxity. The authors prefer 18 G or 19 G barbed EuroThreads for optimal lift ( Figs. 9.4 and 9.5 ).
