INTRODUCTION
As the person ages, the scaffolding dermal
facial skin, as well as the fat component are weakened.
The affected areas generally include cheeks,
eyebrows, mandibular area and neck. This is attributed
to the fact that the connective tissue of the
skin becomes thinner and the elastic fibers collapses
[1]. The surgical facelift procedure to correct facial
aging has been, so far, an elaborated and complicated
procedure that takes a long time to recover
179
from [2]. The introduction of absorbable barbed
sutures produces a lifting action for facial aging
[3-6]. This delivers predictable long-term results
with less morbidity, less downtime and greater
patient satisfaction [7]. It is a simple approach that
allows a safe reduction of mild degree of aged
face. Depending on the material that makes up the
sutures and filling threads, they have been classified
as non-absorbable and absorbable threads [8].
PATIENTS AND METHODS
This study is clinical pilot study. It included
twelve patients with mild to moderate mid face
laxity. They were selected from the attendances of
the Outpatient Clinics of Dermatology and Venerology
Department and Plastic and Reconstructive
Surgery Department, Tanta University Hospitals.
The study was accepted by Ethical Committee of
the university.
Inclusion criteria:
Patients with mild to moderate laxity of mid
face, evidenced by moderately deep folds who
accepted to be included in this study, signed a
written consent and continued till the end of the
follow-up period.
Exclusion criteria:
• Pregnant and breast-feeding females.
• Patients with thin translucent skin with minimal
subcutaneous fat.
• Morbid obese patients with tight facial skin.
• Patients with overabundance of skin, requiring
surgical removal.
• Patients with any procoagulative or thrombophilic
disorders.
• Patients having any infectious diseases or
chronic diseases such as chronic renal failure,
hepatic insufficiency, hepatitis, cardiovascular
disorders, diabetes mellitus, thyroid disorders
and cancer.
• Patients with history of keloid formation.
All patients were subjected to complete medical
history taking, general and dermatological examination
for any associated skin diseases and for
exclusion of any systemic disease, complete blood
picture to exclude anemia, bleeding disorders and
any systemic disease and clinical assessment of
the mid face laxity according to Glogaue photoaging
scale (I=mild; minimal wrinkles, mild pigment
and no keratosis, II=moderate; wrinkles in motion,
visible brown spots and palpable keratosis, III=
advanced; wrinkles at rest, obvious discoloration
and visible keratosis and IV=severe; wrinkles
throughout, no normal skin and yellow-grey skin
color) [9].
Digital photographs were taken before the procedure,
immediately after the procedure, one month
and three months after the procedure. They include
front, right lateral and left lateral views. Therapeutic
regimen as multiple threads inserted in the mid
face on both sides according to the surface area
was done.
Procedure of thread lift:
Before the procedure, the skin was cleansed
with cotton gauze soaked in 70% ethanol. The
procedure was performed in minor surgery room
in Outpatient Clinic of Dermatology and Venereology
Department, Tanta University Hospitals in
a well-ventilated area. Permanent markers were
used to mark out the entry, exit points and the pass
way of the needle. Local anesthesia with 2% lidocaine
and 1:200,000 epinephrine was injected in
each side of the face. The needle trocar was introduced
through the skin and is advanced along the
mapped pathway. The trocar was removed, and the
suture was inserted under the skin. The protruding
suture was slightly pulled backward. Gentle finger
massage is done over the suture. Two sides of the
face were compared for symmetry. The protruding
suture was snipped with suture scissor. Topical
antibiotic cream was applied.
Post procedure instructions:
All patients were instructed to avoid rubbing
and friction of the face. The patients used an antiinflammatory,
anti-edematous cream and analgesic
three times daily for one week if pain is marked.
180 Vol. 44, No. 1 / Assessment of Efficacy & Safety of Thread Lift in Mid Face
Follow-up for assessment the efficacy of the
threads and demonstration of any side effects as
ecchymosis, swelling, infection or migration of
threads and treating them were reported after 1
and 3 months.
Degree of improvement of wrinkles was reported
according to physician assessment regarding to
the five point rating system (0=no improvement
(0%), I=mild (1-25%), II=moderate (26-50%),
III=marked (51-75%) and IV=excellent (76-
100%))(10) and patients' satisfaction. Pain assessment
was done regarding 5-point pain scale (0=no
pain, I=mild, II=moderate, III=severe and IV=
intolerable) [11].
Statistical analysis:
Data were fed to the computer and analyzed
using IBM SPSS software package version 20.0.
(Armonk, NY: IBM Corp). Qualitative data were
described using number and percent. Quantitative
data were described using range (minimum and
maximum), mean, standard deviation and median.
Significance of the obtained results was judged at
the 5% level [12].
RESULTS
This study was carried out on 12 female patients
suffering from mild to moderate mid face laxity.
There were 7 patients (58.33%) aged 50 years or
more and 5 patients (41.67%) aged 30-<50 years
with mean ± SD 49.25±7.24.
As regards the degree of mid face laxity, 7
patients (58.33%) had mild laxity and 5 patients
(41.67%) had moderate laxity.
The mid face laxity was corrected by the absorbable
bidirectional pulling cog threads 20G X
100 (150) 2D (Made in Korea). The number of the
threads inserted for each patient was different.
Seven patients (58.33%) inserted 2 threads in each
side of the mid face, 3 patients (25%) inserted 3
threads in each side and 2 patients (16.67%) inserted
4 threads in each side with mean ± SD 2.58±0.79
(Table 1).
There were 4 patients (33.33%) getting marked
improvement and 6 patients (50%) getting moderate
improvement. All of them (83.33%) were
satisfied with their procedure. The remaining 2
patients (16.67%) had mild response and they
were not satisfied with their procedure (Table 2),
Figs. (1-3).
Egypt, J. Plast. Reconstr. Surg., January 2020 181
Table (1): Descriptive analysis of the studied patients according
to number of the inserted threads.
Number of inserted threads
2 threads for each side
3 threads for each side
4 threads for each side
Min.-max.
Mean ± SD
58.33
25
16.67
%
7
3
2
No.=12
2-4
2.58±0.79
Table (2): Descriptive analysis of the studied patients according
to number of the inserted threads.
Degree of improvement:
Marked
Moderate
Mild
Patients opinion:
Satisfied
Not satisfied
33.33
50
16.67
83.33
16.67
%
462
10
2
No.=12
Fig. (1): 46yrs. old female patient with mild degree of mid face laxity; (A): Before the procedure, (B): 1 month after the procedure
with moderate degree of improvement, (C): 3 months after the procedure with moderate degree of improvement.
(A)
(B)
(C)
182 Vol. 44, No. 1 / Assessment of Efficacy & Safety of Thread Lift in Mid Face
Fig. (2): 50yrs. old female patient with moderate degree of mid face laxity; (A): Before the procedure, (B): 1 month after the
procedure with marked degree of improvement, (C): 3 months after the procedure with marked degree of improvement.
(A)
(B)
(C)
Egypt, J. Plast. Reconstr. Surg., January 2020 183
Few side effects had been reported upon the
procedure. All patients (100%) had pain. Four
patients (33.33%) had slight ecchymosis and 3
patients (25%) had slight edema.
Regarding 5-point pain scale, 6 patients (50%)
suffered from mild pain, 3 patients (25%) suffered
from moderate pain and 3 patients (25%) suffered
from severe pain. Pain disappeared after 7 days in
3 patients (25%), after 10 days in 6 patients (50%)
and after 14 days in 3 patients (25%). Ecchymosis
disappeared after 7 days in one patient (8.33%),
after 10 days in one patient (8.33%) and after 14
days in 2 patients (16.67%). Edema disappeared
after 7 days in one patient (8.33%), after 10 days
in one patient (8.33%) and after 14 days in one
patient (8.33%) (Tables 3,4).
As regard follow-up of the patients after 1 month,
10 patients (83.33%) had been improved with no
side effects while after 3 months, they had more
improvement while slight improvement with no side
effects after 1 month reported in 2 patients (16.67%)
and still the same result after 3 months (Table 5).
Fig. (3): 51yrs. old female patient with moderate degree of mid face laxity; (A): Before the procedure, (B): 1 month after the
procedure with mild degree of improvement, (C): 3 months after the procedure with mild degree of improvement.
(A)
(B)
(C)
DISCUSSION
With age, the facial support structure weakens
and the facial fat has to be reduced. The affected
areas generally include the cheeks, eyebrows, other
areas around the eyes, the jowls and the neck. As
the skin ages, the connective tissue in the skin
becomes thinner and the elastic fibers undergo
breakdown, so the face loses some of its elasticity
and it begins to sag and wrinkle [13].
Rejuvenation is introduced by the preferred
four (Rs) techniques, which are relaxation, refilling,
reposition and resurfacing. Relaxation using BTX.
Refilling using fat transfer or fillers. Reposition
of sagging soft tissue can be achieved with various
kinds of threads that have been improved with the
development of biomaterials. Resurfacing procedures
using mechanical force, chemical materials
or lasers can rejuvenate fine wrinkles [14].
Thread lift may be a good alternative to the
more invasive procedures that are necessary to
correct problems of faces of elderly. Thread lift
emerged because many people would like a face
lift but cannot afford it or refuse the long recovery
time of the standard face lift. Thread lifts cost less
and require less downtime for many people. Some
surgeons promote the thread lift as a lunchtime lift
or weekend face lift [15].
Barbed sutures are modified polypropylene
sutures which are either bidirectional or unidirectional.
They intend to create fibrosis for longer
lasting results [16]. Fibrous capsular contraction
elicited around the threads. Barbs are the smallest
part of the thread and likely to dissolve first [17].
The aim of this study was to evaluate the safety
and the efficacy of thread lift in mild to moderate
mid face laxity.
This current study was done on 12 female
patients. The age of the patients ranged from 40-
60 years. Savoia et al., 2014 [18] reported the age
ranged from 37-65 years in their study while Kalra,
2008 [15] reported that the ideal age for using thread
lift ranged from 35-45 years.
In the current study, all patients were female
for cosmetic complaints and this goes with Lycka
et al., 2004 [19] and Han et al., 2016 [20]. They
reported that all their studied patients were females.
This current study was done on the mid face.
Studies done on thread lift are variable. Han et al.,
2016 [20] did their study on mid face, while Badin
et al., 2005 [21] did their study on mid and lower
face. Kaminer et al., 2008 [22] and Savoia et al.,
2014 [18] tried their studies on the whole face and
neck.
This current study was done using the pulling
cog threads which are absorbable bidirectional
threads fixed inside trocars. The procedure did not
require general anesthesia, no bleeding, no scarring
and the patient could return to his daily activities
shortly after the procedure. The effect of these
threads produced by immediate mechanical effect
then inflammatory reaction and fibrosis around
threads and barbs on both sides in the bidirectional
type but in the unidirectional type the barbs located
on one side and the lift in one direction. Suh et al.,
2015 [23] used the polydioxanone bidirectional cog
threads. Atiyeh et al., 2010 [24] used the lunch time
bidirectional threads which are a type of polypropylene
barbed sutures. Sapountzis et al., 2014 [25]
used new polypropylene barbed threads sealed
with distal mesh named REEBORN which consist
of five parts from distal to proximal as follow: A
smooth part used as a guidance for the insertion
of the needle, a segment with cogs, mesh segment,
184 Vol. 44, No. 1 / Assessment of Efficacy & Safety of Thread Lift in Mid Face
Table (3): Analysis of the reported side effects of the procedure.
Pain disappearance:
After 7 days
After 10 days
After 14 days
Ecchymosis disappearance:
After 7 days
After 10 days
After 14 days
Edema disappearance:
After 7 days
After 10 days
After 14 days
25
20
25
8.33
8.33
16.67
8.33
8.33
8.33
363
112
111
Table (4): Distribution of the studied patients according to
degree of pain.
50
25
25
%
633
No.=12
Mild
Moderate
Sever
Degree of pain
After 1 month:
Improvement with no side effects
Slight Improvement with no side effects
After 3 months:
More improvement with no side effects
Slight improvement with no side effects
Table (5): Distribution of the studied patients according to
follow-up after 1 and 3 months.
83.33
16.67
83.33
16.67
No.=12 %
10
2
10
2
Follow-up
Egypt, J. Plast. Reconstr. Surg., January 2020 185
proximal cogs segment and smooth segment for
fixation to the mesh and the deep temporal fascia.
The needle, trocar and canula were used to create
a sub SMAS plane while thread placement and the
mesh were used for thread fixation to the deep
temporal fascia. Vestita et al., 2016 [26] achieved
facial rejuvenation by injection of substances aimed
at stimulating collagen production called home
made bio stimulating thread lift which consists of
polydioxanone suture, a 1mm lipofilling cannula
and a small piece of polystyrene. Kang et al., 2017
[27] made a vertical lifting technique with polydioxanone
sutures which inserted vertically downward
in the anterior malar and submalar areas.
In this study, the number of the used threads
was 2-4 threads, that were inserted in each side of
the mid face for each patient according to the
degree of laxity. Sapountzis et al., 2014 [25] used
two threads for mid face, while Suh et al., 2015
[23] and Silva-Siwady et al., 2005 [28] tried 5
threads on each side for each patient, 3 for upper
and central cheek and 2 for mandibular area.
In the current study, 83.33% of patients showed
improvement and patients were satisfied with the
used cog threads. Suh et al., 2015 [23] reported
87% success with cog threads used for 31 patients.
Park et al., 2014 [29] reported 98% success with
cog threads used for 200 patients, while Kang et
al., 2017 [27] reported 89.7% success with polydioxanone
threads used for 39 patients.
Regarding the side effects of the procedure in
the current study, the patients suffered from slight
side effects as pain (100%), slight edema (100%)
and slight ecchymosis (100%) which resolved
spontaneously. Other studies reported the same
side effects [18,19,21,23]. More dangerous side effects
were reported in Silva-Siwady et al., 2005 [28] as
thread migration and partial expulsion. Rachel et
al., 2010 [7] and Sulamanidze et al., 2011 [31]
reported skin dimpling, hypercorrection, hypocorrection,
transient paresthesia, thread migration and
injury to major vessels, nerve branches, parotid
capsule and duct. Kalra, 2008 [15] reported thread
knots, infection and asymmetry. Yeo et al., 2017
[32] reported alopecia at 3 weeks after thread lifting
then resolved at 5 months due to ischemia of tension
anchoring process.
This current study approved that thread lift as
an antiaging procedure is simple, effective with
minimal invasive technique for mild and moderate
laxity of the face with little spontaneously resolved
side effects. This agrees with other studies [18-
22,25,28,29]. On the other hand, Abraham et al.,
2009 [33] reported a lot of complications and they
also found that the thread lift was unable to accomplish
the goal of long term results with less morbidity,
less downtime and greater patient satisfaction
probably because it needs special experience and
detailed knowledge of anatomy and the possibility
of aberrant or different pathway of some nerves
or vessels in some individuals. Also, the appropriate
good selection of patients with mild or moderate
face laxity and not to patients with marked laxity
and cutaneous hypotonicity.
Some studies encourage the use of thread lift
in combination with other procedure for better
results as Wu, 2014 [17] who made thread lift with
botox in the glabella, brow and lateral orbital
regions. Augmented effect of both as thread lift
induced tightness and firmness while botox relaxed
overactive contracting muscles and improved wrinkles.
Moreover, hyaluronic acid as a filler with its
viscoelastic properties and high-water retention
capacity fills out aging hollows of the face. Williams
and Smith, 2007 [34] preferred to do thread
lift in combination with lipotransfer as liposuction
utilized autologous fat as a natural filler for better
results of rejuvenation procedure.
