察爾斯大夫 美麗殿堂 Dr. Charles Meridien Palace

Barbed Sutures for Aesthetic Facial Plastic Surgery：Indications and Techniques（1）

Clinics in Plastic Surgery

Volume 35, Issue 3, July 2008, Pages 451–461

Facelifts, Part I

Malcolm D. Paul, MD, FACS

Aesthetic and Plastic Surgery Institute, University of California, Irvine, Suite 810, 1401 Avocado, Newport Beach, CA 92660, USA

This article describes the indications and techniques related to the use of barbed sutures in facial aesthetic plastic surgery. The principle applications for barbed sutures in facial aesthetic plastic surgery are those involving lifts of the brow, midface, and the lower face and neck. Usually all three areas require surgical maneuvers to create a harmonious rejuvenation. Regardless of where in the face bidirectional barbed sutures are planned, five essential steps are needed: (1) making the incision or incisions, (2) dissecting soft tissue, (3) proximal anchoring, (4) deploying threads, and (5) molding soft tissue.

Keywords

Barbed sutures; Brow-lifting; Midface-lifting; Lower face-lifting; Neck-lifting

Barbed Suture Lift

International Society of Aesthetic Plastic Surgery（ISAPS）

（http://www.isaps.org/techniques-and-risks-barbed-suture-lift.html）

Procedure :

These are non-surgical procedures whereby barbed sutures are inserted into the face to create a Lifting effect or a Tightening and Firming of the soft facial tissues. This is useful for those with Flabby faces or Aging of the mid-face, Jowls, Brow and Neck. Selective regional lifting is possible. Threads come in various configurations : Short, bi-directional threads (APTOS, Feather lift); or Long bi-directional slings (BARBED SUTURE LIFT), or Long uni-directional threads (Contour threads). Different threads create different effects (e.g., Firming vs. Lifting). These threads can be used in conjunction with traditional open facelift surgery or endoscopic techniques.

Length :

Approximately 30 to 40 minutes

Anesthesia :

Local anesthesia with or without light sedation.

Inpatient/Outpatient :

This is a simple outpatient procedure. The patient can leave immediately completion.

Possible Side Effects :

Temporary discomfort and pain in the temples or behind the ear. Post-operative swelling and bruising is minimal. Some patients experience difficulty in opening their mouth widely. Puckering or dimpling of skin and pleating usually fades within two to three weeks.

Risks :

Bleeding at the time of the procedure causing a hematoma (accumulation of blood) in the temple, infection of the threads, granuloma (suture reaction), snapping of threads, migration, extrusion, localized pain when thread end abuts against underside of the skin (which is easy to locate, shorten ,or remove completely). Collective risk of complications is 15-20%, but all are minor and easily corrected.

Recovery :

Patients look presentable after 24 to 48 hours. Occasionally, puckering and pleating may persist for several weeks.

Results :

These are excellent techniques for achieving a temporary facelift effect. The results last one to two years after which new threads need to be inserted to maintain or enhance the effect. These threads should be viewed in the same way as other temporary procedures and fillers such as Botox or temporary fillers where loss of result after a period of time is not considered a failure. Together with other non-surgical techniques such as Botox injections, Hyaluronic acid soft tissue fillers, and IPL（Intensed pulse light）, Laser therapy, or Thermage (the use of radiofrequency to tighen the dermis of the skin), the rejuvenation can be powerful but is temporary.

「埋線拉提」造逆齡肌搭配雷射緊實提升

【中時健康楊欣菲／台北報導】2013.09.10

　　今年將過40歲生日的美女林熙蕾，雖然已為人母，但身材依舊保持纖細，臉蛋絲毫看不出歲月痕跡。她分享個人凍齡養生術是生活作息規律，多運動、多休息、不熬夜，飲食講求均衡，不吃冰、不吃辣、晚上不吃水果。

　　林熙蕾的凍齡秘方看似容易，但想要見效，卻要恆心長久持續，現代醫學美容發達，許多人借助微整形的力量，讓變美變年輕的夢想更快速實現。美麗優品時尚診所陳雲堃院長表示，針對熟齡肌的鬆弛、皺紋、斑點等問題，目前也有4D天使線拉提及三波長拉提雷射搭配治療供選擇，可改善讓肌膚狀態，回復年輕光彩。

　　醫美埋線是在臉部鬆弛部位埋入心臟外科手術專用的PDO線，目前已進展至第四代，從第一代簡單的直線、逐漸演變到第二代的單螺旋線、第三代雙螺旋線，現在最新的4D天使線，線材構造上多了羽毛倒鉤的設計，對於增強拉提的效果較為顯著，民眾在進行療程前，也應多留意線材的選擇。

　　天使線埋入後一到兩個月開始持續刺激膠原蛋白增生，臉部肌膚緊實度越來越提昇，且因其倒鉤設計，能加強上下拉提的效果。天使線創造出來的肌膚緊實，不會像開刀拉皮那樣假假不自然，它有刺激膠原蛋白、增強微循環的多重作用，使臉部保有彈性且更加亮白。

　　有別於一般中醫減重埋線使用的羊腸線，吸收時間較短，只有7天，PDO線的吸收時間則將近8個月，由於線材吸收越慢，引起的發炎反應越低，越不容易引起發炎現象，且效期更長。

　　陳雲堃院長指出，天使線針對臉部鬆弛療效特別好，將天使線埋入夫妻宮位置，就能使眼角上提，雙眼皮更明顯，眼皮不再鬆弛。此外，天使線對頸紋改善的速度最快，目前低頭族越來越多，頸紋發生的年齡越來越早，愛美人士要提前預防。

　　由於早期雷射無法一次到位達到拉皮手術的肌膚繃緊效果，國外文獻指出，中高能量的多次治療效果優於高能量單次治療。因此，陳雲堃院長也研究並搭配出三種不同波長的拉提雷射，將三種超過700奈米的長波雷射同時打，同時刺激不同厚度的真皮層，來增強膠原蛋白增生的功效，約1個月1次，至少需持續半年，效果才會顯著。

　　除了改善臉部鬆弛，若還有斑點、色素沉澱、臉部泛紅等問題，則可搭配三波長拉提雷射，進行複合式治療。通常埋線之後，全臉追加1、2次三波長雷射搭配，60天後改善的程度都令患者感到滿意。

　　陳雲堃院長提醒，不論是使用天使線或是三波長拉提雷射，微整形的技術門檻其實相當高，需慎選經驗豐富的醫師進行。埋線下針的位置、拉提的方向、位置的深淺都是影響療效的關鍵，都需要靠經驗判斷，而經驗尚淺的醫師比較常用短線，療效就差很多。

Facial lifting with Aptos methods（5）

Factors Which Determine the Outcome of Success in Threadlift       

These various developments and the resultant experience have lead to elucidation of certain principles which determine the outcome of success in thread lifting. [4],[5]

These factors are：

1、Correct understanding of the Aptos lifting concept

2、Knowledge of topographic anatomy, especially anatomy of face

3、Consideration of the facial muscles kinetics

4、Knowledge of the pathogenesis of ageing and ptosis of soft tissues and

5、Correct determination of indications.

These factors are now further described in detail.

Correct understanding of the aptos thread concept

Prominences on threads are located in every 0.5 mm and each of them is responsible for its own tissue area. Number of prominences on each thread is about 20. This is why Aptos lifting is even and uniform along the line. This is the major difference of Aptos from classical and endoscopic lifting methods, where mobilized tissues（Skin, Subcutaneous Muscle Aponeurosis「SMAS」）are lifted and hung only to points fixed by stitches.

Knowledge of topographic anatomy

It is known that facial and cervical layers of soft tissues can be shifted relative to each other, but only in specific and different blocks and areas. For instance, it is easy to shift skin of lateral areas of the forehead, eyebrow tail, mental area, cheek and malar areas. At the same time, any attempt to shift tissues of the posterior area of the face above the malar bone and its arch perimeter is difficult since in this area the skin is closely tied to the periosteum.

Consideration of the facial muscles kinetics

It is not advisable to lift soft tissues in the active muscle area, especially vectorially; it would counteract the muscle work. Such areas need elastic lifting by Aptos Springs as outlined above.

Knowledge of the pathogenesis of facial ageing

It is well-known that soft tissues ptosis is of a focal nature; some areas sag more than others. Some areas are resistant to sagging as they are held up by bundles（raper points）of connective tissues, vessels and nerves. Therefore, it is logical to lift in places, where these anatomic formations do not create any impediments.

Correct determination of indications

The same methods shall not be advised to all and everybody. It is important to assess the suitability of different aesthetic techniques and then recommend the most suitable method or combination of methods applicable in a specific patient.

Choosing the Appropriate Method in Different Areas[1]

The different methods for face lifting for different indications are as follows：

For eyebrows

Aptos Thread method for mild light lifting

Aptos Thread 2G method for more stable lifting

For cheekbone areas

Aptos Thread method for mild lifting, elimination of plaintive furrow and creation of high volume

Aptos thread 2G method for more stable lifting

Aptos Needle method for additional stable lifting, elimination of plaintive furrow and creation of high volume

Aptos Needle 2G method for additional stable lifting, elimination of plaintive furrow and creation of high volume

For marionette lines：Aptos Spring method

For mental areas

Aptos Thread method（light lifting）,

Aptos Thread 2G method（more stable lifting）,

Aptos Needle 2G method（additional stable lifting）.

For sub-maxillary areas

Aptos Needle method,

Aptos Needle 2G method

Side Effects[4]

While threadlift is a relatively safe method, side effects can occur, particularly if all points described are not given proper consideration.

The possible side effects which are specific to threadlift include：

1、breach of threads due to unilateral weakening of prominences；

2、abruption of threads to the skin surface, their migration；

3、asymmetry, hyper-correction, thread visualization；[Figure 8]

4、linear haemorrhage along the thread；

5、retraction of the skin in entry and exit points of needles and；

6、short-term（up to 3 months）and unstable results.

In addition, other infrequent complications which may occur include inflammation of surrounding tissue, suppuration, damage to the parotid duct [Figure 9], branches of the facial nerve and regional nerve and vessels.

Results of Aptos are shown in [Figure 10],[Figure 11].

Figure 8. Exposure of the thread

Figure 9. Breach of the ductus parotideus

Figure 10. (A) Before Aptos, (B) After Aptos

Figure 11. (A) Before Aptos, (B) After Aptos

Conclusions      

Threadlift, as an anti-ageing procedure is gaining more popularity as it is a simple, minimally invasive procedure that can be done with local infiltrative anesthesia. Short healing time, reliable and long lasting effects and the possibility of combining with other aesthetic procedures such as Botox® , fillers, lasers, peels and liposuction are added advantages.

However, it should also be emphasized that threadlift is a relatively new procedure and like all new procedures, it requires further study and development, for proper evaluation.

References       

1.    Sulamanidze M, Shiffman, Paikidze T, Sulamanidze G. Facial lifting with APTOS Threads. International Journal of Cosmetic Surgery and Aesthetic Dermatology 2001;3:275-281.    

2.    Sulamanidze M, Sulamanidze G. Lifting of soft tissues: old philosophy, new approach - a method of internal stitching (Aptos needle). Journal of the Japan Society of Aesthetic Surgery 2005;42:182.    

3.    Sulamanidze M, Sulamanidze G. APTOS SPRING - a new concept of lifting. Journal of the Japan Society of Aesthetic Surgery 2005;42:183.    

4.    Sulamanidze M.A., Fournier P.F., Paikidze T.G., Sulamanidze G.M. Removal of facial soft tissue ptosis with special threads, Dermatology Surgery 2002;28:367-371.    

5.    Adamyan A, Skuba N, Sulamanidze M, Khusnutdinova Z. Morphological foundations of facelift using APTOS filaments, Annals of Plastic Reconstructive and Aesthetic Surgery, 2002;3:19-27.    

APTOS SPRING - A new concept of lifting

MA Sulamanidze, TG Paikidze, GM Sulamanidze

Akt Dermatol 2004; 30 - 81

Clinic of Plastic and Aesthetic Surgery, Total Charm, Moscow, Russia

Congress Abstract

The operation of rhitidoplasty is known not to allow carrying out an effective lifting of soft tissues of those facial areas that are maximally remote from the cut line, as well as those being in the zone of active action of the masticatory and mimic muscles. The APTOS THREAD method is not used on these areas, for the permanent muscular movement leads to destruction of the threads' cogs in the immediate postoperative period, with the resulting outcome being of short duration. To solve this problem, we have devised a new thread called APTOS SPRING which after being inserted Subcutaneously is capable of stretching and contracting simultaneously with the muscles involved. Along with it, the thread provides a good lifting effect, yielding excellent results that persist over time. The APTOS SPRING is a spring-like twisted polypropylene 2/0 or 3/0 thread which during the production process is exposed to a special treatment allowing it to possess springing properties. The little spring is reeled onto the injection needle sized 1.1×100mm or 0.8×90mm in the compressed condition. Prior to installation, the spring is elongated along the length of the needle to be thus inserted under the skin. After removal of the needle and slightly pulling up the spring, the leftovers are cut from the both sides, and the thread's ends - springs are buried under the derma. The APTOS SPRING, contracting, pulls up the ptosed tissues, and during the mimic, masticatory or other facial movements of the face, it elongates simultaneously with the muscles. We used the APTOS SPRING method for the first time in February 2003 for lifting the angle of the mouth and wrinkles of “mourning“ to be thereafter used on other areas of the face, as well. The operations are easy and rapid to perform, with no excessive operational wound and haemorrhage, with inconsiderably pronounced postoperative pain syndrome, absence of a cutaneous wound and scar, and a short rehabilitation period. Over more than one-year period, we have performed a total of 67 operations using this technique, to be accompanied and followed by invariably good and stable outcomes.

Facial lifting with Aptos methods（4）

The latest innovation in this series is the Aptos Needle 2G, which is more stable and radical than the previous Aptos Needle [2] . Aptos Needle 2G, has one thread with diverse prominences and two needles; these needles are double-edged and the thread is connected to them in the central area, as in case of the Aptos Needle [Figure 6].

Lifting of facial areas with active muscular movements such as perioral area presented special challenges. For such cases,（lifting of so-called sadness fold or jowls）, the principle of elastic lifting was developed in 2003. Elastic lifting is achieved by spring threads called Aptos Springs, made of polypropylene, which keep "memory". [3] Aptos Springs are able to lift and fix soft tissues and at the same time also stretch and contract together with muscles. The lifting effect of such springs is supplemented by fibrous tissue accrued around threads [Figure 7].

Facial lifting with Aptos methods（3）

However, in recent years（in 2002）we have returned to the idea of using a single product - a needle with thread, but the suggested suturing material was different from previous modifications by two needles to which one thread end was attached; the thread had diverse prominences and needles were paired by temporary commissure; thus their spikes would constitute a single point. Such device allowed for double increase of the thread lever and, therefore, allowed for increase of power and lifting stability. The idea of paired needles and new surgery techniques was an important innovation, which allowed for positioning threads without cuts, via simple puncture, since surgeons received an opportunity to introduce two needles with a single point, split them subcutaneously at the needed depth and pull them in different directions afterwards. This method of surgical invasion and the relevant product was called the Aptos Thread [Figure 4].

It was later noticed that in some cases of rejuvenation and lifting surgeries, the threads with prominences alone, did not always lead to desirable long-lasting outcomes and additional lift and suture by smooth threads was also needed. Therefore, in the next stage of our research, a double-edged needle with the smooth suturing thread, attached to the needle in its central area - called Aptos Needle was created in 2003. This thread allows for double patency and also ensures introduction of the thread underneath the skin and subcutaneous suturing of soft tissues, without a skin retraction or a lifted stitch [Figure 5]. Further Aptos Needle modifications allowed for development of effective non-invasive aesthetic surgeries for suturing and lifting of soft tissues of the cheek, submaxillary and cervical areas（2003）, chin, ptotic breast（2004）and slack shoulder tissues（2005）.

Facial lifting with Aptos methods（2）

The early threads were threads with unilateral prominences, which were attached to a long needle. According to markings made on the skin, we would pull several threads subcutaneously through the small cut in the temporal region, where the lower remainder of the thread together with the needle would be cut off after pulling it out off the skin and the upper end after moderate lifting would be sutured to the fascia of the temporal muscle [Figure 2]. The same method was used to lift soft tissues of the sub-maxillary and cervical areas with fixing the upper end of the thread to the periosteum of the mastoid. These methods were not fully satisfactory, the results were not long-lasting and also required cuts.

Later, a needleless thread was created; it had converging prominences and could be introduced subcutaneously through a conducting needle; it also needed a more simplified manipulation, without needing a significant incision [Figure 3]. Accordingly, the optimal skin marking was developed for each area of the face, with full consideration for different anatomical, functional and pathological features of the different areas and pathologies. This technique of thread lifting became popular very soon and came to be called the Aptos Thread.

Facial lifting with Aptos methods（1）

M. Sulamanidze, G. Sulamanidze

Clinic of Plastic and Aesthetic Surgery, Total Charm, Tbilisi, Georgia

REVIEW ARTICLE      

Journal of Cutaneous and Aesthetic Surgery

Year : 2008 | Volume : 1 | Issue : 1 | Page : 7-11

Abstract     

Face lift hitherto had been a complicated and elaborate procedure. The introduction of threads to lift skin has been a major advance in lifting sagging skin. These threads which have barbs on their surface have simplified the procedure and have the possibilities of combination with other rejuvenation procedures. The article traces the evolution of threadlift.

Keywords : Aptos, facelift, threadlift

How to cite this article :

Sulamanidze M, Sulamanidze G. Facial lifting with aptos methods. J Cutan Aesthet Surg 2008;1:7-11

How to cite this URL :

Sulamanidze M, Sulamanidze G. Facial lifting with aptos methods. J Cutan Aesthet Surg [serial online] 2008 [cited 2013 Sep 10];1:7-11. Available from: http://www.jcasonline.com/text.asp?2008/1/1/7/41149

Introduction     

Accumulated experience of past years with aggressive and serious invasive surgeries for face lifts, with their resultant complications have lead to research about finding answer to one question: Is it possible to lift soft ptotic tissues in lesser volume as well as less radically, with rather smaller scale invasion? We have been seriously dealing with this problem since 1988 and describe here the evolution of this minimally invasive face lift method.

Early years：Here are the main objectives that we first set to ourselves：

to conduct research for the possibility of shifting various layers of soft facial tissues between each other or entirely, without cuts and surgical mobilization.

to examine possibilities of reducing skin space, its retraction and adaptation without excision.

to develop a new technique of low invasion surgery and manipulation as well as materials and tools for conducting such interventions.

to study the results of such invasion and create new refined methods.

The very first thing that we decided to do was - to uplift the eyebrow tail. For that we have used thick silk, which we have pulled subcutaneously with the regular long needle and in the area of the temporal fascia. But methodology turned out to be unsound due to necessity of making a incision to visualize the temporal fascia, impression on the skin of the needle entry and exit points, presence of only one vectorial direction of tension leading to fast weakening of the bundle, sliding of tissues along threads and as a consequence, short-term results (1-3 months).

However, this preliminary experience provided evidence that layers of soft tissues shifted easily and skin, despite its rugosity, gradually fell out during first days after the surgery.

Another important observation was that short-term and weak effect of lifting was due to the fact that soft tissues were involved in only three points of stitches.

These observations encouraged us towards the idea of creating threads with prominences, which would be able to provide equal, multi-point linkage with subcutaneous tissues on its entire length.

Threads with prominences have been used for a very long-period of time - for suturing sinew（ligament, tendon, muscle）and wound edges; however, doctors of our clinic were the first to introduce threads with prominences for continuous suturing of surgical wounds and proposed them for lifting of flabby, ptotic soft tissues, as well as for rejuvenation surgeries. We called such threads Aptos（anti-ptosis）[1] . The first threads with incisions（Aptos Suture）for suturing operational and traumatic wounds with continuous stitches were introduced in 1998 [Figure 1].

Later the same name was adopted to all products and technologies of non-invasive lifting, which were developed and introduced by us into practice.

APTOS suture lifting methods：10 years of experience.

Sulamanidze M, Sulamanidze G.

Clin Plast Surg. 2009 Apr;36(2):281-306,

viii. doi: 10.1016/j.cps.2008.12.003.

Source

Department of Plastic and Reconstructive Surgery, Central Hospital No. 165, 3rd Administration of the Russian Federation Health Ministry, Tbilisi, Georgia.

Abstract

Over the past decade we have developed and successfully used methods of minimally invasive aesthetic surgery, based on special threads provided with microscopic angled barbs (Aptos Thread), double-pointed needles (Aptos Needle), and elastic needles (Aptos Spring). This article describes our original techniques of subcutaneous suturing through and lifting of soft tissue, which make it possible to obtain qualitative, sufficiently long-standing lifting of the face and neck with no cuts or with tiny cutaneous incisions. Our 10-year experience in using the Aptos methods has demonstrated that these are simple, safe, and efficient techniques for rejuvenation of the face and neck.

Barbed Sutures in Facial Rejuvenation

Woffles T. L. Wu, MD

+ Author Affiliations

Singapore, is a plastic surgeon.

Reprint requests : Woffles Wu, MD, One Orchard Boulevard, Suite 09-02, Singapore 249615.

Abstract

Self-retaining barbed sutures, innovations for nonsurgical facial and neck rejuvenation, are currently available as short APTOS® threads or long WOFFLES® threads. The author uses APTOS threads for malar rounding, facial tightening and firming, and uses WOFFLES threads as a sling, suspending ptotic facial tissues to the firm, dense tissues of the temporal scalp.

Outcomes in Thread lift for Facial Rejuvenation

Garvey, Patrick B. MD*; Ricciardelli, Edward J. MD†; Gampper, Thomas MD*

Annals of Plastic Surgery : May 2009 - Volume 62 - Issue 5 - pp 482-485

Southeastern Society of Plastic and Reconstructive Surgeons

doi: 10.1097/SAP.0b013e31818c18ed

Abstract

The search for less invasive surgical techniques to address the effects of facial aging led to the development of barbed polypropylene sutures for facial suspension. Theoretical advantages of these “threadlifts” included limited scarring, rapid recovery, relative safety, and reduced cost when compared with a standard rhytidectomy. The goal of this study was to evaluate the outcomes of patients undergoing threadlifts to determine the actual complication rates, the durability of results, and the rates of reoperative surgery. A single surgeon's initial 2-year experience with 72 patients undergoing threadlifts was retrospectively reviewed. Preoperative patient demographical and clinical data, operative information, and postoperative outcomes data were compiled and evaluated.

A total of 72 thread lifts were performed by 1 surgeon over a 24-month period. Of these patients, 76% underwent threadlift alone, whereas concomitant procedures were performed in 24% of patients. Minor complications were common and usually self-limited. Forty-two percent of patients underwent a secondary procedure after primary threadlift, an average of 8.4 months after the original surgery. Thirty-one percent of patients required revisional surgery for cosmetic reasons an average of 8.7 months after their threadlift. Eleven percent of the patients ultimately required removal of palpable threads.

Threadlift is a safe procedure associated with minor complications. Rates of Revisional surgery for cosmesis are high after threadlift. Time to revisional surgery for cosmesis is short. Results achieved by threadlift are subtle and short-lived. Threadlift is not a minimally invasive replacement of surgical rhytidectomy. Patients should understand the limitations of this technique and its high rates of revisional surgery.

Use of barbed threads in facial rejuvenation（5）

Recovery

Proper postoperative instructions must be given to reduce the risk of complications during recovery.

These instructions include：

1、Limited activities should be done for at least 24 hours.

2、Diet restrictions should be followed e.g. soft foods for seven days.

3、Pain can be managed with oral medications such as Acetaminophen.

4、Ibuprofen is avoided to limit bruising.

5、Though asepsis is strictly adhered to, it is preferable to give Antibiotics for a period of five days as this is, after all, an insertion of a foreign body.

6、Recommend elevating the head on the first day to reduce swelling.

7、The day following the procedure, the patient can resume non-strenuous activities, and all normal activities can usually be resumed within seven days.

8、Social situations are to be avoided for up to one week - three weeks for weddings, reunions and other formal occasions.

Postoperative care

1、Swelling and Bruising can be prevented by ice packs.

2、Movements are strictly restricted by taping the face, especially the area that has been operated. This is best advised for about a week.

3、Sleeping on the sides with the face against the pillow, can undo the effect of the procedure. Hence the patient is advised to sleep on the back for a week. Avoid excessive mouth opening and massage of any kind for three weeks.

Risks and complications and their management [4]

1、The thread lift is a relatively new procedure, and its techniques are still being developed. Results have varied greatly among patients, but continue to improve.

2、A significant risk of the thread lift procedure is that one may not notice any improvement.

3、Asymmetry is a very bothersome consequence. One has to carry out the procedure with great precision, from noticing pre-procedure asymmetries, to perfectly balanced markings, to ensuring the symmetry with the patient's consent before cutting off the ends of the thread.

4、Some thread lift patients with thin skin have reported that the sutures became visible under the skin shortly after the procedure. Rippling can persist for long. The surgeons need to be aware of this problem, and have to be careful while inserting the thread so as to keep it at the optimum depth. This does require some experience, and hence there is a learning curve for this.

5、Some patients experience a lack of sensitivity or numbness in the treated area, which usually subsides within weeks of the procedure.

6、Infection in the treatment area is an infrequent complication. If an infection develops, treat it with antibiotics. Rarely, an infection may require surgical drainage. Scar tissue formation is also possible. The knot of the thread in the scalp can cause formation of granulation tissue, bleed and be palpable. Sometimes, Hair roots are pushed in deep, leading to hair sinuses and inclusion cysts.

7、Some surgeons have noted rare Migration or even total Extrusion of the sutures, causing an unbalanced facial appearance. With this, or if the thread breaks, a simple reinsertion solves the problem. If a very large bore cannula has been used to place bi-directional threads, then the track created is also very large-sized, and this can lead to an early extrusion of the thread [Figure 7].

Some clinical cases of Thread Lift [Figure 8].

Figure 7a: Hair sinus at site of entry Figure

7b: Hair root entangled within the knot of the thread Figure

7c: Unilateral puckering of skin requiring correction Figure

7d: Rippling caused by too superficial placement of thread Figure

7e: Crusting at the site of entry of thread Figure

7f: Infection causing extrusion of threads Figure

7g: Before Thread Lift Figure

7h: An extreme grade of rippling immediately following thread lift. The author had to undo the procdure

Figure 8: (a) Sagging cheeks (b) After Cheek Lift with two Bi-directional threads each side

Figure 8: (c) Before profile improvement, (d) Besides rhinoplasty and chin augmentation, this girl was given a minimal, subtle cheek lift with threads only

Figure 8: (e) Sagging cheeks and jowls (f) Cheek Lift and Jowls Lift by two pairs of Contour Threads. each side (Other procedures done were lip augmentation/ chin augmentation and blepharoplasty)

Figure 8: (g) Sagging Cheeks (h) Ogee curve created with Cheek Lift by Threads

Figure 8: (i) Before Lift (j) After Thread lift, producing high cheek bone effect and reducing smile lines

References       

1、Khazanchi R, Aggarwal A, Johar M. Anatomy of ageing face. Indian J Plast Surg 2007;40:223-9.    

2、Wu WT. Barbed sutures in facial rejuvenation. Aesthet Surg J 2004;24:582-7.    

3、DeLorenzi C. Barbed sutures: Rationale and technique. Aesthet Surg J 2006;26:223-9.    

4、Paul MD. Complications of barbed sutures. Aesthet Plast Surg 2008;32:149.    

Use of barbed threads in facial rejuvenation（4）

Uni-directional threads

Such threads are always placed in pairs. An equilateral triangle is marked in the temporal area, with its base parallel to the hair line, and the apex positioned more posterior. From the two corners of the line forming the base of the triangle, the uni-directional threads on their long needles are inserted, both parallel to each other, advancing at the same Sub-dermal depth and in a Sinuous manner, to points stopping just short of the smile lines [Figure 5].

The two threads in the temporal area are then brought out together from the third apical point, with the help of the curved cutting needle attached to the tail of the thread, this time taking a very deep sub-temporal fascia bite. At this exit point, they are tied together, and the knot buried under the skin, so as to ensure that it is not palpable.

The threads at the smile line are left about an inch long, taped and the patient sent over to the recovery room. Once the patient has overcome all effects of any anaesthesia, maybe even on the second day, she is called back to help in the actual lift. While she holds up the mirror and watches herself, the surgeon holds the end of the thread firmly down and pushes the skin of the cheek back over it, gradually deploying more and more barbs. This is done to a desired effect, to which the patient consents. Once both sides are done, both the patient as well as the surgeon agree to the extent of the lift as well as symmetry, etc. Only then are the free ends actually snipped close to the skin. The area from the temporal area down to the cheeks is taped, in an upward supporting style, to prevent the patient from over animating and undoing the effect of the thread lift. These tapes are preferably left in for about a week [Figure 6].

Figure 5a : Parallel markings for a pair of threads for jowl lift

Figure 5b : Zigzag manoeuvre to advance the barbed threads engaging maximum tissue（Picture courtesy Contour®）

Figure 6a : Deployment of the two threads by pulling the thread down and pushing the skin up, to the desired level

Figure 6b : Taping at the end of the procedure to prevent undoing of the lift till some fibrosis occurs

Use of barbed threads in facial rejuvenation（3）

Candidates for Thread lift

Right candidates

Ideal candidates for thread lifts include people with Minimal signs of ageing who need just a small lift. Usually, these are women between 35 and 45. The threads are indicated because these patients have begun to see more prominence of the jaw, a relaxed or minimally sagging mid-facial appearance or slight bags under the eyes or on the neck.

Older people may be advised to undergo a thread lift during the more aggressive facelift procedure to provide additional support for the soft tissue area that was elevated in the facelift.

Other thread lift candidates include those who have had some relapse from a previous procedure such as a facelift or neck lift.

Ideal patients are also those who understand and accept the possibility of the risks and complications outlined below, who understand the limitations of these threads, have realistic expectations and who are prepared to follow the post-operative regimen.

Poor candidates

Those patients who have excessively sagging skin at an advanced age will show a very limited improvement.

Those patients who are obese, or have very heavy, rugged skin too will show no improvement.

All other contraindications of implants, etc. also hold good here, like Multiple skin allergic reactions or infections, Dandruff, Hair lice, Immunologically compromising diseases like cancer/ HIV etc., Systemic diseases like diabetes, tuberculosis, etc.

Surgical procedure

Bi-directional threads

A classical example of their use is to lift the cheeks.

The anaesthesia chosen differs depending upon the patient, the surgeon and any associated procedures. When several other procedures are being done simultaneously, one can choose a general anaesthesia. When a lunch time thread lift alone has been planned, only a local anaesthetic can be infiltrated along the expected track. At most other times, if the patient is willing for a longer day care stay, twilight IV sedation with local anaesthetic is given. The last is the author's most preferred method.

A spinal needle is inserted under appropriate anaesthesia from the pre-tragal area, in a curved direction to a point below the cheek, and then up again towards a point stopping just short of the smile line. As this needle is advanced, it is actually progressed in a Sinuous manner, moving the needle tip from side to side. Also, the depth of the needle is at all times maintained At the same Sub-dermal level, gliding just Above the Fat layer.

A similar needle is passed about one to one and a half centimetres above this line. Through the two needles, the bi-directional threads are inserted, making sure the thread and its barbs do not get 'caught' and do not damage.

Once the thread has been passed through, it is positioned such that the centre of the thread gets placed in the centre of the track. Once done, the needle is slowly withdrawn. The tissue can be 'gathered' over the thread, and once the desired effect has been reached, the long ends of the thread are then cut off [Figure 4].

Figure 4a : Defining the lowermost cheek point

Figure 4b : Marking the cheek curve

Figure 4c : Ensuring bilaterally symmetrical markings

Figure 4d : Inserting the spinal needle along the curve

Figure 4e : Thread firmly fixed, now does not budge on traction in either direction

Figure 4f : Thread snipped close to the skin

Use of barbed threads in facial rejuvenation（2）

Types of threads

A large number of manufacturing companies, pioneers of thread lift and surgeons worldwide have their own patents as to not only the design of the threads, but also the minor variations of method of deploying them. However, essentially, there are two types of barbed threads which are available. These are :

Bi-directional threads, with no anchoring points, inserted within a hollow needle and placed in such a manner that the thread cannot move either way because of the two-way direction of barbs fixing it nicely. Examples are the APTOS® threads.

Uni-directional barbed threads, which are anchored at a higher level fixation point. Examples are the Contour® and Silhouette® threads [Figure 2],[Figure 3].

Figure 2：Bi- directional Barbs（Courtesy APTOS®）

Figure 3：Uni-directional Cogs（Courtesy Silhouette®）

Use of barbed threads in facial rejuvenation（1）

Rakesh Kalra

Dept. of Cosmetic & Plastic Surgery, Ashirwad Hospital, Ashirwad Enclave, Dehradun-248 006, India

Indian Journal of Plastic Surgery

Year : 2008 | Volume : 41 | Issue : 3 | Page : 93-100

Correspondence Address:

Rakesh Kalra

Ashirwad Hospital, Ashirwad Enclave, Dehradun-248 006 India

PMID: 20174549

Abstract     

Use of barbed threads, available with uni- and bi-directional cogs or barbs, is a semi-invasive method of lifting sagging skin of the face. Areas treated with this method include the eyebrows, the cheeks, the jowls and the neck. Ease of use and a shorter down-time have made their use popular. Specific indications, operative procedures, risks and complications are described and some clinical results of the author shown.

Keywords : barbed threads, barbs, cogs, thread lift, facial rejuvenation, APTOS, SILHOUETTE, CONTOUR

How to cite this article :

Kalra R. Use of barbed threads in facial rejuvenation. Indian J Plast Surg 2008;41:93-100

How to cite this URL :

Kalra R. Use of barbed threads in facial rejuvenation. Indian J Plast Surg [serial online] 2008 [cited 2013 Sep 9];41:93-100. Available from: http://www.ijps.org/text.asp?2008/41/3/93/43605

Introduction     

As we age, our facial support structure weakens, and we lose facial fat. The affected areas generally include the cheeks, the eyebrows and other areas around the eyes, the jowls and the neck. The result is a longer, older-looking face. As the skin ages, the connective tissue in the skin becomes thinner. The elastic fibres in the skin undergo a type of "breakdown". The face thus loses some of its elasticity. The lack of elasticity brings with it the departure of certain face-shaping supports. The face begins to "sag" and "wrinkle". Younger people may experience cheek and brow ptosis (sagging, here caused by weakened muscles) as well. [1]

For these people especially, a thread lift may be a good alternative to the more invasive procedures necessary to correct problems in older people's faces. Thread lifts emerged recently because many people would like a facelift, but can't afford it or don't want the long recovery time of the standard facelift. It is, perhaps, better considered as a lesser, or preliminary procedure. Thread lifts cost less and require less downtime for many people. Some surgeons promote the thread lift as a "lunchtime lift" or "weekend facelift." Usually it can be performed in about one hour.

Place of barbed threads amongst the spectrum of procedures for non-surgical facial rejuvenation

A wide variety of procedures are being offered these days as non-surgical modalities for facial rejuvenation. These are :

Botulinum toxin, which has a temporary effect lasting only three months.

Fillers, which are limited to providing only limited volume and also last for about one to two years.

Radio frequency which is limited to treating only very superficial wrinkles.

Mesotherapy, which deposits so-called useful chemicals just under the skin, supposedly enhancing their utility in rejuvenating the skin colour and tone.

Cosmetic camouflaging which is only a temporary measure to look good.

The thread lift provides an actual 'lift', and is a semi-invasive procedure. It has a long-lasting effect and in a milder form matches the effect of brow lift or a lower face and neck lift.

The Dynamics of Thread lift

Barbs along the thread act as cogs to grasp, lift and suspend a relaxed facial area. The barbs open like an umbrella to form a support structure that lifts the sagging tissue. These barbs under the skin also tend to gather tissues to fill out and lift the cheeks and sagging skin.

Barbs on the thread grab hold of skin tissue. This creates tension in the thread, and the tension lifts the skin tissue. Collagen formation occurs around the threads and their cogs or barbs, producing an increasing effect [2],[3] [Figure 1].

Figure 1 : Histological slide showing collagen deposit around the thread and its knots (Source-Product Presentation .Silhouette Lift Sutures Suspension System. by Roberto Pizzamiglio M. D., Marbella-Spain and Franco Perego, M. D., Monza-Italy.)

Avoiding Complications with Aptos® Sutures

Marlen Sulamanidze, MD, PhD

George Sulamanidze, MD, PhD

Ivan Vozdvizhensky, MD, PhD

Constantin Sulamanidze, MD

Drs. Marlen Sulamanidze and George Sulamanidze are plastic surgeons in private practice in Moscow, Russia

Dr. Vozdvizhensky is Chief of the Department of Plastic and Reconstructive Surgery, Central Hospital No. 165, Third Administration of the Russian Federation Health Ministry, Moscow, Russia

Dr. Constantin Sulamanidze is a resident in plastic, reconstructive, and aesthetic surgery at the B. V. Petrovsky Research Scientific Center, Moscow, Russia

Drs. Marlen Sulamanidze, George Sulamanidze, and Constantin Sulamanidze are also co-owners of Aptos Ltd., Moscow, Russia

Dr. G. Sulamanidze, V. Orbeliani Str, 18, 0105, Tbilisi, Georgia. E-mail: gracia@aptos.ru

Abstract

Background :

Over the past decade, several methods of minimally-invasive thread-mediated lifting have been widely adopted in aesthetic surgery. Early use of these methods met with great enthusiasm, and thread lifting was often performed without sufficient regard for proper indications, controls, or outcomes. Soon after, reports of early-relapse ptosis, complications, and other undesirable side effects began to appear in the literature.

Objectives :

The authors describe the current best practices associated with thread lifting to ensure proper use and improved results.

Methods :

The authors retrospectively reviewed their collective case data, analyzing the results of 12,788 face and neck thread lift procedures in 6098 patients over 12.5 years.

Results :

The data showed inconsistent results and early relapse of deformity with the Aptos Thread and Aptos Thread 2G methods. Complications included thread visibility, migration, and exposure; Linear bleeding along the needle course; Skin dimpling; Hypocorrection and Hypercorrection; Transient paresthesias; and a small number of cases of injury to major Vessels, Nerve branches, and Parotid capsule/duct. As new devices were developed and the indications for each technique refined, soft tissue suspension became more effective and durable, and the incidence of complications correspondingly decreased in the latter part of the series.

Conclusions :

Thread lifting is a relatively modern trend in aesthetic surgery that demands a similarly novel approach from surgeons. When performed properly, thread lifting is associated with minor and infrequent complications and is a helpful clinical alternative to traditional facial rejuvenation techniques.

Complications of facial suspension sutures.

Eric R. Helling, MD,

Anire Okpaku, MD,

Peter T. H. Wang, MD, DMD and

Richard A. Levine, MD, DDS

Aesthet Surg J. 2007 Mar-Apr;27(2):155-61. doi: 10.1016/j.asj.2006.12.005.

（http://www.ncbi.nlm.nih.gov/pubmed/19341641）

Source

University of Texas Health Sciences Center, San Antonio, TX, USA.

Abstract

BACKGROUND :

Barbed suture suspension has gained popularity as an inexpensive, “non-surgical” facial rejuvenation procedure. Initial studies on this procedure have reported minimal complications.

OBJECTIVE :

In this article, we review and evaluate several cases involving complications resulting from barbed suture suspension.

METHODS:

Four case histories of patients who required removal of suspension sutures because of symptomatic suture, failure, settling, or infection are summarized. The suspension sutures involved were examined after removal and compared to suture withdrawn through bovine muscle.

RESULTS:

Two patients reported chronic foreign body sensation. One patient had facial weakness. One patient had obvious dimpling. One patient had localized infection resulting from suture placement. On removal, the barbs on the suspension sutures appeared to be reflected Against the direction of lift. Additionally, some sutures were clearly Mobile. Forced withdrawal of new suture through bovine muscle did not result in similar anteversion of suture barbs. This would suggest the barb orientation noted at surgery was not the result of the removal process. Identification can be difficult, as the suture in some cases is clear. Once the sutures had been identified, they were easily pulled out without the need for additional surgical access.

CONCLUSIONS:

Suture suspension may gradually fail due to Eversion of suture barbs or Migration through tissues. Although the complication rate for this technique has been reported to be low, we believe that surgeons performing this procedure should be aware the rate may be higher than indicated in the literature.

童顏針讓女神變形？線提拉融合穴位抗老不露餡

【中時健康趙欣／台北報導】2013.09.09

44歲的王菲跟46歲的王祖賢，最近傳出施打「童顏針」整形，近日周刊拍攝到王祖賢變得鼻高臉腫，而王菲原本凹陷的臉頰則顯圓潤豐滿，雖然傳言都未得到當事人的證實，但這種「顯而易見」的改變，確實會讓想利用醫美技術低調變美的人士，心中有了些疑慮。

想要不著痕跡的變年輕變漂亮，緊緻的臉部線條是一大關鍵。配合每個人不同的狀況與條件，醫學美容其實提供很多種方式可以選擇。例如目前很流行的來自韓國的線提拉術，利用比頭髮還細的手術縫線PDO，埋入身體的再生細胞層，針對臉部鬆弛的皮膚與肌肉提拉，同時促進膠原蛋白增生，讓臉部更有彈性。

雅得麗生活診所醫美部主任醫師楊定宇表示，想像輪廓是一棟建築，要有鋼筋跟水泥才能穩固，早期只有使用玻尿酸跟微晶瓷來填補，就如同建築架構中只灌入水泥般，現在希望結構更穩妥，因此加上線提拉術，在皮膚基底中做出猶如建築中鋼筋般的支架。而源自韓國的線拉提術進入台灣之後，經過創新改良，融合中醫的穴位埋線原理，對已經有初老徵象，尤其恐懼開刀，不希望進行手術拉皮者，是十分適合的一種非手術拉皮方式。

中西醫美合併發揮加乘妙效，楊定宇醫師指出，原本韓國的線提拉術只負責處理鬆弛的部位，加入中醫概念後，將線埋入改善臉部浮腫或皺紋的穴位上，持續刺激：像是針對眼袋刺激承泣穴，臉頰容易浮腫就刺激頰車穴，頸部容易浮腫就可以刺激承漿穴，藉此達到相輔相成的作用。

原本中醫針灸需要一週進行2到3次才能維持效果，現在將醫學美容融入中醫穴位治療，同時提拉與持續刺激穴位，過一段時間就會發現穴位回春、瘦臉、消水腫、去紋路等多重成效。

楊定宇醫師說明，只要下針位置精準，技術愈好的醫師，能利用越少的線達到成效，基本上半臉用不到10條線，甚至3到4條就有不錯的效果。醫師表示，線提拉術除了結合玻尿酸跟微晶瓷，也有醫師會安排在線提拉療程前去打電波拉皮，都能增強一定的提拉效果；另外一種透過將針接電的方式，在送線進入皮下的過程中同時放電，原理類似中醫的電針，讓肌肉接觸到微電流時收縮，讓線更緊密的放置在皮下，更強化固定結構，重回年輕面容。

（中時健康：http://health.chinatimes.com/contents.aspx?cid=2,20&id=16890）