OPINION

Dermal threads are a versatile appliance in the toolbox of aesthetic medicine practitioners. Dr Gulhima Arora shares all we need to know about threads – from the history, evolution, types, and possible complications in usage.

Dr Gulhima Arora

The last decade has seen a renewed interest in dermal threads among both doctors and patients. Dermal threads can lift, contour, rejuvenate, volumize and certain types of threads can even produce lipolysis. A good understanding of the techniques of insertion are key to a satisfying clinical outcome.

HISTORY OF THREADS

The history of dermal threads dates back to the 1990s when Professor George Sulamanidze introduced the Antiptosis Suture (APTOS), which was a bidirectional barbed thread for ptotic skin. In 1992, the ‘Contour threads’, which are barbed polypropylene threads were introduced by Prof. George Ruff. In 2010, the Koreans launched the polydioxanone sutures and since then, many studies are being carried out the world-over, to improve on the existing technology, techniques of insertion, and material ued for dermal threads.

TYPES OF THREADS

Broadly they may be classified as:

• Non-absorbable, like nylon or polypropylene

• Absorbable, like polydioxanone (PDO), Poly L-Lactic acid (PLLA) or Polycaprolactone (PCL)

They may also be free-floating or anchoring threads. The anchoring threads are used for lifting and contouring, and the free-floating are used threads as rejuvenation threads or as helpers to the former.

Mono threads are single filament, smooth threads. They are mostly used for tightening and rejuvenation and not for lift. Screw/Tornado threads, which are single or twin filaments, are wound around the delivery system. They are used like mono threads having a stronger action. They are better in volumizing sunken areas. Cog/barbed threads are threads with barbs cut or moulded into the main filament. These barbs are uni/ bidirectional and have a greater lifting and anchoring effect.

Dermal threads are used on the face, neck, and body to lift, contour, tighten and rejuvenate.

Aesthetic doctors generally prefer to use absorbable materials; the different materials used are:

• PDO: Have been around the longest. They last for six to eight months and get absorbed fully after that.

They have a good flexibility causing patient’s only slight discomfort.

• PLLA: These last up to 18 months. They have a low flexibility and cause patient’s quite a bit of discomfort.

• PCL: Threads last up to two years and cause almost no discomfort. They have a high flexibility.

THE EVOLUTION

• First generation: Non-absorbable, Aptos, Serdev

• Second generation: Non-absorbable, Goretex, Polypropylene

• Third generation: Absorbable, PDO Mono, Screw, Cogs (Barbed), PLLA, PLGA, Silhouette soft

• Fourth generation: Absorbable, PCL, PDO press cog (Concertina Design), Cavern Screw non-absorbable elasticum

• Fifth generation: Absorbable, shape memory thread

• Sixth generation: Absorbable, solid state HA thread

MECHANISM OF ACTION

Dermal threads cause an immediate action due to the mechanical traction of the threads when using lifting threads. But, the main mechanism of action is the activation of the reparative process, stimulating the mesenchymal cells to produce collagen and elastin fibers.\ Numerous histopathological studies on skin with thread insertion have proved that there is a capsule of chronic inflammatory cells that form around the inserted threads. They also stimulate angiogenesis. The threads are also biostimulatory and continue their action even after their absorption.

Thread vectors for thread insertion for face lift

INDICATIONS

Dermal threads are used on the face, neck, and body to lift, contour, tighten and rejuvenate. They can be used for the following areas

• Ageing face: Lifting, volumising, rejuvenating

Yongtrakul P, Sirithanabadeekul P, Siriphan P. Thread Lift: Classification, Technique, and How to Approach to the Patient. World Acad Science, Engineering and Technology International Journal of Medical and Health Sciences 2016;10:547-55

• Breast Ptosis

• Ageing neck: Double chin reduction, wrinkle attenuation

• Alopecia (androgenetic)

• Periorbital rejuvenation: Eye bags, brow lift, wrinkles, tear trough

• Limb toning

• Muscle relaxation

• Hip-up

• Cellulite reduction

• Pain relief

• Stretch marks

The indications on the face that they can be used for are:

• Forehead: Wrinkling, contouring

• Eyebrow: Lifting and shaping

• Nose

• Mid-face: Nasolabial fold, cheek, lift and contouring

• Lower Face: Marionette line, jowl, jaw

The 5 Rights

I propose ‘The 5 Rights’, which are essential for an optimum outcome of the procedure. 3

1. Right patient: An ideal patient is between 30-50 years of age, with mild-moderate sagging and realistic expectations.

2. Right knowledge: The relevant anatomy pertaining to the area, is important to give the desired result and avoid complications.

3. Right technique: The anchoring points and insertion techniques should be correct.

4. Right thread: It is important to decide the number, material, size and delivery.

5. Right orientation: The vectors should be marked and followed keeping the aesthetic balance of the face in mind.

Vectors for full face lift

Dr Jacques Otto 5-point full face lift

Techniques

A good knowledge of the superficial fat pads and retaining ligaments is essential for the aesthetic doctor. The correct plane of insertion in the superficial fat pad is key for a correct outcome. The retaining ligaments, true or false, are used as anchoring points for lifting sutures.

Practical Tips from the Author

•A cross-hatched technique can be used to fill or rejuvenate.

Techniques of thread insertion

Vectors for thread insertion for breast ptosis

Vectors for thread insertion for cheek lift

Yongtrakul P, Sirithanabadeekul P, Siriphan P. Thread Lift: Classification, Technique, and How to Approach to the Patient. World Acad Science, Engineering and Technology International Journal of Medical and Health Sciences 2016;10:547-55

•A fanning technique can be used when lifting.

• Parallel inserting technique can be used for contouring, e.g., neck, jawline, eyebrows. Helper threads can also be inserted parallel to each other.

Correct anchoring is important while using lifting threads. Anchoring can be of two types:

• Hard Anchoring: Here, threads are anchored to the deep temporal fascia or periosteum. There is pain and discomfort. The threads easily break down.

• Soft Anchoring: Utilises retaining ligaments, dense fibrotic tissues, and subcutaneous tissue. It is less painful with less discomfort. It maintains the effect longer.

Using the same entry point made in the area of a retaining ligament, in order to insert two or three threads, helps in better fixation and longevity. Knotting, twisting, using a ‘U vector’, and looping the threads to insert them are a few anchoring techniques.

Using the right orientation or vectors is of utmost importance. Refer to the vectors for thread insertion in the figures.

Anesthesia

Monofilaments can be inserted without any anesthesia with minimal discomfort. However, a topical anesthetic may be applied 45 minutes prior to the procedure. Lifting threads need anesthesia at the entry points or along the entire track of the vector. Some doctors also give a tumescent anesthesia in the entire area.

Techniques used for thread insertion - (A, B) Crosshatch; (C, D) Hammock; (E) Linear threading 

Complications

Most of the studies show that thread lifts come with few side-effects and complications. A few complications that are unique to the procedure are:

• Migration of threads

• Extrusion of threads

• Visible threads

• Puckering and dimpling at the entry point.

• Folding of skin in an area distal to the lifting suture.

• Asymmetry

• Rarely, granulomas, hematomas and nerve damage can occur.

Dermal threads are a useful tool in the armamentarium of aesthetic doctors, as they are versatile, can be used for several body area combinations, have a minimal downtime, are cost-effective and have far less dramatic complications as some other procedures.

Dr Gulhima Arora

Dermatologist and Aesthetic Dermatologist, Mehektagul Dermaclinic, is a renowned boardcertified dermatologist in practice for over 18 years. She conducts regular workshops to train dermatologists in various aesthetic procedures. She has been a convener for the IADVL Special Interest Group on lasers and aesthetics. She is a key opinion leader for silhouette soft threads in India.