Amid several popular treatments for aesthetic outcomes, in a complete roar, the fourth generation-threads have made inroads in India. Shriyal Sethumadhavan from Aesthetic Medicine, in association with Relife Menarini Group, explores the gaps in popular aesthetic treatments that these threads are going to fill.

Shriyal Sethumadhavan

I ndia has been outlining its own aesthetic growth story. Aesthetic surgery and procedures – invasive and non-invasive – have been on a rise, with some of the common in-demand ones being orbital surgery or facial plastic surgery for scars and post facial fractures, cosmetic rhinoplasty, laser procedures for skin care, botulinum toxin and filler injections. While the COVID-19 outbreak did impact the industry leading to a decline in demand in the year 2020, at present, several companies and distributers are known to have scaled back their operations.

A global survey conducted by the International Society of Aesthetic Plastic Surgery (ISAPS) reveals that India has performed 390,793 surgical and 505,103 non-surgical procedures in the year 2018. What’s more, today the country ranks fourth in the world for the number of cosmetic surgery procedures performed. 1 And, for its ageing population, an emerging treatment modality has been threads – safe, feasible, patient-friendly and minimally invasive.

Making the right choice

There are several instances where patients want a solution to sagging skin. Ageing leads to loss of fat in the cheeks, eye area, jowls and the neck. In order to address the concern of ageing skin, it becomes important for a dermatologists’ to analyse the condition, patient requirement in terms of visibility and duration of results, and accordingly determine the ideal treatment option, be it with energy-based devices, botulinum toxin, fillers and/or threads.

However, each of these treatment approaches are different and it is important to consider that in the decision-making and keep the patients’ informed and aware accordingly. While fillers are done for contouring and volume augmentation, they voluminise specific areas of concern along with requiring touch-ups. In the case of dynamic wrinkles, botulinum toxins are more than often opted for. Energy-based devices are a preferred choice in the case of a more generalised and minor skin tightening.

When compared to the above mentioned treatments and their indication, threads are approved for mild to moderate lifting followed by skin revitalisation. When placed under the skin, the thread-lift treatment tighten and lift the loose or sagging areas on the face. This helps reduce the effects of ageing. Additionally, threads can also be used to rejuvenate the face. All of this can be achieved in a one-time procedure. The ability to treat sagging skin in the most precise manner and offering immediate results is what makes threads among the most preferred treatments. No wonder the demand for threads have been on a rise in recent times.

When placed under the skin, the thread-lift treatment tighten and lift the loose or sagging areas on the face.

Materials generally used in manufacturing cosmetic threads include PDO (polydioxanone), PLA (polylactic acid), and caprolactone threads. Eligible for population in the age group 30-60 years, this procedure takes less than an hour. 2 Amid this growing popularity of threads, much to the benefit of aesthetic physicians, the fourth generation threads – PCLA – have recently made inroads into the India market. Companies such as Relife Menarini Group have introduced the PLCA threads (also referred to as barbed threads) that are bridging the gap in popular aesthetic treatments for aesthetic outcomes.

A new generation steps in!

Common indications of the fourth generation threads include contouring, lifting, and reinforcement of the middle and lower thirds of the face and neck. These double needle threads are used to address movement of tissues in two vectors, namely transversal and sagittal, for repositioning and reshaping of the forehead, cheeks, jawline and neck.3

These are absorbable, monofilament, suspension barbed threads of synthetic origin with convergent bidirectional barbs. The 12 cm thread has two parts with bidirectional and convergent barbs that are found on each side. At the central part of this thread, there is a smooth area that is approximately 1 cm long. The 23-cm variant has barbs along its length on both sides and a central smooth part that is 1.5 cm long. At each extremity, there is a straight cut-edge double-needle that is (1) 100 mm long with a diameter of 0.8–0.83 mm for the 12-cm-long thread and (2) 150 mm long with a diameter of 1.26–1.28 mm for the 23-cm-long thread. 4

Two straight needles are used to insert the thread in different directions depending on the technique used. This specific insertion modality and the ability to create an angle between the two thread tracks allow for various insertion patterns and the creation of anchoring points that increase thread grip. When the thread is pulled, the tissue accumulates between the two sides of the angle.5The natural disposition of bidirectional barbs are such that they lead to tissue accumulation and support ligaments.

Histological analysis

A sustained lifting effect is what the dermatologist as well as the patient always wants to achieve and experience.

Once placed, PLCL is cleaved into polylactic acid and polyc aprolactone, which are eventually hydrolysed into lactic acid and six-hydroxyc aproic acid. These degradation products are ultimately resorbed through specific metabolic pathways with low tissue reactivity. This degradative process takes approximately 9-12 months, which is sufficient time for tissue regeneration that could result in a sustained lifting effect.6

Histological analysis of tissue surrounding these threads has demonstrated that after two months, these threads connect to the high and lateral dermis retinacula cutis system, SMAS (superficial musculoaponeurotic system), and the downward muscular bands with no apparent signs of inflammation. After the thread is absorbed, a more permanent and homogenous fibrous capsule replaces the thread while it is resorbed. In a cross section of skin taken two months after insertion, a fragment of thread is seen as a dark-coloured ovoid figure surrounded by the cells and connective tissue creating a fibrotic capsule.7

Reports indicate that when the tissue has been examined, no overt signs of inflammation have been seen. After absorption, a more permanent collection of scarred connective tissue replaces the capsule while the absorbed thread is no longer apparent. This capsule apparently enhances tissue firmness. An increased thickness of the dermis suggests formation of collagen, elastin, and other connective tissue.8

In terms of beneficiary effects, these threads have been designed to have a barbed tridimensional geometry. Their stability is considered to provide a substantial scaffold, where development of connective tissue and angiogenesis can occur. These properties have been likely responsible for clinical results of gradual increase in lift and revitalisation for up to six to twelve months after the procedure. These properties establish that the threads have excellent tissue integration. The inflammatory and collagenesis process is seen local to where the threads have been placed, and there are no extensive reactions or extended puckering seen on the healing skin. This signifies that the thread placement has no effect on the movement of the facial muscles of expression in the treated area. 9

Efficacy and safety

Be it for rejuvenation or lifting of ptotic facial tissue, bioabsorbable threads have been gaining popularity. Common indications include contouring, lifting, and reinforcement of the middle and lower thirds of the face and neck; eliminating jowls and ptosis of the mental area; and double needle threads are used to address movement of tissue into two vectors, namely transversal and sagittal, for repositioning and reshaping of the forehead, cheeks, jawline and neck.

There are several studies world over that confirm the efficacy and safety of the fourth generation threads:10

What’s more, in facial rejuvenation procedures, the bioabsorbable monofilament fourth generation threads have a good biocompatibility profile, efficacy, excellent safety and tolerability. The results last for over 18 months due to the collagen-stimulating properties and because these are stronger than earlier generation threads.11

Also, it is known that the fourth-generation threads (12 cm and 23 cm) show greater elasticity and a lower plasticity in comparison to PLLA (27.5 cm) and PLLA-co-PCL (100 mm). In terms of tensile strength, these threads are two times stronger than PLLA (27.5 cm) and PLLA-co-PCL (100 mm). Also, as clinical papers indicate, these are more reliable as suture wires.12

Clinical trials

The fourth generation threads have been used by aesthetic medicine practitioners worldwide for years. It has a good biocompatibility profile, with excellent safety and tolerability. Several studies conducted on these threads have emphasised on their effectiveness and how these are suitable for facial rejuvenation procedures. None of the patients in the assessed studies have developed serious complications. And the procedure has been considered satisfactory with good to excellent clinical results. Clinical studies also reveal that results last over 18 months due to the collagen-stimulating properties as well because these are stronger than the earlier generation threads.13

To gather more insights from the dermatologists who have been using the fourth generation threads, the Aesthetic Medicine team, in association with Relife Menarini Group, the manufacturers of Definisse Threads, reached out to three experienced dermatologists from across India. Read on to know more on…

Patient selection and counselling by Dr Malavika Kohli, Dermatology and Aesthetics Director, Skin Secrets;

A painless, effortless, and safe procedure by Dr Indu Ballani, MD Dermatology, and Clinical and Aesthetic Dermatologist, New Delhi;

And, Combination treatments with the fourth-generation threads by Dr Maya Vedamurthy, Director, RSV Skin Clinic, and Senior Consultant, Apollo Hospitals, Chennai.