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Thread lifts versus surgery

Article-Thread lifts versus surgery

facial aesthetics, thread lift, facelift

Thread-lifting techniques have evolved to provide satisfactory short-term results, particularly in the midface, said an expert at summer Cosmetic Bootcamp held June 21-24 in Aspen, Colorado. However, he added, thread lifting often works best in conjunction with other procedures such as fat injections and fat contouring. And even at its best, thread lifting cannot approach the results or longevity of specialized surgical results.

Choosing between thread lifts and surgical lifts requires knowing what patients want, and how long they want results to last, said Providence, Rhode Island-based plastic surgeon Patrick Sullivan, M.D. For patients who want to be ready for a near-term event, with little postprocedural downtime, he explained, thread lifts may suffice. But if patients can tolerate a longer recovery in pursuit of more beneficial and durable results, the pendulum swings toward surgery.

After the original non-resorbable barbed sutures became available, said Dr. Sullivan, many patients who had undergone the procedure elsewhere presented at his practice with threads protruding through their skin. Newer resorbable barbed threads are little better, he said. "Those hooks don't seem to do the job as well as some of the other technologies."

The cone-and-suture structure of the Silhouette Instalift (Sinclair) is much more effective, said Dr. Sullivan. In the perioral area, he said, the bidirectional cones seem better able to lift and hold tissue in position. Over time, the polyglactin (glycolide/L-lactin or PGLA) material of which they are made resorbs into the body, forming a temporary filler, as polymethylmethacrylate does.

For perioral lifting, he marks three parallel entry points in the mid-cheek, which correspond to exit points in the upper cheek and perioral area. He then guides a long 18-gauge needle approximately 5 mm under the skin's surface to the upper-cheek exit point.

"You can see the different cones being brought through this one entrance site. This opening is not even made with a knife." Then he returns to the central entry point with the other end of the needle and anchors the other end of the suture in the perioral region. "It's very important to feed those cones in perfectly so they don't cause any tethering."

Next, gentle upward pushing across the length of the thread provides medial and lateral lifting as one locks the cones into place. "You can see this lifting, right on the table, which I find very satisfying."
Nobody knows how long Instalift results last, said Dr. Sullivan. He advised curbing patients' expectations regarding both duration and the procedure's effect. "The limited results I get are very different from what I get from surgery."

Patient selection is critical. One patient he treated underwent surgical blepharoplasty, then decided three days later that her face needed lifting. But she had to return to work the following week. "When you have somebody who wants something extra to better match their upper face, the Instalift is a possibility to consider." For this patient, he said, the procedure provided modest lifting in the perioral area, and with threads along the jawline as well, but nothing in the neck.

"A better candidate might be someone who wants more at the same time." For example, one patient wanted an eyelid lift and fat injections to raise her cheeks and pre-jowl sulcus. "We also removed some fat from the jowl at the same time. When you combine treatments, that's a better approach." For this patient, he first inserted threads extending from the mid-cheek to exit points in the perioral area. "As we mark those out, we can really get a feel for what we want to lift. Then you can create the other exit points back up against the hairline."

The neck area is more challenging to treat with Instalift because patients find the postauricular exit openings less comfortable than preauricular ones, said Dr. Sullivan. Furthermore, Dr. Sullivan said he does not show patient results beyond six weeks for this procedure because after that, results are unimpressive.
For one female patient he treated, the Instalift facelift worked very well initially. "But when she returned 1.5 years later, we didn't see any improvement. Then you get into the value proposition, because each thread costs $150." However, he said that combining facial thread lifting with procedures such as blepharoplasty and fat injections gives patients more bang for their buck.

Regarding adverse events, Dr. Sullivan said that none of his patients have experienced tethering that lasted beyond five days. "But it has been reported. Some people say you have to make sure that the area of the central entrance point is very smooth, because tethering can last months." 
Poor candidates for neck thread lifts include those with subplatysmal fat, which one

can detect when patients swallow. "If you can feel that fat pull away from you, then it's probably deep to the platysma and more difficult to get with something like Kybella (deoxycholate, Allergan)."

Such patients are better candidates for procedures such as surgical neck lifting and contouring, he said.  "And if they are concerned about their face as well, the superficial muscular aponeurotic system (SMAS) lift can be very effective if done by the right surgeon. Surgical results vary greatly between surgeons.” A female patient for whom Dr. Sullivan performed an extended SMAS lift maintained very good results nearly eight years later, he said.

Other contraindications to thread lifts include heavy jowls, and deflation of the pre-jowl sulcus or posterior jawline. "A thread is not going to put enough volume in those locations. So fat injections, or one of the other synthetic materials, would be helpful there."

Men with thick, heavy skin and little subcutaneous fat also make poor neck thread-lifting candidates, said Dr. Sullivan. With such patients, he said, it's difficult to find anchoring points that will hold as long as he would like, and patients likely will have tethering or visible sutures. For a male bodybuilder with thick platysmal bands, Dr. Sullivan performed a full-width transection of the platysma, keeping incisions very low on the neck so the muscle incision would not be visible under the skin since the patient had no fat.

Nearly 2.5 years later, Dr. Sullivan said, the patient maintained an improved jawline and a far  better lift than threads would have provided. "Additionally, in his neck region, we were able to get control of the platysma, and you couldn't see any area where we did the full-width division inferiorly. Thus there are no scars visible at all from all of his face and neck surgery. His result is very natural, and that is just what he wanted."