THREAD

LIFT
D R. M D RA I H A N U L
ISLAM
Consultant, VitaSkin
INTRODUCTI
ON
 THREAD lifting is a cosmetic procedure that lifts and realigns
sagging tissue, while adding definition to facial contours by
using threads.
Facial
Aging

 Facial aging reflects a combination of skeletal and connective

tissue changes

 Signs of aging include poor definition of the mandibular

margin, wrinkles of the forehead, vertical wrinkles in the
glabellar area, drooping of the zygomatic malar region, and
deepening of the naso- buccal fold.

 Another main factor in the effect of aging on appearance is

gravity, which causes ptosis of the facial soft tissue, such
as the downward shift of the malar fat pad that creates
hollowness of the mid-facial and infra-orbital area
SURGICAL ANATOMY
FOR NONSURGICAL
T H R E A D S ? PARADOX?
F-Front;
T-Temporal;
G-
Glabellar;
N-Nose;
PO-Periorbital;
ML-Lateral
Malar; MM-
Middle Malar;
PO- Perioral;
SMa-
Submalar; Ma-
Mandibular;
Me- Mental
Region
Face
L ay e r s
(1) S k i n;
(2)S u b cu t a n e o
u s layer;
(3) S M A S ;
(4)S u b
aponeurotic,
containing
ligaments and
soft tissue
spaces and
(5) D e e p f a s c i a
A fresh-frozen
cadaver where
s u b c u t a n e o u s fat
compartments were
exposed and
separated.
1: na s ol a bi a l
s u b c u t a n e o u s fat
compartment;

2: m e d i a l
s u b c u t a n e o u s fat
compartment;

3: m i d d l e
s u b c u t a n e o u s fat
A fr e sh -
fr oze n
specimen
where
nasolabial
fat
compartment
where
removed
show ing the
facial a r t e r y
just b e l o w t h e
subcutaneous
fat.
BASIC DEFINITIONS:
FIXING/DIRECTION/HANGING
POINTS
Types of
Thread
 The types of thread can be divided into three main
 categories

 1. Mode of Absorption

 2. Barbed and Non-Barbed Thread (Smooth Threads)

3. Length of Threads
TREND OF THREADS: A
G O L D E N ERA
CHARECTERISTICS
There are 3 characteristics for threads:
1. Absorption
2. Length
3. Surface texture (Smooth vs barbed).
A BS O R B A B L E
THREADS
CLASSIFICATION
TYPES OF
THREADS
• Uni-Directional Barbed
• Bi-Directional
• Non-Barbed
BARB
S
These barbs not only ma ke
sure the thread doesn't
move, but they cause
small abrasions in the
tissues, triggering the skin
to produce collagen to
repair itself.
NON-Barbed
Threads
Non-barbed
threads c o m e in
two types:
monofilament plain
and monofilament
spiral.
COG
• C o g threads Threads
are similar to mono
threads but contain barbs that
attach to the underside of the
skin.
• These barbs offer enhanced
support to the structure of the
skin to lift s a g g i n g tissue.
• These threads effectively
promotes collagen formation
around the threads and
their barbs.
SCREW
THREADS
SPIRAL
(COG)
E M B O SS I N G
PDO
TYPES OF
THREAD

Bi-d irect i o n a l B a r b s Uni-directional C o n e s

PLLA (Co urte sy S i l h o u e t te ® )
( Co u rtesy A P T O S ® )

P u re G o l d thread PP(2-0)
With (P olypropyle n e
P G A ( Polyglycolid )
e)
Mode of
Absorption
 Absorbable threads including -Polydioxanone thread (PDO),
Silhouette Soft thread (Poly-I-lactic acid or sculptra in solid
form), and fine thread with bi-directional absorbable cone.

 Non-absorbable thread including APTOS thread, Contour

thread, Silhouette lift thread, Woffl es thread
(Polypropylene)
Barbed and Non-Barbed
Thread (Smooth Threads)
 a) Barbed Thread - There are 3 types of barbed thread
 1)Bi-directional t h r e a d (Long suture) are inserted into a
hollow needle and then placed in the treated area. Bidirectional
threads have barbs in opposing direction. . W h e n inserted,
bidirectional threads are unable to m o v e either way
 2)Uni-directional b a r b e d t h r e a d s (Long sutures) are
designed to be anchored to a fixed structure, such a s the deep
temporal fascia. Unidirectional threads present barbs that are all
angled in one direction and hence requiring anchoring to a fixed
structure, often a facial ligament
 3)C o g g e d T h r e a d s (Short sutures): Examples include P D O
Uni- directional co gged thread, P D O Bi-directional cogged
thread, and P D O Multi-directional co gged thread
 b) N o n - B a r b e d T h r e a d s ( S m o o t h Th re ad) - There are two types of Non-
 barbed thread
1) Monofi lament Plain: Examples include Miracu plain thread and TR lift
 thread.
2)Monofi lament Screw or Spiral: Examples include K2 screw lifting and T
Screw lifting thread
Length of
Threads
 S h o r t s u t u r e is defined by any thread shorter than 90 mm in
 length.
L o n g s u t u r e is defined by any thread longer than 90 mm in
length
E N D O F PART 1:
Q&A
DR. RAIHAN-UL-ISLAM
C o n s u l t a n t D e r m ato lo g is t ,
S k in , H air & L as e r E x p e r t

[Link]

h a i r s k i n te e t h @ g m a i l . c o m
Dr. Raihan

[Link]

[Link]
I n s er ti on
tec h n i q u e
1. Stepladder serial insertion
2. S a m e level insertion
3. N arrow interval insertion
4. M e s h technique
5. N eed lin g
6. Twisting
7. Fan shape insertion
Treatment
Algorithm
 Design the treatment technique with a marker or pencil-based
 drawing Prophylactic antibiotics 1 hour before treatment
 anti-bacterial product such a s chlorhexidine prior to thread
 insertion
For superficial Plain threads, apply a 7 - 1 5 % lidocaine cream 4 5 minutes
 before the procedure.

 For cog thread and any long thread (more than 9 0 mm),
Local anesthesia, such a s 1 - 2 % solution of Lidocaine with Epinephrine
(1/200,000), should be injected at the insertion area.
How to Apply the Thread
Lift Procedure
 Protocols for Short Suture
 The protocol for threads shorter than 9 0 mm, such as
Polydioxanone thread (Plain, Screw, Spiral and C o g thread),
involves the use of the free floating method.
 If severe skin laxity or excess adipose tissue is present, more
threads can be inserted
 a ) L o w e r Face A r e a a n d
 Jawline
Step [Link] five to 1 0 Mono Plain or Screw threads for each side
 For skin tightening and rejuvenation, insert the needle into the dermis
plane. For lipolysis, insert the needle deeper into the subcutaneous
plane.
 Step [Link] four to six cog threads for each side at insertion
point (A), located 1.5 cm pre-auricular and 1 cm below the
lower border of the zygomatic bone, extending down to the
superficial musculoaponeurotic system ( SMAS) plane. Follow
this line until you meet the end-points
 Step [Link] two to five Mono Plain or Screw threads in
another three directions. This step creates a meshwork
relative to Steps 1 and 2
 b ) M i d -Fa c e a n d C h e e k
 Area
Step [Link] four to six cog threads for each side, down to the
S M A S plane
 Step [Link] five to 1 0 Mono Plain or Screw threads for
each side
 Step 3.(Naso-labial fold) Insert 3-5 Mono Screw threads for
each side. Insert the 1st screw thread into the Naso- labial
fold straight, and then insert the 2nd to 5th thread in a zig-
zag fashion
 c) Peri-Ocular
 Area
Medial and Lateral eyebrow lift:
 Insert two to four C o g threads at insertion point (A), located
1 cm below the hairline. Insert the 1st C o g thread through
sub-dermis ending at point B, 1 cm above the brow, in order
to avoid trauma to the temporal branch of the facial nerve
 Once the C o g thread is anchored, slowly retract the cannula
and clamp the C o g thread. Insert the 2nd C o g thread
subdermally towards end-point C, 1 cm above the brow and
parallel to the lateral canthus line. Clamp both C o g threads
together and trim them close to the skin
 Crows
 feet:
Insert five Mono Plain threads, 3 0 m m in length using a 31- G
needle, into the dermis for each side. Insert the 1st to 3rd
threads in a horizontal direction and 4th and 5th threads in a
vertical direction to create a meshwork.
 Tear trough lift: Select and insert five Mono Plain threads, 3 0
m m in length using a 31- G needle, into the sub-dermis of the
lower eyelid on each side
 d) Neck
 Area
Insert 10-15 Mono Screw threads horizontally and 10-15
Mono Plain threads vertically for each side, deep into the
subdermis
Protocols for Long
Suture
 The protocol for thread longer than 9 0 mm, such as APTOS
2/0, 4/0, Silhouette Lift, Silhouette Soft, or Contour thread.
Most long sutures are barbed, including bi-directional and
uni-directional threads. The procedure technique that is
usually applied for uni-directional thread is the fixed method
(with an anchoring point), while the procedure technique for
bi-directional thread is the free-floating method (without an
anchoring point). A third type of procedure is a double needle
technique that also uses the free-floating method (without an
anchoring point). All procedures can be performed under local
anesthesia.
 For the Fixed method (with an anchoring point), 3-4 m m
incisions for insertion of a straight needle are necessary. The
incision point should be located at the deep temporal fascia or
periosteum so that it can be used a s an anchoring point.
 For lower face and cheek lifting, the anchoring point is made
posterior to the frontal and temporal hairline.
 For neck lifting, the anchoring point is made posterior
to the sternocleidomastoid muscle.
a) Lower Face Area and
Jawline
 Technique 1 Lower Face Thread Lift
 Uni-directional threads are recommended. Select
two long barbed threads for each side. Tie a knot
in the thread at the deep tendon fascia. Insert the
needle at the incision point, deep to the SMAS, and
at the 2nd halfway point the needle should be
more superficial, a s it mo v es into the
subcutaneous plane. At 1.5 cm medial to the
marionette lines, the needle is brought out, leaving
the thread in the tissues. Pull the thread lightly and
then trim the excess thread
 Technique 2 Lower Face Thread
 Lift
Bi-directional threads are recommended. Select
two bidirectional threads for each side. Make a
puncture wound in the pre-tragus area (point
A). Insert “a flexible hollow needle” deep to
the papillary dermis and then follow the line,
maneuvering the needle in a slight zigzag
pattern until the tip of the needle passes
through the exit point (point B). Insert the
thread into the needle and carefully withdraw
the needle leaving the thread positioned in
the dermis. Pull the thread lightly and then
trim the excess thread
 Technique 3 Redefinition of the Mandibular Contour
Double needle technique
 Select one double needle thread for each side. Insert
both straight needles into the sub-dermal layer
through two adjacent inlet holes both ends of the
thread and then trim the excess. No sutures are
necessary
 Technique 4 Woffl es
 Lift
Choose three to four Woffl es threads for each side. Make a small incision at
point B. Insert the introducer from point A upwards until it exits at point B.
Then, remove the stillete and insert one Woffl es thread from point B
downward to point A until half of the thread has been inserted. Re-insert the
introducer from point C upwards until it exits at point B again. Introduce the
other half of the Woffl es thread into point B until it exits at point C. Remove the
needle, pull the end of the thread firmly while pushing the skin upward in a
vertical direction, and then trim the excess thread
b) Mid-Face and Cheek Area: Malar Fat Pad
Lifting
 Technique 1 Straight Needle with Anchoring Point
 Choose 3-4 long barbed threads for each side. Make a 1 cm
incision. Tie a knot of the thread at the deep tendon fascia. Insert
the needle at the incision point. Angle the needle upward from the
periosteum to the malar fat pad area. At 1 cm lateral from the
naso-labial crease, the needle is brought out, leaving the thread
in the tissues. Pull the end of the thread firmly and push the skin
of the cheek back over it. Then trim the excess thread
 Technique 2 Curved Needle with Anchoring Point (5 cm or 6 cm Needle
with 4 5 cm Thread)
 Make a 2 m m to 3 m m incision along the “crow’s feet” wrinkles (Point 1).
Insert the needle at the incision point. Pass the needle through the
subcutaneous area along a triangular path to Points 2 and 3 and return to
Point 1. At Point 1, the needle is brought out, and threaded back into the
wound again. Both ends of the thread are brought together and attached
to the orbital periosteum with several knot
 Technique 3 Double needle without anchoring point
 technique.
Insert two needles in a single puncture and then separate
them from each other. Advance the needles medially in the
direction of the malar fat pad, moving to the surface at the
marked points, and then return to the temple area where the
threads are anchored to the zygomatic periosteum. No
sutures are necessary
c) Eyebrow
Lifting
 Technique 1 Straight Needle with Anchoring Point Make four to
six incisions, 2 cm above the hairline [28]. Introduce the
thread into the subgaleal plane up to the superior eyebrow
margin, where it passes outside the skin and over the
eyebrow via a 1 m m cutaneous incision. The eyebrow anchor
is made and the thread is passed across laterally, after which
it is turned upward toward the scalp area. Apply traction and
make a knot, creating a rectangle
 Technique 2 Double Needle without Anchoring Point Insert both straight
needles at the hairline. Follow the line within the subcutaneous tissue,
advancing both needles downward until reaching the central eyebrow. Using
the s a m e exit hole, reinsert the medially positioned needle and follow the
contour of the eyebrow toward the nasal edge, while the lateral needle
follows the contour of the eyebrow laterally. Both needles are then advanced
upward until reaching the hairline, forming a symmetrical pattern. No sutures
are necessary
 Technique 3 Double Needle without Anchoring Point In a single puncture,
insert both straight needles into the temple area and then trace the needles
downward toward the temporal muscle. Separate the needles from each
other and insert them deep into the temporal fascia before withdrawing into
the subcutaneous space. Follow the line to the highest point of the brow. At
this time, the needles are moved to the surface, turned around, and
reinserted to trace medially in the direction of the glabella. In the middle of
the upper glabella, both needles are brought out together. Pull the four
sutures ends lightly and trim the excess thread. No sutures are necessary
d) Neck
Lifting
 Technique 1 Straight Needle with Anchoring Point Make a
1 cm incision in the retroauricular area. Tie a knot. Trace
the threads medially and exit at the midline
 Technique 2 Long Straight Needle with Anchoring Point Make a 1 cm incision
bilaterally in the retroauricular area. At the incision area make a “Holder”
thread with 2/0 Prolene and anchor it on the periosteum to support the other
threads. Trace the thread along the first marked line until it appears on the
other side. The needle is brought to the surface, turned around, and
reinserted at the point it is brought out. Finally, trim the excess thread
 Technique 3 Double Needle without Anchoring Point Insert
both straight needles into the aponeurosis of the platysma.
Follow the line to the area of the sternocleidomastoid muscle.
Pull both ends of the threads lightly and then trim the excess
thread. No sutures are necessary
How to Choose the
Appropriate Technique for the
Selected Patient
COMPLICATIO
NS
 Short-term swelling, bruising and
 pain Infection
 Dissatisfaction with Facial
 Contour Paresthesia
 Dimpling
 Subcutaneous
 Induration Thread
 Extrusion
Facial Nerve Injury
Aptos Threads and Woffl es
Threads
 The Aptos threads were described by Sulamanidze et al. in
2 0 0 2 and are made of 2-0 polypropylene line with dents
provided during the manufacturing process, thus creating
slant edges with sharp ends.

 Woffl es threads were described by

Wu
Contour Threads
(Nonresorbable)
 They consist of a 25-cm length of 2-0 polypropylene suture with a
central 10-cm segment of 5 0 unidirectional helicoidally confi gured
barbs
Multianchor Suspension
Suture (Resorbable)
 Eremia and Willoughby used a multianchor suspension
suture assembled from 2-0 absorbable monofi lament
material, with five to nine equally spaced knots through which
are secured 7- to 9-mm bits of similar suture material
Silhouette
Soft
 Poly-l-lactic acid, the principal component of Silhouette Soft
(Sinclair Pharma, London, United Kingdom), is a well-known
polymer that has been used for ma n y years in a large
number of biomedical and pharmaceutical applications. It is
because this polymer is particularly biocompatible in the
human body, and also completely biodegradable They consist
of a 37.3-cm length of 3-0 polypropylene suture with a central
8-cm segment of nine knots at approximately 10-mm
intervals. Each knot is intercalated with an absorbable cone of
polyl- lactic acid, making up a series of eight engaging
elements.
Polydioxanone Threads
(Resorbable)
 8 C o g polydioxanone threads have barbs,
which stick to tissues when inserted and result
in lifting.
Depending on the direction of the spikes,
cog polydioxanone threads are
categorized a s unidirectional,
bidirectional, or multidirectional
LFL (Lead Fine Lift) P D O
threads
 Mechanism
 Production of collagen in response to the presence and
irritation of a foreign body (thread) plus mechanical injury (by
needle) stimulates blood flow and increases metabolism in
the treated area
PDO
THTEADS
 Ty p e s of P D O Micro-
Thread
There are five types of P D O threads that can be used for a P D O facelift
8

treatment: s :
1. P D O M o n o – these threads are 6/0-8/0 and are inserted with a 26-31G
needle using the “Quilting Inn” technique into the medium to deep dermis of
the skin. They promote remodelling of he tissues. Length varies from 12-
60mm.
2. P D S c r e w – These 5/0-8/0 micro threads have a spiral shape and are
inserted with a 26-31G needle. They are placed into the superfi cial or s u b
dermis and/or the deep dermis. They induce biostimulation and retraction
lines along the vectors of traction. The usual length is 25-60mm.
3. P D O E m b o s s e d T h r e a d – this is a thread with microgrooves that allow re-
growth of tissues into the grooves of the thread. They are positioned at the
mid to deep levels of the subdermal layer. The length is normally 25-60mm.
4. P D O C o g s – these are barbed threads that can be mono, bi a s well a s three-
directional with a length of 50-90mm. This thread is mainly aims to create
suspension of the tissues by stimulating collagen production by fi broblasts
along the axis of the thread.
5. P D O M i n i C a n n u l a s – The u s e of blunt cannulas for inserting barbed or
straight threads minimises the risk of haematomas in delicate areas such
a s around the ey es and the temporal region. They are also ones suitable for
the nose tip and neck.
 D e p t h of P D O
 Insertion:
The correct depth for inserting barbed PD O threads is in the
Superficial Muscular Aponeurotic System (SMAS). If they are
inserted too superficially within the dermal plane then they
m a y be seen or felt and would fail to provide the required
lifting and collagen production stimulation.
 Placed too deep and they would pose a greater risk of damage
to
arteries, veins, the facial nerve and causing other structural
damage.