Thread lifts for facial rejuvenation – not always the best choice

Thread lifts have gained increasing popularity in recent years as one of the minimally invasive procedures. Subcutaneous placement of the threads is used to reshape the face by tissue tightening, repositioning ptosis, and realignment of the superficial fat pads. Both permanent and absorbable threads are on the market. Permanent threads can be made of silicone and gold. For absorbable thread, various materials have been used such as polydioxanone (PDO), polyglycolic acid, poly-L-lactic acid (PLLA), polycaprolactone (PCL), and poly-lactic acid-polycaprolactone (P[LA-CLA] or PCLA or PLCL). Their effect is temporary.

Histological studies suggest the induction of fibroblasts to increase the production of extracellular matrix components such as collagen, elastin, and hyaluronic acid around the threads. In the case of absorbable threads, these tissue modifications last longer than the thread itself.

The choice between non-absorbable and absorbable threads shows parallels with filler material. While the longer duration of lifting (one to two years) is in favor of non-absorbable material; there is a long-term risk for chronic inflammatory adverse reactions. The PDO threads persist for at least two months while threads made of copolymer poly (ε-caprolactone-co-L-lactic acid) can persist for 12 – 15 months, PLLA 18 – 24 months. Absorbable threads offer gradual degradation within the body but need repeated applications over time. Hyaluronic acid fillers provide a durability of the effect between 6 and 12 months, calcium hydroxyl apatite can last about 24 months.

Compared with filler injections and adipose tissue transfer, the threads offer less elasticity, except for PCL and silicone threads. Volumizing has been aimed by multiple threads and technical modifications, but it remains still a challenge to generate a substantial volume or distinctive shapes. Fillers seem to be a more versatile tool.

Threads depend on their anchoring and tensile strength to withstand the stress of gravitational and mimic forces. The holding strength is built between the entry or fixing point and the hanging point. Threads and retaining ligaments interact, which is important for the exact placement of threads. Soft-tissue glideplanes of the face need consideration. Lifting within the loose skin might be less effective over time than insertion into the deeper plane including the superficial musculoaponeurotic system. Excessively resilient threads can lead to skin irregularities and visibility.

If we consider the safety issues, temporary swelling is the most reported complication (pooled incidence of 35%), followed by skin dimpling (10%), paresthesia (6%), thread visibility/palpability (4%), infection (2%), and thread extrusion (2%). Absorbable threads bear a lower risk of extrusion and paresthesia. Patients older than 50 years have a higher risk of adverse events including dimpling. The long-term satisfaction rate is initially very high with 98% but decreases over time.

Visibility and palpability depend not only on the experience of the user. It is well known that massive weight loss may accelerate apparent cervicofacial aging. In the case of previous thread lifts, even a minor weight loss may cause visibility of well-positioned threads. Patients should be informed about this unwanted side effect. Those, who are on a diet and exercise to reduce weight, are not ideal candidates for thread lifts.