Suspension Threadlifting
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Introduction
Rejuvenation of the aging face involves modalities that will refill, resurface, relax and resuspend. As cosmetic rejuvenation procedures have become simpler and less aggressive, downtime has decreased and safety has increased. Most facial rejuvenation involves a combination of procedures that can be tailored to the needs of the patient. Suspension threadlifting provides a less invasive method for resuspending the aging face. Both here in the United States and abroad, the most recent minimally invasive lifting technique has been the barbed threads used for suspension. The Aptos subdermal suspension threads evolved from the concept of skin and fascia adhering to the barbed suture, creating elevation. This was developed by Marlen and George Sulamanidze in Russia. Concomitantly, the barbed suture or Contour Thread developed by Dr. Greg Ruff at Duke University and in the United States is now FDA approved and used as a similar unidirectional barbed suspension thread.

Mechanism of Action
Aptos is derived from the Greek “Anti” plus “Ptosis”. It is a barbed thread that adheres to the dermis and acts as a gathering stitch. The Aptos thread is based on the concept that the skin can be lifted and held in a suspended position with barbs alone without affecting the underlying muscle or bone. The barbed adherence is performed without suturing or anchoring to fascia muscle or bone. The thread itself is a polypropylene suture with barbed incisions in two directions. The bidirectional barbs hold tissue in both inferior and superior direction, giving greater adherence.
Greg Ruff, M.D. has independently developed a different concept of barbed suture for facial suspension. Having used the model of the porcupine quill (erethizon dursaton) as a multi-barbed suture that maintains a hold or grasp on soft tissue through an even and spiral diffusion of barbs on each quill, Dr. Ruff began work on the “quill suture” in the early 90’s as a closure technique for surgical wounds. It was found to be self-anchoring with no knots, giving a faster and more efficient closure with tension broadly distributed. The “Contour Suture” was thus developed as a unidirectional barbed monofilament suture with a different pattern of insertion and anchored superiorly to a fixed structure. (Figure 1)

Safety and Efficacy
Marlen Sulamanidze developed the Aptos thread in the 90’s. At present, it is not an approved device in the US. Animal studies revealed the non-inflammatory status of the non-barbed praline suture while the barbed areas developed a fibrotic cuff over a period of 3 months. It is this fibrous sheath which theoretically holds the tissue in place. For Contour Threads, data has been obtained as to tensile strength, tissue stretch and histologic studies of fibroblast migration and collagen development. The studies demonstrated the thread to be a safe and reliable technique for facial suspension. In 2005, the FDA has approved it for suture suspension for cheeks, jowls and brow. The procedure itself is performed under local anesthesia as an outpatient with minimal trauma and thus little bruising and erythmosas with little resultant downtime. Potential complications, though, can include asymmetry, visible threads, suture spitting, post-operative pain, infection, and correction destroyed by manipulation.

Indications
The Aptos thread is not an approved device in the US. In 2005, the FDA approved Contour Threads for suture suspension of the cheeks, jowls and brow.

Proper Patient Selection
The patients who benefit most from threadlifting procedures are patients with some ptosis of the cheeks, jowls and brow, but not a lot of excess sagging skin. Also, heavyset patients are less likely to obtain optimal results due to destruction of correction by stretching and release of the barbs on the suture. The procedure can be combined well with other minimally invasive procedures such as skin and soft tissue filling agents and botulinim toxin.

Contraindications
The use of blood thinners increases risk of postoperative bruising but is not an absolute contraindication. Patients with active skin infection should be fully treated prior to thread placement. Also, patients with unrealistic expectations should be excluded. Patients should understand that this is not a face lift and thus more radical lifting and correction cannot be achieved.

Pre-Procedure Patient Education
Patients are educated on the risks and benefits of threadlifting. They are shown before, during, and after photographs of previously treated patients so that they can better understand the process involved in recovery after the lifting procedure. They are told that the threadlift procedure is not a substitute for a facelift, but rather a less invasive alternative that will provide some correction of ptosis but not to the degree of a facelift. The patient must understand that there is a period of “downtime” in which excessive pressure or movement may break the barb-hold on the elevated skin and destroy correction. There are also temporary folds, dimples and furrows where the skin is abnormally tight which will correct over 3 weeks as the threads commonly lose 20% of pulled correction. In addition, long-term expectations are discussed with the patient including the possibility that over time the correction will diminish. Patient questions should also be answered.

Procedure Protocol
Tray Set-Up
The tray used for insertion of threads for both Aptos Threads and Contour Threads is a standard excision tray with a needle holder, forceps, scalpel (with a number 11 or 15 blade), suture scissors, Gradle scissors (or similar) for undermining, gauze, a small bowl of saline, and the appropriate threads. For Aptos Threads, a 20 gauge spinal needle is also needed. For Contour Threads, an undermining needle may be used. (Table 1)
Procedure
1) A map of vectors is drawn on the patient’s face in a seated position to determine the pathways of the threads and the number of threads needed to obtain the necessary elevation. For Aptos threads the pathways are drawn along the appropriate vectors and do not need to connect in the scalp (Figure 2). Unlike the Aptos threads, Contour Threads are used in pairs with the pathways ascending superiorly to a pointed V in the temporal scalp (Figure 3).
2) The patient’s face is cleansed and sterilized with an appropriate surgical scrub so that the procedure can be performed sterily.
3) Although the procedure can be performed with local anesthesia alone, minimal anxiolytic sedation (diazepam 5-10 mg sublingually to supplement the local anesthesia alone) is often advisable. 1% lidocaine with 1:150,000 epinephrine with bicarbonate is used to infiltrate the skin and subcutaneous pathway. One can use a 1 ½ inch 30 gauge needle and 10 cc syringe producing first a bleb intradermally at the point of insertion, then a subcutaneous infiltration of the suture pathway. This can easily be performed with a 20 gauge spiral needle. This usually produces enough anesthesia for painless placement of the suspension suture.
4a) For Aptos Threads: A 20 gauge spinal needle – trochar in place – is introduced through the skin and advanced along the mapped pathway with a “serpiginous” pattern. This is to increase the tissue area of barbed contact and the changing of direction creates a stronger barbed attachment. The needle is advanced to its termination at the nasolabial fold and exited to the skin. The trochar is removed and the barbed suture introduced into the spinal needle from the termination point to the beginning. The inferior portion of protruding thread is clamped with a hemostat for security as the spinal needle is removed. At the same time, the cheek is compressed upward. After the needle is removed superiorly, the thread is pulled in both directions, opening the barb and holding the skin in its upward compressed position. The two sides are then compared for symmetry and even correction. At this time, change can be made to equal the elevation and create a natural lifting. The protruding sutures are then snipped with suture scissors and the suture tucked in to the subcutaneous tissue.
4b) For Contour Threads: There are 2 suture types available for use. The CT-200 I is a 25 cm. 2-0 polypropylene barbed suture which is swagged onto a 7 inch straight needle with a tapered cutting tip and 26 mm. ½ circle tapered needle on the opposite end for suture fixation. At the superior point in the temporal scalp, the fixation needle is used to anchor the suture in the temporal fascia. The CT-200 is the first suture developed and commonly used now for neck lifting. The CT 400 suture has paired barbed sutures with 2 straight taper-cut needles attached together with non-barbed portion of 3-0 proline suture. The paired insertion thus does not require suturing the 2 barbed sections together but does require passage to deep fascia superiorly for fixation. Like the Aptos threads, an initial incision is made superiorly and the straight needle threaded through the subcutaneous tissue in a serpentine pattern (Figure 4). Each pair of threads is sutured into the superior temporal fascia. In some patients an additional incision can be made in between the threads and also on either side near the insertion point in the temporalis fascia. A small undermining needle can then be inserted and used to free the surrounding tissue to allow for a more plate-like lift. As the threads are pulled downward, the cheek then can be massaged upward into proper position. The lift can be adjusted for symmetry and a natural appearance with the patient awake, in a seated position, checking for approval and satisfaction. The protruding sutures are then snipped with suture scissors and the suture tucked in to the subcutaneous tissue.
5) Antibiotic ointment is placed over the needle holes and steri-strips or micropore tape is placed over the cheeks for surface anti-tension suspension (Figure 5).

Post Procedure Instructions
Post-operatively, the patient is warned against excessive cheek or moderate mouth movement that, early on, can break the correction. Also, the patient is advised against massage or aggressively scraping the cheeks for the first few days which can also dislodge the barbs. The tape is left in place for the first few days and patients are also advised to sleep propped up and stabilized to prevent rolling over and dislodging the barbs from sleep compression. In a majority of patients, the correction is well maintained if the early postoperative care is followed. 0.25% Acetic acid soaks are used everyday and polysporin is applied to suture insertion points.

Recommendations for Follow-Up
Patients return 3 to 7 days post-procedure for minor corrections of dimpling and asymmetry. Care must be taken to not undo too much of the correction because 25-35% of the correction will relax with time and most dimples will resolve with tincture of time. It is important to reassure patients in the early stages of recovery because their appearance is often quite pulled.

Complications
As discussed in the safety and efficacy section, complications seen include asymmetry, visible threads, suture spitting, post-operative pain, infection, and correction destroyed by manipulation. Pre and postoperative photographs are important with threadlifting procedures. Often patients have degrees of natural facial asymmetry that were not apparent to them preoperatively. In the early postoperative period it is easy to release some of the barbs and decrease the amount of lift to improve symmetry.
Threads may be visible early on, especially in the patient who has thin skin and little subcutaneous tissue. This usually improves with time. If it persists to the patient’s dissatisfaction after three or four weeks, the barbed suture can be removed. In addition, if threads are placed too superficially they often remain visible. Care must be taken intraoperatively to insure the threads are placed in the appropriate subcutaneous plane.
Suture migration or spitting at the surface has been seen. The protruding suture can be easily snipped or a wandering suture removed. One of the most common complaints is a firm papule at the insertion point of a Contour Thread. Occasionally the tail end of the thread needs to be trimmed closure to the knot to avoid this complication.
Infection is rare, especially with pre-operative antibiotics. Precautions of asepsis and sterility should prevent this.
The patient may complain of a pinching pain. This may be due to a barb irritating a peripheral nerve. This usually occurs within the first week and subsides. The patient needs reassurance and this is usually all that is necessary; though, if it persists and creates a symptomatic problem, the suture may be removed. True neurasthenia or prolonged motor nerve injury is rare but theoretically can occur, especially in the temporal and mandibular area where the facial nerve is most superficial.
The most common important adverse sequelae is the destruction of correction by releasing the barbs. Correct technique of insertion – using a serpentine pattern – along with proper post-operative protection can guard against this problem. Patients need to be aware that manipulation of the face in the early postoperative period can completely undo their lift. Manipulation includes the use of makeup, vigorous massage or face washing or rolling over in their sleep. If the lift is undone, additional threads will have to be placed.

Pearls
Patient selection and preoperative education make a huge difference in outcomes. Patients need to understand that the procedure does involve some postoperative downtime and that the true result is not apparent immediately. For physicians, this means resisting the urge to release every dimple and pull on the skin as the end lift will be significantly decreased. Also, patients who need facelifts are not good candidates for threadlifting.

Pitfalls
Failing to insert the suture in a serpiginous pattern will lessen the likelihood of a long-term lift.
Failing to obtain preoperative photographs will make it difficult to assess postoperative lift and symmetry.

Table 1. CONTOUR THREADS TRAY SET-UP
SUPPLY
• Contour Threads
• Mohs’ Pack (includes sterile towels, 2x2s, 4x4s, cotton tipped applicators)
• Mohs’ Instruments (includes scalpel handle, needle holder, Iris scissors, Gradle scissors, Bishop-Harmon or Castroviejo forceps, skin hooks, and Brown-Adson forceps)
• Purple marking pen
• Sterile Saline in large cup
• Number #15 Blade x2
• x1 25 gauge Spinal Needle
• Ultradex Scrub Brush to prep patient’s face and hairline
• Appropriate size sterile gloves
LOCAL ANESTHESIA
• x4 or more 3cc Syringes of Lidocaine with SB (8.4% Sodium Bicarbonate)
• x4 or more 5cc Syringes with Lidocaine with Epinephrine
• 30 gauge ½ inch needle
MEDICATIONS:
Take or Written Verbal Orders from Physician

Table 2. Procedure Checklist
? Preoperative photographs including a frontal view of the entire face, side views taken at 90? and 45? from each side
? Informed Consent
? Mapping of thread pathways while patient is sitting upright
? Injection of thread tracts with local anesthesia (generally 1% lidocaine with epinephrine)
? Confirmation of the number of threads needed
? Insertion of the threads and contouring
? Post-operative instructions and follow-up appointment given
? Procedure note documented in chart

Table 3. Sample Procedure Note
The patient received a fully informed consultation and consent prior to surgery and photographs were taken. The patient approved of an outline of ___________ threads on either side to elevate ________________________.
DESCRIPTION OF THE PROCEDURE: The pathways for the cogged threads were outlined with a gentian violet marking pen and the entire face was prepped with ________________ and draped sterily. _____________ cc’s of ____________________ was injected along the pathway on ___________________. The needle thread was inserted into the temporal subcutaneous tissue and advanced serpiginously to the exit point along the nasolabial fold, the oral commissure and the lower cheeks. The cogged thread was inserted and advanced fully. The needle was then extracted with cheek elevation. ______________ threads were placed on each _________________ and a similar pattern was used along the retroauricular neck and the medial neck area bilaterally. The tips of the suture were then clipped and the suture end was pushed back in the subcutaneous tissue.

The patient tolerated the procedure well and left the operating room in stable condition and will be discharged home.