ORIGINAL ARTICLES
Effect of Cog Threads under Rat Skin
HYO JOOK JANG, MD, MS,✽ WON SEOK LEE, MD,† KUN HWANG, MD, PHD,✽ JUN HO PARK, MD,✽ AND DAE
JOONG KIM, PHD‡
✽
Department of Plastic Surgery, College of Medicine, Inha University, Incheon, Korea; †Dr. Lee’s Aesthetic Plastic
Surgical Clinic, Seoul, Korea; ‡Department of Anatomy, College of Medicine, Inha University, Incheon, Korea
BACKGROUND. The aging face loses the tensile strength of struc-
tural integrity. Cog threads have been used recently to tighten lax
skin and soft tissue.
OBJECTIVE. A comparative study of the effects of cog, monofila-
ment, and multifilament threads under rat skin.
METHODS. Each cog, monofilament, and multifilament thread was
inserted under the facial skin of a cadaver and the panniculus
carnosus of rat dorsal skin. The maximum holding strength
(MHS) of the thread and the tearing strength of the skin around
the thread were measured with a tensiometer. The thickness of
the capsule around the thread and the myofibroblasts was
observed histologically.
RESULTS. In the cadaver, the MHS of the cog thread was 190.7

65.6 g. It was greater than that of the monofilament (22.4
7.7
g) or multifilament (40.4
19.7 g) thread. In the rat, the MHS
THIS STUDY WAS SUPPORTED BY A GRANT FROM THE KOREA HEALTH 21 R&D PROJECT, MINISTRY OF
HEALTH AND WELFARE, REPUBLIC OF KOREA.
THERE ARE many articles on the subject of facial rejuve-
nation surgery. The less invasive the surgery is, the faster the
recovery is. In cases of evasive surgical indications or reluc-
tance to undergo aggressive esthetic surgery, a simpler
method may be desirable because the result is satisfactorily
acceptable. Recently, Sulamanidze and colleagues and
Lycka and colleagues exploited a technique to employ
antiptosis subdermal suspension threads (APTOS, Moscow,
Russia).1,2 The biocompatible smooth thread is rigged with
many thorny cogs. The cog is buried under the skin, and it
pulls the suspended tissue in a uniform direction of traction.
Owing to the absence of major surgical trauma and signifi-
cant morbidity, the use of cog thread became a prevailing
option in rejuvenation of the aging face. However, it is
uncertain yet how cog threads maintain the skin in traction.
The aim of this study was to compare the effectiveness
of cog thread under rat skin with that of monofilament
Address correspondence and reprint requests to: Kun Hwang, MD,
PhD, Department of Plastic Surgery, College of Medicine, Inha Uni-
versity, 7–206, 3-Ga, Sinheung-dong, Jung-gu, Incheon 400–711,
Korea; or e-mail: jokerhg@inha.ac.kr.
© 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc
ISSN: 1076–0512 • Dermatol Surg 2005;31:1639–1644.
of the cog thread was 95.1
18.8 g. It was greater than that of
the monofilament (4.3
1.3 g) or multifilament (10.9
2.1 g)
thread in the second week. The thickness of the capsule around
the cog thread was 93.0
3.2 µm. It was thicker than the
monofilament thread’s capsule, 39.2
12.1 µm, in the fourth
week. The number of myofibroblasts presented significantly
more in the cog (96.0
72.4) than in the monofilament thread
(4.3
4.4). The rumpled in-between skin suspended by each of
the three different threads returned to its original state in 2
weeks.
CONCLUSION. The cog thread placed under the rat skin immedi-
ately pulled the skin and subcutaneous tissue. The myofibrob-
lasts around the thread played a role in fibrous tissue contracture
4 weeks postinsertion of the thread. These findings could be the
basis for clinical application.
and multifilament thread and to gain insight into how the
cog thread works.
Materials and Methods
Materials
Tensiometer
We designed a tensiometer for this study. The apparatus
measures either the maximum holding strength (MHS) of
the thread to pull the thread out of the skin or the tearing
strength of the skin around the thread. Two load cells
(capable of weighing 0.3 g to 3 kg and 5 g to 50 kg) were
mounted on the weight reading scale, which is controlled
by a motorized test stand.
Cadaver
The right cheeks of 10 formalin-preserved Korean cadav-
ers were used for the study.
Rat
One hundred fourteen Sprague-Dawley rats (weight 400 g)
were used in the study. The rats were divided into four
groups:
1640 JANG ET AL: EFFECT OF COG THREADS UNDER RAT SKIN
1. Monofilament group: 2-0 monofilament (Prolene,
Ethicon, Inc, Somerville, NJ, USA)
2. Multifilament group: 2-0 multifilament (Vicryl,
Ethicon, Inc)
3. Cog thread group: 2-0 cog thread (Aptos, APTOS)
4. Control group: spinal needle inserted and removed
without threading
Methods
Facial Skin of the Cadaver
Two monofilament, two multifilament, and two cog
threads were introduced under the right cheeks of 10
embalmed Korean cadavers (Figure 1). The MHS of the
thread was measured by a unit of gram weight.
Figure 1. The operative design for the cadaveric test.
Figure 2. Threading under the rat dorsal skin. After threading through the spinal needle to the length of 5 cm (upper), the skin was rumpled
and shortened to a length of 3.5 cm by pulling both ends of the thread (lower). D = dermis; E = epidermis; M = muscle layer; P = panniculus
carnosus.
Dermatol Surg 31:12:December 2005
MHS of Rat Dorsal Skin
Rats were anesthetized by intraperitoneal injection of 4%
chloral hydrate (0.8 mL/100 g body weight), and a 4 
8 cm2 area on the backs was prepared. Each kind of thread
was buried in the panniculus carnosus under the dorsal
skin of 54 rats (Figure 2). The entering and exiting points
of the thread were pulled together so that a 50 mm–long
in-between skin (the skin between the entrance and exit
points of the thread) was rumpled and shortened to 35 mm
and fixed on the skin with retention sutures.
Two and 4 weeks later, one end of the installed thread
was cut and the other end was hooked to the tensiometer.
The MHS of the thread was measured by a unit of gram
weight, and the distance of the thread moved in the skin
was measured.
Rat Dorsal Skin: Change in the In-Between Skin Pulled
by Both Ends of the Thread
The rat dorsal skin, 50 mm long, was rumpled to 35 mm
by pulling with monofilament, multifilament, and cog
thread. The length of the in-between skin at the entrance
and exit of each different thread was measured with a
Vernier caliper (Mitutoyo Corp. Tokyo, Japan) at an inter-
val of 2 and 4 weeks after installing the thread.
Rat Dorsal Skin: Tensile Strength to Tear the Skin
around the Thread
We measured the tensile strength needed to tear the skin of
the monofilament group, cog thread group, and control
group at 2 and 4 weeks after the operation.
The 36 rats were divided equally into groups. The skin
and the panniculus carnosus were harvested according to
the preoperative design. After harvesting, the incision was
done with a number 11 blade on both sides of the skin
Dermatol Surg 31:12:December 2005
(Figure 3). The skin was put on the stand, and both ends
were gripped by the tensiometer. Then the skin was torn by
the grip of the tensiometer, recording the tensile strength
and the distance of skin stretched.
Thickness of the Capsule and Myofibroblasts
For a histologic study, a 1  0.5 cm specimen of the cap-
sule including monofilament and cog thread was obtained
at 2 and 4 weeks. The sample was treated with 10%
formaldehyde solution for 24 hours, cut in 20 µm thick-
ness, and washed three times every 5 minutes with 0.1%
mol/L phosphate-buffered saline solution. Then it was
dehydrated with alcohol by decreasing the concentration
and was washed in distilled water for 5 minutes and three
times every 5 minutes in phosphate-buffered saline solu-
tion. The sliced sample was coated with normal goat
serum followed by an application of primary antiserum
and kept at room temperature for 24 hours. Monoclonal
 smooth muscle actin antibody was employed to detect
the myofibroblast. The prepared sample slide was coun-
terstained with hematoxylin, viewed under a light micro-
scope, and photomicrographed. The myofibroblasts in the
capsule and 30 µm around the capsule were counted.
Statistical Analysis
Statistical analysis was done by the Kruskal-Wallis test.
Results
Facial Skin of the Cadaver
The MHS of the monofilament, multifilament, and cog
threads was 22.3
7.65 g, 40.4
19.66 g, and 190.7

65.0 g, respectively. The cog thread held significantly more
than the other threads (p = .000). The distance that the
monofilament, multifilament, and cog threads moved in
the skin was 7.9
5.81 mm, 9.3
9.63 mm, and 22.6

9.88 mm, respectively. The distance of the cog thread
group was significantly longer than that of the other
groups (p = .000).
Figure 3. The skin for the tearing test.
JANG ET AL: EFFECT OF COG THREADS UNDER RAT SKIN 1641
MHS of Rat Dorsal Skin
Immediate MHS
The immediate MHS of the monofilament, multifilament,
and cog threads was 4.1
0.4 g, 11.4
2.4 g, and 68.0

26.9 g, respectively. The cog thread held significantly
more than the other threads (p = .001). The distance that
the monofilament, multifilament, and cog threads moved
in the skin was 8.3
6.3 mm, 12.0
8.5 mm, and 20.1

11.1 mm, respectively. There was no significant differ-
ence between the distances (p = .102).
MHS at 2 Weeks
At 2 weeks, the MHS of the monofilament, multifilament,
and cog threads was 4.3
1.3 g, 10.9
2.1 g, and 95.10

18.8 g, respectively. The cog thread held significantly
more than the others (p = .001). The distance of the
monofilament, multifilament, and cog groups was 8.3

6.3 mm, 12.0
8.5 mm, and 20.1
11.1 mm, respec-
tively. The distance of the cog thread group was signifi-
cantly longer than that of the other groups (p = .002).
MHS at 4 Weeks
At 4 weeks, the MSH of the monofilament, multifilament,
and cog threads was 5.1
0.7 g, 12.5
2.3 g, and 83.9

27.7 g, respectively. The cog thread held significantly
more than the others (p = .001). The distance of the
monofilament, multilfilament, and cog thread groups was
13.7
8.4 mm, 16.7
11.8 mm, and 27.7
10.2 mm,
respectively. There was no significant difference between
the distances (p = .076).
Change in MHS
The MHS of the cog thread increased significantly in 2
weeks, whereas the MHS of the monofilament and multi-
filament threads did not change significantly with time.
Rat Dorsal Skin: Change in the In-Between Skin
Pulled by Both Ends of the Thread
The entering and exiting points of the thread were pulled
together so as to rumple and shorten the 50 mm–long in-
between skin to 35 mm and were fixed on the skin with
sutures. As one end of the monofilament and multifila-
ment thread was cut, the rumpled skin returned immedi-
ately to its original length, but the cog threaded skin was
35 mm immediately postoperatively. But the length of the
skin with the cog thread was significantly increased to 49

1.0 mm at 2 weeks (Figure 4). The other groups showed
no significant change in length with time.
Rat Dorsal Skin: Tensile Strength to Tear the Skin
around the Thread
2 Weeks Later
The tensile strength of the control group was 10.4

1.3 kg and that of the monofilament group was 9.3

1642 JANG ET AL: EFFECT OF COG THREADS UNDER RAT SKIN Dermatol Surg 31:12:December 2005

2.1 kg. The strength of the cog thread group was 10.1

2.4 kg. There was no significant difference between the
strengths (p = .461). The length that the skin of the con-
trol, monofilament, and cog thread groups stretched until
tearing was 22.1
4.8 mm, 29.5
7.3 mm, and 20.5

1.1 mm, respectively. There was no significant difference
between the distances (p = .023).
4 Weeks Later
The tensile strength of the control and monofilament
groups was 10.9
0.8 kg and 9.8
1.0 kg, respectively.
The strength of the cog thread group was 9.6
2.4 kg.
There was no significant difference between the strengths
(p = .241). The length of the control, monofilament, and
15.0
Stretched skin length (mm)
cog thread groups was 15.2
1.6 mm, 18.0
2.0 mm,
and 18.5
4.0 mm, respectively. There was no significant
difference between the distances (p = .054).
Thickness of the Capsule and Myofibroblasts
2 Weeks Later
No capsular formation was seen around the monofilament
thread at 2 weeks. One of nine cog threads formed a cap-
sule. On three occasions, acute inflammatory and minimal
fibrosis reactions were seen. The thickness of the capsule
was 43.5 µm.
4 Weeks Later
The monofilament and cog thread groups induced capsule
formation, except one slide of the monofilament group. All
nine cogs and eight of nine monofilament threads formed
capsules. The capsule consisted of fibroblasts, extracellu-

monofilament
mutifilament lar collagen, neovascularization, and inflammatory cells
cog thread (Figure 5). The thickness of the capsule around the cog
10.0
thread was 93.0
32.1 µm, which was thicker than the
monofilament thread (39.2
12.1 µm) (p = .028). As
many as 90.6
72.4 of myofibroblasts were seen in the
5.0
capsule and 30 µm around the capsule of the cog thread
and 4.3
4.4 in the monofilament thread (p = .006).
0.0
0 1 2 3 4 Discussion
Time (week) This study was done to observe the effect of cog thread
Figure 4. The change in the in-between skin pulled by both ends of under the skin, making a comparison with monofilament
the thread. and multifilament thread. We developed a tensiometer,

Figure 5. Microphotograph of the capsule around the cog thread (A, C) and the monofilament thread (B, D). The capsule around the cog
thread was thicker than that of the monofilament. There were more myfibroblasts (arrows, C) in the capsule of the cog thread than in that
of the monofilament (arrow, D). A and C: hematoxylin-eosin stain; 100 original magnification; B and D: hematoxylin-eosin stain; 400 orig-
inal magnification.
Dermatol Surg 31:12:December 2005
which can measure the tensile strength by a unit of weight
of 0.3 g to 3 kg for MHS and 5 g to 50 kg for tearing
strength. In the cadaver, the MHS or tearing strength of
the cog thread was 190.7 g. It was significantly greater
than the strength of the monofilament or multifilament
thread. The force of 190 g is higher than the force required
to epilate five hairs of a healthy man at once3 or the early
orthopedic maxillary expanding force of the cleft palate.4
We observed three different kinds of thread in the pan-
niculus carnosus, a thin well-defined subcutaneous muscle
layer under the dorsal skin of the rat. Each rat was kept in
an isolated cage so as not to disturb the installed thread.
The MHS of the cog thread was 95.1 g on average at 2
weeks. It was more than the MHS of the monofilament
and multifilament threads but less than 190.7 g in the
cadaver. The cog thread threshold was inferior in the pan-
niculus carnosus to the superficial musculoaponeurotic
system of the cadaver cheek.
The rumpled and shortened in-between skin pulled by
the thread returned to its original status 2 weeks after the
operation. This was due to the fact that the rat’s pannicu-
lus carnosus is more flexible and stretchy than human
facial skin and its MHS was only one-third of that of the
cadaver in our study.
We also measured the tensile strength needed to tear the
skin around the thread. But there was no significant dif-
ference between groups. From this result, we know that
the thread had no effect on the force needed to tear the
skin around it.
The capsule was not formed in 2 weeks except in one of
nine cases but was found in all cases except one in 4
weeks. The capsulation around the cog thread was
remarkably thicker than that of the monofilament. A
thorny cog might cause significant damage to the soft tis-
sue and scar formation. We used monoclonal  smooth
muscle actin antibody for immunostaining myofibroblasts
in the capsule. Contractile fibroblasts, known as myofi-
broblasts, are assumed to be an active culprit in wound
contraction. Originally described by Gabbiani and Ryan
and their colleagues,5,6 myofibroblasts have also been
found in other conditions, such as Dupuytren’s contrac-
ture7 and the contracture of fibrous capsules around sili-
cone breast implants.8 They share the electron microscopic
characteristics of fibroblasts and of smooth muscle cells
and have specific life cycles. They are apparent during the
active phase of wound contraction and more prominent in
JANG ET AL: EFFECT OF COG THREADS UNDER RAT SKIN 1643
3 weeks; after 8 weeks, the myofibroblasts decrease. At 20
weeks, by which time the wound is stable, they cannot be
seen.9,10 They are commonly seen in fibrous capsules, indi-
cating that the contraction of these fibrous capsules is sim-
ilar to the contraction of scar tissues in other areas of the
body. More myofibroblasts in the capsules exert more con-
tractile force.
In our study, myofibroblasts were found in all capsules
around the threads and were more prominent in the cog
thread than in the monofilament thread. Therefore, the
numerous cogs of the thread could induce stimuli for the
formation of myofibroblasts. Finally, we are unsure that
the result of our study is supportive in clinical application
at this time. Yet the cog application has a lot of impact on
lax skin surgery. A long-term study in live facial skin is
required to obtain further information on the effectiveness
of the cog thread.
Acknowledgments We thank Robert S. Chung, MD, FACS, pro-
fessor emeritus, Konyang University, Daejeon, Korea, for review-
ing the manuscript. We are also grateful to Kwan Hyun Youn,
MA, for his illustrations.
References
1. Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze GM.
Removal of facial soft tissue ptosis with special threads. Dermatol
Surg 2002;28:367–71.
2. Lycka B, Bazan C, Poletti E, Treen B. The emerging technique of the
antiptosis subdermal suspension thread. Dermatol Surg
2004;30:41–4.
3. Smelser DN, Smelser NB, Krumdieck CL, et al. Field use of hair epi-
lation force in nutrition status assessment. Am J Clin Nutr
1982;35:342–6.
4. Robert M. A statement regarding early treatment. Am J Orthod
Dentofac Orthop 2000;117:556–8.
5. Gabbiani G, Ryan GB, Majno G. Presence of modified fibroblasts in
granulation tissue and possible role in wound contraction. Experien-
tia 1971;27:549–50.
6. Ryan GB, Cliff WJ, Gabbiani G, et al. Myofibroblasts in human
granulation tissue. Hum Pathol 1974;5:55–67.
7. Gabbiani G, Majno G.. Dupuytren’s contracture; fibroblast contrac-
tion? An ultrastructural study. Am J Pathol 1972;66:131–46.
8. Rudolph R, Abraham J, Vecchione T, et al. Myofibroblasts and free
silicon around breast implants. Plast Reconstr Surg 1978;62:185–96.
9. Gabbiani G, Hirschel BJ, Ryan GB, et al. Granulation tissue as a con-
tractile organ: a study of structure and function. J Exp Med
1972;135:719–32.
10. Rudolph R, Guber S, Suzuki M, Woodward M. The life cycle of the
myofibroblast. Surg Gynecol Obstet 1977;145:389–94.
1644 JANG ET AL: EFFECT OF COG THREADS UNDER RAT SKIN
Commentary
This is an important basic science study to complement the exist-
ing clinical published studies (Sulamanidze, Lycka) concerning
cog threads. The basic premise supposes that the cogs will induce
a fibrotic reaction within skin and fascia, which will induce con-
tracture, producing a lifting effect with a positive effect on the
aging face. The studies examine the biomechanical effect of cogs
versus suture on cadaver skin as well as a rat skin model meas-
uring tensile strength and distance of skin movement over time.
Dermatol Surg 31:12:December 2005
In both instances, the cog thread suture was significantly more
effective in holding lax skin in place. In addition, the histologic
studies demonstrating myofibroblasts and fibrous tissue sur-
rounding the cogged sutures only add a scientific explanation to
the clinical effect seen with “cogged threads.” These conclusions
should stimulate further work to evaluate why and how the
threads respond in different clinical situations.
GARY MONHEIT, MD
Birmingham, AL