Version of Record: https://www.sciencedirect.

com/science/article/pii/S2542432720300060
Manuscript_f12c99aa5e9d3777ba61a98ac729075d

Update on Thread-lifting

Leah K. Spring, DO FAAD (Corresponding author)

Fellow, SkinCare Physicians, Chestnut Hill MA
Leah.k.spring@gmail.com
160 Boylston St #1418
Chestnut Hill, MA 02467

Daniel J. Callaghan III, MD FAAD

Colorado Dermatology Specialists
Danieljcallaghan3@gmail.com

Disclosures:
Dr. Spring: The views expressed in this chapter are those of the authors and do not necessarily
reflect the official policy or position of the Department of the Navy, Department of Defense, nor
the US Government. Dr. Spring is a military service member: this work was prepared as part of
her official duties and as such is not eligible for copyright protection.
Dr. Callaghan: nothing to disclose.

KEYWORDS
Thread-lifting
Facial rejuvenation
Barbed sutures
Absorbable suspension sutures

KEY POINTS

• Women and men are increasingly seeking noninvasive facial rejuvenation procedures

with minimal downtimes, low cost, and low risk.

• Thread-lifting utilizes barbed or coned sutures placed along specific trajectories to lift the

superficial musculoaponeurotic system. Older sutures were made of non-absorbable

materials whereas newer sutures are made of absorbable materials.

• Both the degree and duration of cosmetic effect may be limited.

• There is a paucity of high-quality evidence in the medical literature regarding consistent

efficacy, safety, and longevity data on this procedure.

© 2020 published by Elsevier. This manuscript is made available under the Elsevier user license
https://www.elsevier.com/open-access/userlicense/1.0/
INTRODUCTION

Facial aging is the manifestation of predictable, progressive morphologic changes that begin as

early as the late twenties. The skin becomes thinner and loss of elasticity (a process accelerated

by exposure to ultraviolet light) leads to rhytids. Progressive lipoatrophy (specifically from the

buccal and malar fat pads, perioral and periorbital regions, and chin) creates a flat and hollow

appearance of the cheeks, infraorbital, and perioral region. Gradual weakening of the facial-

retaining ligaments of the cheek and the superficial muscular aponeurotic system (SMAS) cause

an elongated and accentuated nasolabial fold and ptosis of the mid and lateral face, respectively.

Finally, bony absorption of the maxilla and mandible enlarge the pre-jowl sulcus, creating the

“jowl.”1

Noninvasive procedures such as neurotoxins, injectable fillers, radiofrequency, chemical peels,

and laser resurfacing are highly effective tools for facial rejuvenation through softening of

dynamic movement and appearance of rhytids, volume replacement, skin tightening, and textural

improvement respectively, but they do not effectively address laxity of the underlying ptotic

tissues.2 Skin tightening procedures such as those using radiofrequency or ultrasound energy are

effective, but the results may not be dramatic enough to fully address the needs of some patients.

Surgical lifting with redundant skin excision (a SMAS rhytidectomy, or “facelift”), first

described in the literature in 19073, remains the gold standard procedure to correct age-associated

laxity and ptosis. Although surgical technique has evolved over the past 100 years, SMAS

rhytidectomy requires general anesthesia and is accompanied by possible complications such as

infection, hematoma, skin necrosis, seroma, and injury to the frontal and marginal branches of
the facial nerve. The procedure is also expensive ($6,000 to well over $15,000), results in well-

placed but permanent scars, and requires a 10-28 day recovery before the patient is able to return

to work.2 The permanence of the procedure is generally considered a desirable attribute, but not

in every case. For example, for some patients a SMAS rhytidectomy that looks natural shortly

after the procedure may look unnatural decades later as they continue to age. Patients

(particularly younger patients) have begun to seek out less invasive, less costly, and less risky

alternative interventions. According to the American Society for Aesthetic Plastic Surgery,

surgical facial rejuvenation saw a percent increase of 19.5% from 1997 to 2016, while

nonsurgical facial rejuvenation procedures increased 6,956.5% during the same time period.4

The use of a barbed suture to lift ptotic facial tissues (“thread-lifting”) was introduced in the late

1990s by Sulamanidze and colleagues.5 This procedure entailed the subcutaneous placement of

barbed sutures along a specific trajectories to lift and tack the ptotic tissue, and was billed as a

minimally invasive procedure with rapid recovery and results that approximated a surgical

facelift, but with fewer complications, shorter downtimes, decreased cost, and increased

convenience for both physician and patient.6 The original antiptosis suture Aptos (Aptos, Ltd.,

Moscow, Russia), a 2-0 polypropylene suture with bidirectional barbs, elicited positive results

initially, with 70% of patients retaining appreciable lift at 12 to 24 months, and 60% at 36

months (the time period still used in marketing promotions today). However, subsequent reports

detailing a number of complications including suture extrusion, asymmetry, pain, thread

migration, infections, granulomas, nerve damage, Stensen’s duct rupture, and scarring appearing

as late as two years after the procedure resulted in a decrease in popularity of the Aptos threads.7

Aptos threads are not cleared by the FDA.

Between 2001 and 2006, a variety of nonabsorbable and absorbable barbed sutures were

introduced, and the “lunch-time facelift” or “incisionless facelift” began to gain popularity.8,9

In 2004, the FDA approved thread lifting (Contour Lift, Contour Threads) for mid- and lower

facial rejuvenation. Contour Threads (Surgical Specialties, Corp., Reading, PA), 2-0

nonabsorbable polypropylene sutures with a central segment of unidirectional barbs, were

reported to produce average patient satisfaction of 6.9 on a scale of 1 to 10 and physician-rated

improvement of 4.6 on a scale of 1 to 10.10 Within 5 years of FDA approval, multiple studies

reported complication rates as high as 69% (intractable pain, dimpling, ecchymosis, contour

irregularity, swelling, infection, and thread extrusion)11, with 50% of patients experiencing

recurrence of laxity within 6 months11, and 42% requiring revisional surgery at an average of 8.4

months.12 FDA approval was revoked, and Contour Threads were removed from the market in

2007.

Silhouette Lifts (Sinclair Pharma, Irvine, CA), not to be confused with Silhouette Instalift, are

non-absorbable 3-0 polypropylene sutures with nine absorbable polylactide/glycolide copolymer

(PGMA) cones that are currently approved by the FDA for midface suspension surgery. A 2008

study involving 17 subjects found that at 9 months, 90% of subjects were ‘very satisfied’ with

the other 10% reporting they were ‘moderately satisfied’. In this study only minor adverse events

were reported.13 To our knowledge, no larger or longer-term studies were performed, and

Silhouette Lifts are not being actively marketed at this time in favor of Silhouette Instalift

(United States) and Silhouette Soft (Europe).

Because of the complications reported with nonabsorbable barbed sutures, there has been a shift

towards absorbable suture material. Polydioxanone (PDO) threads have been reported to

produce an immediate effect of tissue lifting secondary to the mechanical action of thread

insertion and setting, and despite being naturally degraded over 4-6 months, stimulate type 1

collagen and transforming growth factor-β1 (TGF-β1). However, this “long term effect” has its

limitations: while 160 patients who underwent barbed PDO thread placement for malar

augmentation, correction of nasolabial grooves, and mandibular lines noted immediate

improvement in facial ptosis, this effect was notably diminished by six months, and was absent

by one year. Over one-third of patients experienced a complication: superficial displacement

(11.2%), transient erythema (9.4%), infection (6.2%), skin dimpling (6.2%), and facial stiffness

(1.2%).14 There are a number of PDO threads on the market, including Quill Knotless Tissue-

Closure Device and Synthetic Absorbable Barbed Suture (Quill Medical, Inc., Research Triangle

Park, NC), Contour Thread Synthetic Absorbable PDO Barbed Suture (Surgical Specialties,

Corp) and PDS Barbed Sutures (Ethicon, Inc., Somerville, NJ). Although these threads are FDA

approved as suture materials, they are not cleared for mid-face suspension. Four separate studies

out of South Korea evaluating a total of 127 patients treated with PDO threads found patient

satisfaction rates to be higher than 86%.15,16,17,18 Suh et al found that in addition to the benefit of

lifting the tissue, 70% of patients had either ‘good’ or ‘excellent’ improvements in skin texture.15

Unfortunately, these studies were limited by a follow up of no longer than 7 months.

Poly-L-Lactic Acid (PLLA) Threads (Silhouette Soft sutures). The unique design and potential

collagen-stimulating properties of PLLA has sparked a growing interest in this type of thread.
Recently, interest in PLLA threads has grown, likely due to effective marketing that espouses

PLLA’s ability to regenerate collagen, creating results that “increase with time.” The sutures

(Silhouette Instalift in the United States and Silhouette Soft in Europe) are composed of a

monofilament thread made of PLLA and cones made of Polyglycolide/L-lactide (PLGA, which

is 82% L-Lactic acid—18% Glycolic copolymer). The use of cones rather than barbs is felt to

decrease the risk of dimpling, extrusion or palpability.19 Four to eight cones are positioned on

one side of the suture, with each set facing in opposite directions and pointed towards the end of

the suture (“bidirectional”).

Only a handful of studies have been published in the literature to date. A small pilot study of 20

women demonstrated clinical improvement in 75% at 6 months, and 55% at 1 year when rated

by blinded physicians using the Global Aesthetic Improvement Scale. Eighty percent of patients

experienced post-procedural edema, swelling, and skin contour irregularities, while 10%

developed paresthesias that resolved in 2-4 weeks. The authors concluded PLLA suture

placement was most effective in a very specific subset of patients: younger than 51 and with only

mild to moderate skin laxity of the jawline and neck angle.20 A study of 148 patients that did not

assess efficacy described an overall complication rate of 27%, most commonly skin dimpling

(11.4%), ecchymosis (8.1%), pain (2.7%), suture extrusion (2.7%), and suture migration

(1.35%).8

Ogilvie et al prospectively reviewed 100 patients treated by a single physician with absorbable

suture suspension for ptotic skin of the mid and lower face. An anonymous survey was sent to

patients and at 3 months revealed that 83% of responders found absorbable suture suspension to
be an effective treatment at improving age related change. Patient photographs were reviewed by

independent reviewers at 6 months who found that on average, facial volume deficits improved

by one degree on the Allergan Photometric Midface Volume Deficit Scale. Side effects were

mild and included edema and bruising, no signs of dimpling or excessive skin bunching. There

were no complaints of cone palpability after the first week. Notably 16% of patients underwent

additional suture placement for result enhancement, but all of these patients were for neck

concerns.21

Nestor conducted a prospected, masked study that followed 20 patients through 12 weeks and

extended the study to 12-months with 11 patients. Using 3D surface imaging he found that at

week 8, 85% of patients had facial lifts of 0.5mm or greater (p = 0.04), 50% had 1.0 mm or

greater (p = 0.08), and 30% had 0.5mm or greater (p = 0.03). At 12-months, although patients

continued to show lift, with 60% have 0.05 mm or greater, 50% having 1.0 mm or greater and

30% having 1.5 mm or greater, the number of subjects (11) was too small to show a statistically

significant difference. The procedure was well tolerated with minimal adverse events.22

Despite a paucity of evidence in the literature, PLLA threads are marketed as having “proven its

safety and efficacy all over the world” to “regenerate collagen,” producing results that “increase

over time.” Though an expert consensus concluded that patients do not require retreatment for 18

to 24 months, to our knowledge there are no studies beyond 12 months.23 In the literature, the

evidence for the sutures lasting 18 months largely comes from histologic evidence that PLLA

thread dissolves at 18 months, however there are no clinical studies that demonstrate efficacy for

this length of time.24

PROCEDURE AND TECHNIQUE

This section will focus on the technique for PLLA threads and does not directly apply to non-

absorbable or PDO threads. In the hands of an experienced surgeon, this procedure typically

takes between 30 and 45 minutes.

Preoperative Planning and Patient Selection

The ideal patient has strong bony projections with skin thick enough so the suture and cones are

not palpable. Patients with visible nasolabial folds or marionette lines, jowling or loss of

definition along the mandibular border are also excellent candidates. Patients with excessive skin

laxity or thin skin are non-ideal patients and may be better suited for a SMAS rhytidectomy.

Preoperative planning is a crucial and time-consuming part of the procedure. Although sutures

come in 3 sizes (8, 12 or 16), the 8-cone suture is best suited for the face.23 For patients with

mild to moderate mid-facial aging, 2 to 3 sutures per side is generally adequate, whereas for

patients with moderate to severe facial aging, 3 to 4 sutures per side is oftentimes necessary.

As with any surgical procedure, there are multiple ways to plan and execute the procedure that

needs to be tailored for the patient, but may vary from surgeon to surgeon. That said, an expert

consensus panel recommends ‘straight-line vector planning’ to achieve optimal results with these

threads.23 Placing the suture perpendicular to the plane it is designed to elevate increases the

lifting capacity of the suture and reduces the chance it could come displaced. By placing the

sutures in a straight line, the opposing cones of the sutures act in unison to provide maximum
support and lift, and also evenly distribute the sutures to maximize the collagen stimulated by the

PLLA.

The patient should be marked in full upright position so that gravity is naturally pulling the tissue

down. Once the tissue that needs to be lifted is identified (the ‘zone of action’), a single-entry

site and two exit sites are marked for each suture, with the exit site being placed approximately

1.5 cm past the zone of action. This should be repeated for the additional sutures, taking care to

adhere to straight-line vector planning. By placing the exit point 1.5 cm past the zone of action,

this ensures that the inferior-most cone stays within the zone of action.

Prep & Patient Positioning

Although the patient is marked fully upright, during the procedure they should be reclined at a

45-degree angle. The patient should be draped and scrubbed in fashion with any other surgical

procedure.

Procedural Approach

• Approximately 0.5 cc of 1% lidocaine with epinephrine is injected into the skin and

subcutaneous layer at entry and exit sites only. Injection along the needle pathway in the

subcutaneous plane is not required, as this part of the procedure should be painless. If the

patient experiences discomfort, the suture is in an incorrect plane.

• An 18-gauge needle, held perpendicular to the skin, is inserted into the subcutaneous

tissue, and then removed.

• The 23-gauge, 12 cm guiding needle of the suspension suture is inserted into the entry

site to a depth of 5 mm (utilizing the depth mark on the needle as a guide) and directed 90

degrees either superiorly or inferiorly along the desired axis of lift.

• The needle is advanced toward, then through the marked and anesthetized exit site. It is

important to maintain the 5 mm depth of the needle to ensure that the sutures are not

placed too superficially. Patient discomfort or resistance from the needle is an indicator

the needle is in an incorrect plane. If that occurs carefully withdraw the needle slightly

until you again find the correct plan.

• Once the needle exits the skin, carefully pull the suture through the entry point. A slight

amount of counter traction on the suture may allow it to more easily pass through the

tissue.

• The remaining needle is inserted through the same entry point, and directed in the

opposite angle towards the remaining exit site.

• After both ends of the suture are in position, apply tension to both sides of the suture. If

the suture is in the proper position, the skin will remain taught without any dimples at any

point along it. If there is a dimple at the entry point, this is a sign there is a skin bridge as

a result of the needles entering at slightly different points. This can be resolved with

either gentle massage or subcising the tissue with a needle.

• Next, cut off the needle from the suture. Grasp and apply tension onto the inferior aspect

of the suture and activate the cones by advancing the tissue over the lower cones (away

from the inferior suture). Then grasp the superior aspect of the suture and elevate the

tissue to its desired position. Anchor the tissue in place by advancing the tissue over the

superior cones (away from the superior suture) thereby activating them.
 • Pause a few minutes to allow the sutures to settle, and reevaluate the patient and further

adjust the sutures as necessary.

• When all sutures are in place, sit the patient back up to an upright position and revaluate

them and readjust the threads as necessary. Trim the sutures so they are not exiting the

skin.

Immediate Post-Procedural Care

• After the procedure, an emollient should be placed over the insertion and exit sites and

ice should be applied for 30 minutes.

• At home, patients should be encouraged to apply ice for 24 hours, however care should

be taken to avoid applying substantial pressure, as this can be deleterious.

• Slight puckering may be observed, however this is transient and should resolve in 2 to 3

day.

• For one week after the procedure, patients should be instructed to avoid strenuous activity

or any activity that results in force being applied to the face. As best as possible, facial

expressions that distort the face should be avoided.

COMPLICATIONS

Unmet expectations from patients anticipating dramatic and durable results from an “incisionless

facelift” can be attenuated by a frank discussion on the limitations of thread-lifting. The

informed consent discussion should also include full disclosure of both the acute and

chronic/delayed-onset complications associated with this procedure. As FDA approval was

revoked for Contour Threads because of a high complication rate, the following discussion will

focus on threads still available in the market.

Immediate Postprocedural Complications

Postoperative ecchymosis and swelling are the most commonly experienced side effects,

reported to affect between 47-93% and 43-100% of patients, respectively.13,15,20,25 Other common

acute complications include mild to moderate erythema (40%) and bleeding (25%).26

Paresthesia along suture trajectories (10%) appears to resolve in 2-4 weeks.20

Other acute complications include skin dimpling (5.1% - 11.4%),8,17,18 thread extrusion (2.5-

2.7%,8,17 and visible dermal pinching (3.5%).19 Parotid gland injury27 and severe bitemporal

alopecia28 have also been reported. The risk of all immediate postprocedural complications

appears to increase with the number of threads used.10

Thread-Related Complications

Early thread breakdown and/or failure can occur during repeated stress of facial movement,29 or

when the threads are exposed to other foreign material. Patients who pursue thread-lifting may

have also had, or are planning to, undergo other noninvasive facial rejuvenation procedures such

as injection of hyaluronic acid, the most common filler.4 While it has been suggested that thread-

lifting is more effective when combined with other procedures,6,30 a recent in-vitro study

demonstrated that HA accelerates biodegradation of the suture beginning as soon as 24 hours

after contact via hydrolytic degradation.31 Whether this is relevant in a clinical scenario has yet

to be determined.

Delayed complications

Granulomatous infections presenting 2 weeks to 6 months after thread-lifting have been

described in 5 case reports, but it should be noted that the threads that were reported in these

cases were polyprolene or PDO in composition (although the authors of one case in Thailand

were unable to identify the type of thread).32,33,34,35,36 All patients presented with inflammatory

nodules, erythematous plaques, and ulcers over the nasolabial folds, cheeks, and preauricular

areas, strikingly along the distribution of the threads. Despite aseptic technique during the

procedure, tissue cultures identified Mycobacterium massiliense (a rapidly growing

nontuberculous mycobacterium),35 M. absessus,36 M. fortuitum,32 and Acinetobacter lwoffi .33

All cases resolved with surgical removal and long-term oral antibiotics, however permanent

scarring occurred.

COMPLICATION PREVENTION

• Comprehensive knowledge of facial anatomy in three-dimensions to include the parotid

gland, and the location of facial nerves, arteries, and veins (as well as their anatomic

variances) is critical before performing this “non-invasive” technique.

• Aseptic technique must be employed: the patient should be prepared and draped in the

usual sterile fashion as for any surgical procedure.

• Gentle application of icepacks following the procedure reduces immediate discomfort,

edema, and bleeding.

 • Patients may take acetaminophen (with or without a mild opioid) for moderate to severe

post-procedural pain. Aspirin and ibuprofen should be avoided to minimize hematoma

development.

• Patients should avoid excessive facial movements (full smiles, laughter, violent

coughing, yawning), manual manipulation of the treated area, and strenuous exercise in

the immediate post-procedural period, all of which have been associated with rupture of

the anchoring site and abrupt loss of tightening.

• Patients should be instructed to sleep on their backs, with their head elevated for the first

few nights after surgery. A travel pillow that fits closely around the neck may be used for

several weeks to limit nocturnal motion and ensure a proper sleeping position.9

COMPLICATION TREATMENT

• Suture protrusion (visible, palpable, or subjectively appreciated by the patient) may

resolve with time as a fibrotic cap forms around the distal end of the suture. If the patient

cannot tolerate this sensation, or if the protrusion does not resolve, the distal end may

need to be located, moved extracutaneously, and cut shorter.9

• Asymmetry, dimpling, or linearity (most noticeable under the thin skin of the temples and

neck) can be corrected by a technique described by Horn and Kaminer: firmly apply

retrograde pressure along a suture, thereby forcing release of the underlying barbs from

their attachment to fibrous septae. This produces a “clicking” sensation under the

surgeon’s finger. Threads can be released up to 9 weeks postoperatively, though it

becomes increasingly difficult to do so after the third week.9

 • Erythematous nodules in the distribution of threads should be biopsied for tissue culture

(bacteria, mycobacteria, and fungal). A long-term oral antibiotic regimen (500 mg

clarithromycin twice daily, 100 mg doxycycline twice daily, and 1g amikacin (decreased

to 500 mg daily after 2 months of therapy) for 4-6 months should be initiated. Surgical

removal of the threads is strongly recommended despite the risk of scarring.34

DISCUSSION

Thread-lifting is growing in popularity, a trend fueled by patients’ desire for minimally invasive

procedures, effective marketing by manufacturers, and promotion on social media by both lay

press and medical personnel from multiple backgrounds and tiers of training. This trend will

likely continue as thread-lifting is increasingly marketed and perceived as less of a medical

procedure and more as a beauty treatment.

Commoditization of the Procedure

Compounding this issue is the influx of for-profit “certification” courses open to physicians,

nurses, dentists, medical assistants, and chiropractors. “Cosmetically inclined providers” can

pay up to $1700 to attend a one-time four to eight-hour course to learn the “excellent treatment

option” with “very few contraindications, side effects, and no to minimal down time” with

results that last “1-2 years” and “get better over time.” According to the course websites, thread-

lifting can be expected to generate revenues of three hundred to thirty-five hundred dollars per

treatment. Though these courses promise hands-on training, an informal inquiry to a course

representative revealed that attendees observe treatment during the course, and must bring their

own patients should they wish to practice a skill while under instruction.
Lack of Evidence

As of late 2019, there are no randomized controlled trials utilizing thread lifts for facial ptosis in

the literature. The available body of evidence for facial rejuvenation with barbed sutures is

weak (level of evidence III, at most): the majority of studies have short follow-up periods (most

less than 1 year, no studies longer than 3 years), confounding factors (thread-lifts in combination

with other rejuvenation procedures), no standardized protocols, and no control groups.2,7,37 The

overwhelming majority of the studies’ conclusions are based on subjective assessments (patient-

reported satisfaction) rather than objective measurements.2 One study that did use a control

group and blinded surgeon utilizing an aesthetic grading scale concluded that the thread-lift

provides only limited, short-term improvement that may be largely attributable to post-

procedural inflammation and edema, and considering the “measurable risk of adverse events and

patient discomfort” concluded the evidence could “not justify further use of this procedure for

facial rejuvenation”,6 although this study was with the now discontinued Contour Threads.

Several of the studies published on PLLA threads were funded by Sinclair Pharma, who

manufactures the threads.

Conclusions

Despite the public’s demand for innovative, minimally invasive technology and manufacturer

claims of efficacy and longevity, physicians must remain committed to patient safety, and remain

skeptical of new technology until presented with high-quality, reproducible, controlled, long-

term evidence that consistently demonstrates safety and efficacy. Practitioners who rely on FDA

approval should be cautioned that FDA approval does not necessarily constitute efficacy.38 After
approximately 30 years of use, thread-lifting can no longer be considered “new technology,”

however the lack of consistent evidence is telling. There is likely a role for thread-lifting in

facial rejuvenation as a technique that can elicit subtle, temporary improvement of facial ptosis

in the appropriate patient. Thread-lifting is not, and should not be promoted as, a low-risk

substitution for a surgical facelift. The procedure is likely best performed by a skilled, board

certified physician on a patient who has been made aware of and is willing to accept the both the

potential risks and transient benefit.

1. Bogle MA, Arndt KA, Dover JS, et al. Evaluation of the aging face. In: Kaminer MS,

Arndt KA, Dover JS, Rohrer TE, Zachary CB, editors. Atlas of Cosmetic Surgery, 2nd

edition. Philadelphia: WB Saunders; 2009. p. 37-43.

2. Tavares JP, Oliveira CA, Torres RP, et al. Facial thread lifting with suture suspension.

Braz J Otorhinolaryngol. 2017;83:712-9.

3. Miller CC. Subcutaneous section of the facial muscles to eradicate expression lines. Am

J Surg. 1907;21:235.

4. Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J. 2017;37 (suppl 2):1-

29.

5. Sulamanidze MA, Fournier PF, Paikidze TG, et al. Removal of facial soft tissue ptosis

with special threads. Dermatol Surg 2002;28:367-71.

6. Abraham RF, DeFatta RJ, Williams EF. Thread-lift for facial rejuvenation: assessment

of long-term results. Arch Facial Plast Surg 2009;11:178-83.

7. Tong LX, Rieder EA. Thread-lifts: a double-edged suture? A comprehensive review of

the literature. Dermatol Surg. 2019 Jul;45(7):931-940.

8. Sarigul Guduk S, Karaca N. Safety and complications of absorbable threads made of pol-

L-lactic acid and poly lactide/glycolide: experience with 148 consecutive patients. J

Cosmet Dermatol 2018;17:1189-93.

9. Horn D, Kaminer MS. Suture suspension lifts. In: Kaminer MS, Arndt KA, Dover JS,

Rohrer TE, Zachary CB, editors. Atlas of Cosmetic Surgery, 2nd edition. Philadelphia:

WB Saunders; 2009. p. 505-516.

10. Kaminer MS, Bogart M, Choi C, Wee SA. Long-term efficacy of anchored barbed

sutures in the face and neck. Dermatol Surg 2008;34:1041-7.

11. Rachel JD, Lack EB, Larson B. Incidence of complications and early recurrence in 29

patients after facial rejuvenation with barbed suture lifting. Dermatol Surg 2010

Mar;36(3):348-54.

12. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes in threadlift for facial rejuvenation.

Ann Plat Surg 2009 May;62(5):482-5.

13. Gamboa GM, Vasconez LO. Suture suspension technique for midface and neck

rejuvenation. Ann Plast Surg 2009 May;62(5):478–81.

14. Bertossi D, Botti G, Gauldi A, et al. Effectiveness, longevity, and complications of

facelift by barbed suture insertion. Aesthet Surg J. 2019 Feb 15;39(3):241-247.

15. Suh DH, Jang HW, Lee SJ, et al. Outcomes of polydioxanone knotless thread lifting for

facial rejuvenation. Dermatol Surg. 2015;41:720-725.

16. Kim J, Kim HS, Seo JM, et al. Evaluation of a novel threadlift for the improvement of

nasolabial folds and cheek laxity. J Eur Acad Dermatol Venereol 2017;31:e136–e179.
17. Kang SH, Byun EJ, Kim HS. Vertical lifting: a new optimal thread lifting technique for

Asians. Dermatol Surg 2017;43:1263–70.

18. Lee H, Yoon K, Lee M. Outcome of facial rejuvenation with polydioxanone thread for

Asians. J Cosmet Laser Ther 2018;20:189–92

19. de Benito J, Pizzamiglio R, Theodorou D, et al. Facial rejuvenation and improvement of

malar projection using sutures with absorbable cones: surgical technique and case series.

Aesthetic Plast Surg. 2011;35(2):248-253.

20. Guida S, Persechino F, Rubino G, et al. Improving mandibular contour: a pilot study for

indication of PPLA traction thread use. J Cosmet Laser Ther. 2018 Nov – Dec;20(7-

8):465-469.

21. Ogilvie MP, Few JW Jr, Tomur SS, et al. Rejuvenating the Face: An Analysis of 100

Absorbable Suture Suspension Patients. Aesthet Surg J. 2018 May 15;38(6):654-663. doi:

10.1093/asj/sjx202.

22. Nestor MS. Facial Lift and Patient Satisfaction Following Treatment with Absorbable

Suspension Sutures: 12-Month Data from a Prospective, Masked, Controlled Clinical

Study. J Clin Aesthet Dermatol. 2019 Mar;12(3):18-26. Epub 2019 Mar 1.

23. Lorenc ZP, Goldberg D, Nestor M. Straight-line vector planning for optimal results with

Sihouette InstaLift in minimally invasive tissue repositioning for facial rejuvenation. J

Drugs Dermatol. 2018 July 1:17(7)786-793.

24. Kapicioğlu Y, Gül M, Saraç G, et al. Comparison of Antiaging Effects on Rat Skin of

Cog Thread and Poly-L-Lactic Acid Thread. Dermatol Surg. 2019 Mar;45(3):438-445.

doi: 10.1097/DSS.0000000000001717.
25. Lycka B, Bazan C, Poletti E, et al. The emerging technique of the antiptosis subdermal

suspension thread. Dermatol Surg. 2004 Jan;30(1):41-4; discussion 44.

26. Savoia A, Accardo C, Vannini F, et al. Outcomes in thread lift for facial rejuvenation: a

study performed with happy lift revitalizing. Dermatol Ther. 2014 Jun;4(1):103-14.

27. Yeo SH, Lee YB, Han DG. Complications of the absorbable thread archives of aesthetic

plastic surgery. Arch Aesthetic Plast Surg 2017;23:11-16.

28. Paik SH, Kim HT, Chang SE. Severe bitemporal alopecia as a complication of the

thread lift procedure. Dermatol Surg. 2019 Jul45(7):983-986.

29. Paul MD. Complications of barbed sutures. Aesthet Plast Surg, 32 (2008) 32:149.

30. Ali YH. Two years’ outcome of thread lifting with absorbable barbed PDO threads:

innovative score for objective and subjective assessment. J Cosmet Laser Ther. 2018

Feb;20(1):41-49.

31. Suarez-Vega DV, Velazco de Maldonade GJ, Ortiz RL, et al. In vitro degradation of

polydioxanone lifting threads in hyaluronic acid. J Cutan Aesthet Surg. 2019 Apr-

Jun;12(2):145-148.

32. Cruz Hofling C, Costa Panunto A, Alves Bensi EP, et al. Infection of polypropylene

threads for face-lifting with Mycobacterium fortuitum. Dermatol Surg. 2007

Apr;33(4):492-5.

33. Kasai H, Yashiro K, Kawahara Y. Multiple ulcers on the face due to infection after

thread-lifting. J Dermatol. 2018 Dec;45(12):e336-337.

34. Ahn SK, Choi HJ. Complication After PDO Threads Lift. J Craniofac Surg. 2019

Jul;30(5):e467-e469.
35. Shin JJ, Park JH, Lee JM, et al. Mycobacterium massiliense infection after thread-lift

insertion. Dermatol Surg. 2016 Oct;42(10):1219-22.

36. Yau B, Lang C, Sawhney R. Mycobacterium abscessus abscess post-thread facial

rejuvenation procedure. Eplasty 2015;15:ic19.

37. Gulbitti HA, Colebunders B, Pirayesh A, et al. Thread-lifting sutures: still in the lift? A

systematic review of the literature. Plast Reconstr Surg. 2018 Mar;141(3):341e-347e.

38. Osboun CA, Williams EF. A decade of thread-lifting—what have we learned over the

last 10 years? JAMA Facial Plastic Surgery. 2018;20(5):349-350.