In response to patients looking to avoid the cost and risk associated with surgical facial rejuvenation, plastic surgeon Marlen Sulamanidze, PhD, introduced a barbed suture to lift ptotic facial tissues in the late 1990s. However, this treatment soon fell out of favor, due to temporary results that were riddled with reports of complications.
Neverthless, this was not the end of the road for suspension sutures. In 2002, the technology progressed from the original antiptosis sutures when Woffles Wu, MD, developed a technique using bidirectional barbed sutures to suspend facial tissue from a fixed point within the deep temporal fascia. He called the procedure a nonsurgical facelift. These early contributions began an explosive revolution in thread lifting technologies and methods that is still flourishing 20 years later.
Thanks to innovative and determined companies, improved thread technology and methods have catapulted thread lifting procedures into one of the top nonsurgical treatments for facial rejuvenation. Today, thread lifts are considered by some physicians to be the hottest trend in aesthetics. According to analysts, the aesthetic threads market is projected to record a CAGR of 7.8% over the forecast period 2022-2027.1
The Right Treatment for the Right Results
According to Gideon Kwok, DO, co-owner and medical director for eight Skin Perfect Clinics around Southern California, thread lifts add another minimally invasive option for skin rejuvenation in the physician’s armamentarium of treatments. “An educated practitioner understands that threads are used in one layer of the face, while fillers, toxins, lasers and microneedling are still needed. These can be used in the right combination to help the patient achieve a more natural and balanced look.”
Rahi Sarbaziha, MD, CEO at Dr. Rahi MD in Beverly Hills, Calif., uses thread lifts for patients who desire natural results with a more contoured appearance, and employs a variety of threads to get the job done. “The barbed Polydioxanone (PDO) threads have a slight lifting effect in addition to collagen stimulation. Smooth PDO threads are great for localized collagen stimulation and can help treat acne scars,” she reported. “I also use PDO threads to treat areas that can be considered dermal filler ‘danger zones’ such as in between the eyebrows.”
Dr. Rahi chooses between recommending thread lifts or facial surgery depending primarily on the patient’s goals and her evaluation. “Thread lifts are an option when the patient wants a natural-looking lift,” she explained. “PDO threads can make a difference in millimeters while surgery makes a difference in centimeters. I consult with each patient to ensure they will achieve the results they want.”
Tara Sulyman, MD, founder and CEO of That Face (Chicago, Ill.) says that PDO threads used today are different from those that were used in earlier years. “Thread lifts can lift tissue without adding more volume, and provide collagen stimulation, so patients notice immediate and long-term changes in their skin,” she noted. “On the other end, slipping and extrusion of the threads are a risk, which is why proper training and practice are crucial to achieve consistently successful outcomes.”
To ensure the best results with his use of Poly Lactic-co-Glycolic Acid (PLGA) threads, cosmetic surgeon Babak Farzaneh, MD (Chino Hills and Irvine, Calif.), told us that patient selection is a critical factor to consider. “The best patients are those with realistic expectations, as thread lifts are more of a repositioning technique than a lifting technique. Ideally, they should have strong bone structure and good skin quality that is not too thick or thin,” he emphasized.
Technique & Approach Considerations
Francine Young, RN, co-owner of YK Advanced Aesthetics Training (Newport Beach, Calif.), explained that she uses PDO threads where injectables might be questionable. “These are the same threads used in surgical procedures because there is low to no reactivity, and they completely dissolve in about six months. With threads, I can build the nose bridge, reshape the nose tip or make the nose look less bulbous. Using threads in the nose are very long lasting because you don’t move your nose a whole lot, especially if you combine it with a neurotoxin. The results can last a good year and a half, possibly two years.”
Using a quality thread is important, but the right technique is required for an ideal and long-lasting outcome, Ms. Young continued. “Studies have shown that longevity correlates with vector design,” she stated. “Where you place the threads and how you anchor them is going to be more useful to predict patient outcomes, and how long the treatment will last.”
Dr. Sulyman agreed. “Threads are now fashioned in different ways to optimize the lifting and anchoring capabilities while reducing the risk of slipping; however, it is still important to understand facial anatomy and effective lifting vectors in order to use a minimal number of threads in the most effective manner,” she reported. “The most successful treatments include lifting the midface, cheek, submental and jawline. I also have success using threads to lift the nasal tip.”
In Dr. Kwok’s experience, practitioners should understand how the face is aging so they can take the right approach. “If appropriate, I may do fillers right before adding threads, for foundational support,” he said. According to him, timing matters when using combination treatments. “Toxins should be used in conjunction with and before you do the threads, to avoid pulling on the threads and loosening the results of the lift,” he explained. “And since threads are to help reposition fat, I will use microneedling treatments either four weeks before or after to address skin quality.”
Dr. Rahi emphasized that strong and innovatively designed PDO threads have changed the opinion of providers and added to the scope of her treatment portfolio. “I use threads in other areas of the body. My favorite areas are the abdomen and buttock area,” she commented. “Combining the different types of threads can help with improving stretch marks, tightening and slight lifting of the area in question.”
The improvement in thread technology and training has allowed Ms. Young to find her go-to treatment. “My most successful treatment protocol is my signature vertical, which is a full-face thread lift. I then do a quick cheek pop where I reapproximate the cheeks and lift up the nasal labial folds, then bring it altogether with my snatched jawline treatment,” she shared.
Ms. Young acknowledges the limitations of thread lifts and utilizes additional, minimally invasive options to complete her treatments. “After I lift the skin with threads, I can see where the deficits fall, such as the temple, then I add filler,” she noted. “When you are doing a brow lift it is important to volumize the temples first, then you pick up all the loose s
kin on the brow. Thread lifting requires a bit of finesse and an artistic eye.”
Dr. Sulyman incorporates combination treatments for improved effects and optimal outcomes. “For patients with moderate skin laxity that do not want to undergo surgery, I like to offer a combination of a PDO thread lift, then two weeks later perform a series of three radiofrequency (RF) microneedling treatments, each one month apart, to boost and optimize collagen stimulation,” she reported. “To address tissue sagging and volume loss, I inject fillers to add volume in the appropriate places and then use threads to lift the sagging tissue. I usually perform both of these treatments on the same day.”
Practitioner-Preferred Technologies
Dr. Farzaneh’s technology of choice is Silhouette InstaLift® from Suneva (San Diego, Calif.), the first absorbable suture FDA cleared for cosmetic facial procedures. Dr. Farzaneh explained that the sutures and cones are made from PLGA with Micro-Suspension TechnologyTM for immediate and long-lasting results. “The cone design increases the area of contact to the tissue, allowing for better tissue integration to improve the lift and repositioning. Results can last from 18 to 24 months,” he reported. He added that over time the treatment will stimulate fibroblasts for gradual collagen maturation and help reposition volume in the mid-face for a natural-looking result.
Kaveh Karandish, MD, medical director of PCH MedSpa (Corona Del Mar, Calif.) finds the improved quality of threads allows for greater creativity in treatments. “When the laxity of skin in certain indi
viduals is moderate to severe, we introduce them to a variety of RF devices as well as regenerative modalities such as platelet-rich fibrin (PRF) and exosomes before performing their PDO thread lift,” he shared.
“VIOLA Threads (Brea, Calif.) has a very nice variety of products, including specific threads for a nose and eyebrow lift as well as double blunt tip threads for a neck lift,” Dr. Karandish continued. With a variety of materials and styles, including Cobra (the cutting-type), and Molding (molded-type) threads, Viola Threads address all levels of thread lifting treatments for beginners to advanced users.
“The important decision is always about vectors, number of threads, downtime concerns and the patient’s preferred treatment areas,” Dr. Karandish explained. “I use a cannula for numbing, which I think makes a tangible difference in patient comfort during the procedure. I always combine barbed lifting threads with a good number of smooth or twisted threads for a better outcome. VIOLA threads have a great quality and the grip on skin tissue is one of the best among competitors.”
The products available from V Soft Lift (South Euclid, Ohio) stand out for Louis Malcmacher, DDS (Bay Village, Ohio), president of the American Academy of Facial Esthetics 
(AAFE). “PDO thread technology is leading the regenerative aesthetics revolution with polymer coated PDO threads like V Soft Lift, which provides the most collagen biostimulation we have ever seen,” he exclaimed. “The V Soft Lift PDO threads stimulate collagen and elastin production and when combined with neurotoxin and filler correction, results in up to 40% improvement in aesthetic outcomes for a better, longer-lasting result. A common treatment protocol is to use V Soft Lift lifting PDO threads first, then neurotoxins and fillers, followed by V Soft Lift smooth PDO threads for the best regenerative biostimulation.”
For Hulnara Castellon, NP, an aesthetic specialist in Hermosa Beach, Calif., the most common concerns she addresses are lowering brows and skin laxity in the lower face. In her experience, her patient results have dramatically improved with PDO MAX threads (Liverpool, N.Y.). “PDO MAX threads have amazing lifting capacity and are great for natural tissue reapproximation,” she reported. “My patients return for their annual thread lift and I save them money as they find less need for fillers.” Ms. Castellon also shared that the variety of PDO MAX threads allows her to perform a multitude of advanced techniques.
PDO MAX is one of a few companies who has a 
fully FDA-cleared PDO thread-in-cannula device with over 20 varieties of barbed-, smooth-, ciclone- and multi-thread options, “There Is a Thread for ThatTM” has become the company’s motto because the products can reposition or smooth out skin texture for almost any area of the face and body.
When it comes to innovation, MIRACU® by BENEV (Mission Viejo, Calif.) stands out with 4D multi bi-directional cogs for superior traction and holding. With the unique 16-line mesh thread and cone anchor thread, physicians can provide their patients with long-lasting results. Details matter to MIRACU; threads are molded to increase tensile strength, there is a larger interior needle diameter that does not affect the overall needle diameter, and products are packaged individually to improve thread sterility. MIRACU thread lifts work well when combined with fillers as the mesh network that is created helps reduce migration of fillers, leading to more natural and longer-lasting results.
The current state of thread lifting technology and devices, along with the rise in patient demand, suggests that treatments will continue to expand and improve. As a treatment that once seemed to be fading from the aesthetic market, thread lifting has now firmly established itself in many aesthetic practices, transforming the future of minimally invasive cosmetic treatments.
References:
1. Aesthetic threads market size, share: 2022 - 27: Industry trends. Aesthetic Threads Market Size, Share | 2022 - 27
| Industry Trends. (n.d.). Retrieved November 8, 2022, from https://www. mordorintelligence.com/industry-reports/ aesthetic-thread-market
