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Face
1. The Treatment Of Age Related Facials &
Neck Ptosis With Sub Dermally Placed
Surgical Sutures.
Overview Of The Current Techniques And
Combination Therapies
F.A.C.E. Conference 12th June 2005
Miss Lucy Glancey MRCS
Linia Healthcare Group
Cromwell Hospital, Huntingdon
3. Fat Loss And Re-distribution
Characteristic Of The Aging Face
• Young face : full, with even distribution of
fat, appears balanced without demarcation
of the cosmetic units, series of arcs and
convexities
• Old face :compartmentalisation with “hill
and valley” topography and vivid
demarcation of the cosmetic units which
leaves the face unbalanced
7. “Facial aging is a complex synergy of surface
textural and elastotic changes, relative muscular
hyperactivity and fat dysmorphysm. Conventional
lifting procedures carry with them the morbidity
common to all invasive surgery yet fail to make the
patient look like they did when they were young.
Wrinkle therapies certainly have merit but should
not be the singular focus of anti-aging protocols. The
restorations of youthfull facial contoursshould be
considered the primary goal in any rejuvenation
procedure”
L. Donofrio
9. How Can We Achieve Facial
Contour Restoration?
• Open surgical technique where parallel with
excising excess skin volume should be
added and fat pads repositioned
• As a minimally invasive technique
involving the placement of surgical threads
in the subcutaneous layer known as “thread
lift”
10. Concept
• Thread lift is a procedure where specially
designed or ordinary surgical sutures are passed
into the subcutaneous tissues where they relay on
the trabecular connective tissue network that run
between SMAS and the skin in order to elevate
and reposition fat pads affected by ptosis and
consequently have a “contour restoring effect”.
The aim is to tighten the subcutaneous tissues as
well as the overlying skin
11. History
• Buttkewitz 1956 – demonstrated the correction by a stitch
of a “drooping bucco-labial fold”
• Mario Gonzales Ulloa 1983 in his book “The aging face”
talks about elevating the tissues by means of subcut nylon
threads
• Rene Guillemain 1970 – The Curl Lift using a spinal
needle and a kangaroo tendon
• Marlen Sulamanidse – the Aptos type thread 1980
• Sassaki – 2002 the 2 needle technique
• Maximiliano Mendez Florez 2003 – Double Bevel needle
12. Is It Achievable?
“Supraplatysmal Facelifting is
an Effective Technique in
Facial Rejuvenation”.
Ph. Md. Thierry Besins (Paris) 2004
14. Patient Selection –proper selections
determines the success of every
surgical procedure
• Young patients may only require volume
restoration
• Older patients may require combination of
volume restoration with fixation of the soft
tissues
15. Indications
• Poorly manifested aesthetic contours (flat flabby
face) - beautification
• Ptosis of the soft tissues of the face and neck
- rejuvenation
• Facial asymmetry correction
• Patients who are not ready for a face lift but c/o
“looking tired”
• Patients who do not want to have the traditional,
open surgical face lift
• Patients complaining of insufficient results shortly
after a face lift
• Patients who wish to improve more than one part
of the face
16. Indications cont
• Young patients wanting to modify their
appearance especially by brow or cheekbone
lifting
• Young patients with one or several “weak points”
-Eyebrow ptosis
-Significant naso-labial sulcus
-Significant labio-mental sulcus
-Mild ptosis of the lower face with
pseudo-jowls
-Mild skin excess on the upper neck
• More mature patients who do not wish to have a
major procedure
• Not suitable for a patient with excess skin
18. Advantages
• Simple and effective method
• Excellent results
• Minimal down-time
• Performed under local anesthetic as a day case
• Provides tri dimensional, volumetric approach to the face, avoiding the
“ wind tunnel appearance”
• Economic
• Minimal post-operative scarring
• Simple aftercare and better patient compliance
• More than one part of the face can be addressed at the same time
• Reversible in the case of smooth polypropylene threads
• The results can be modified by adding or removing sutures under L.A.
19. Complications
• Haematoma
• Neuropraxia
• Thread extrusion
• Thread migration
• Infection ( take prophylactic antibiotics)
• Relaxation of tension ( cheese wiring ) leading to post
operative pain
• Palpable threads – too superficial placement , most
common in thinner skins
• Asymmetry
• Poor results study performed on 67 patients 93,7 satisfied
• Patient
• Folds of skin and dimples – resolve with time
20. Facial Areas That Can Be Treated
• Eyebrow
• Mid Face (malar area)
• Lower Face
• Neck
• Chin
21. Factors Determining The Success Of
The Procedure
• Design of the thread
• Material of the thread
• Insertion technique (free floating or
suspension technique)
• Patient selection
• Implementation of combination techniques
when indicated
22. Combination Techniques
The aging process causes certain areas to undergo
fat atrophy while others experience persistence or
hypertrophy of fat hence the need to combine with
other treatment regimes
• Phosphatidilcholine Injections (PPC)
• Sub Dermal Fillers (Restylane Sub Q, Bioalcamid,
Sculptra)
• Fat Transfer
• Chemical Peels
• Dermal fillers and Botulinum toxin
23. Types Of Thread By Design - Free
Floating Threads
• They are endorsed with directional cogs
(barbs) e.g. AptosTM After their insertion
into the skin, The thread’s cogs anchor
forming a supporting structure for the facial
tissues.
• The cogs can be uni or bi directional
(convergent and divergent)
25. Types Of Threads By Design –
suspension threads
• They are smooth therefore have to provide
connection between the ptotic part of the
face and a stable point by the formation of 2
loops
• Each loop has its own anchoring point and
by tightening the 2 point come together
26. Types of thread by Material
• AptosTM threads” are made up of a monofilament
material called
“polypropylene” [–(CH2=CH-CH3)-n].
• Colorant used: phthalocyanine blue. (Innert
material causing little reaction with tissues hence
the need for coggs)
• Happy LiftTM Revitalizing threads” are made of a
monofilament material called “poli (L-lattide-co-
έ-caprolattone -X)”. Bonds with tissues better and
causes more fibrosis
• H.LTM.R. Colorant Used: Natural White.
27. Two Stage Effect
• Immediate lifting effect due to the
mechanical properties of the thread
• Lifting effect due to the fibrosis formed by
the thread “the secondary vector of pull”
28. Histological Effects Used Since Dec
2003
• Increasing in fibroblast
• Increasing in collagen fiber
• Increasing in vascularisation
• Increasing in elastic fiber
• Increasing in Hyaluronic Acid
• Rejuvenation of Matrix
• improvement of the results appear overtime due to
the favorable type of scarring which manifests
itself in further lifting effect
30. In Tissues Of A Rat
Fibrosis around
the Thread
The Prolene
The Cog Thread
31. Histology From human Tissues
1 Year
The
Prolene
Thread
The
Cog
Fibrosis around the Thread
32. Silk based cogged threads marketed as
Happy LiftTM
4-5 months after the procedure- 40-45% reabsorption
33. Silk based threads marketed as Happy
LiftTM
3 months after the procedure increased thickness of the papillary
dermis is observed
3 months after the insertion
H.LTM.R.
34. New Techniques Of Insertion Of Longer
Threads (23,5 cm), Silk Based And
Marketed As Happy Lift ™
• Standard 12 cm
• Long- 23,5 cm
• Ultra short 6 cm
38. Insertion Techniques
Characteristic Points
• Combining free floating and suspension threads
• Ancoring of the cogged threads
• The spinal needle manoeuvre to create a loop
• Curved “Z track”
• Safety aspects: hydrotomy and the use of blunt
liposuction cannula in high risk places e.g.
eyebrows
39. Anchoring concept
• Most cases require proper anchoring of the
sutures to stable structures (temporalis fascia or
periosteum )in order to achieve long lasting results
– 2 anchoring points are necessary
• One loop of the thread will lift the chosen part and
a second loop of the same thread will moor it to
the more resistant tissues of the scalp
• 2 points are marked on the skin: point of insertion
and point of rotation
• Simple spinal needle can be used although there
are many purpose made tools
40. Materials And Tools
• Spinal needles 18G or 20 G
• Nokor needles
• Mosquito forceps
• Non-tooth forceps
• Needle holder
• Sponge holder
• Surgical marker
• Sterile disposable drapes
• Steristrips
• scissors
• For the patient: Hair band
Hair gel
41. Procedure
• Use less local (0,7-0,9 ml per thread) with epinephrine
• -Insert the needle by right line and right depth
• -Be careful during insertion the thread inside the needle
• -Create volume by fingers before removing the needle
• -Insert the thread exactly in the middle of the area
• -Lift the thread from each side before cutting
• -Cut enough the ends of the threads
• -Be careful with the previous thread while inserting
42. Aftercare Instructions
• Ice packs for 1 day
• Avoid hot drinks and food for 2 -3 days
• Minimal facial expression for 3-4 weeks
• No massage for 3 -4 weeks / special low-
impact pillow
57. Who should be performing the
procedure UK peculiarities
The new HCC regulations are slowly putting end to
the so called “office procedure”
There is and increasing pressure from patients who
are requesting minimally invasive manipulations
with fast recovery and not major operations
Increasing influence from practices in Europe and
the USA
Division between doctors from different
backgrounds who work in this industry
58. Conclusion
• “Thread lift” bridged the gap between
injectables and traditional surgery
• Combining different threads and different
techniques as well as both ancoring and free
floating threads gives the most dramatic
results
• For the right patient this procedure can give
results similar to open surgery
