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  1. 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
  2. 2. Botox™ And Fillers AreGreat But Something Is Missing!
  3. 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
  4. 4. Young And Old Faces
  5. 5. The Beauty Triangle
  6. 6. The “Double Bulge” Effect
  7. 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 shouldnot 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
  8. 8. The “Double Bulge” Effect
  9. 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. 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. 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. 12. Is It Achievable? “Supraplatysmal Facelifting is an Effective Technique in Facial Rejuvenation”.Ph. Md. Thierry Besins (Paris) 2004
  13. 13. Buccal and Malar Fat Pads
  14. 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. 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. 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
  17. 17. Contraindications• Diabetes• Anti-coagulants• Auto-immune diseases• Inflammatory skin conditions• Active infections
  18. 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. 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. 20. Facial Areas That Can Be Treated• Eyebrow• Mid Face (malar area)• Lower Face• Neck• Chin
  21. 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. 22. Combination TechniquesThe 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. 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)
  24. 24. Aptos Threads
  25. 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. 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. 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. 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
  29. 29. HISTOLOGY
  30. 30. In Tissues Of A Rat Fibrosis around the Thread The ProleneThe Cog Thread
  31. 31. Histology From human Tissues 1 Year The Prolene ThreadTheCog Fibrosis around the Thread
  32. 32. Silk based cogged threads marketed as Happy LiftTM4-5 months after the procedure- 40-45% reabsorption
  33. 33. Silk based threads marketed as Happy LiftTM3 months after the procedure increased thickness of the papillarydermis is observed 3 months after the insertion H.LTM.R.
  34. 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
  35. 35. Vertical Lifting of jaw line and upper mandibular area.
  36. 36. Vertical Lifting of Middle Face and Cervical area
  37. 37. Whole Face and Cervical area.
  38. 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. 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. 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. 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. 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
  44. 44. Thread Lift Lower Face Before Immediately Post
  45. 45. Thread Lift Mid FaceBefore After
  46. 46. Thread Lift Lower Face Before After
  47. 47. Thread Lift Lower Face & Eyebrow Immediately PostBefore During
  48. 48. Thread Lift Mid & Lower Face Lift Before After
  49. 49. Thread Lift Lower Face and PPC Before Immediately Post
  50. 50. Thread Lift Full Face 7 Days AfterBefore 3 Days After
  51. 51. Thread Lift Full FaceBefore 3 Months After
  52. 52. Thread Lift Full FaceBefore 2 Months After
  53. 53. Thread Lift Full FaceBefore 6 Months After
  54. 54. Thread Lift Full Face 6 Months AfterBefore 3 Months After
  55. 55. Thread Lift Lower Face & PPC
  56. 56. Thread Lift Lower Face & PPC
  57. 57. Who should be performing the procedure UK peculiaritiesThe 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 operationsIncreasing influence from practices in Europe and the USADivision between doctors from different backgrounds who work in this industry
  58. 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
  59. 59. Many Thanks For Your Attention