Introduction

Facial anatomy is characterized by multilayered composition from bones to epidermis. During ageing, all components of facial tissues can become compromised. Soft tissue

retaining ligaments as local reinforcements providing support against gravitational sagging are critical structures in facial ageing. The retaining ligaments also provide some mobility of the different tissue layers which can be used in minimal invasive lifting techniques like facial fillers or thread lifts. These lifts are performed without surgical release limiting the effect.

Nevertheless, facial thread lists have become more popular in recent time. There are different thread products on the market characterized by material, barb shape, microstructure, elasticity, and strength. They can be classified into absorbable and non-absorbable threads. Histologically, there is an increased production of collagen due to induced fibrosis around the threads [1].

Adverse events

Numerous techniques for facial applications of lifting threads have been developed in the last 25 years. The anti-gravitational effect is lasting in most studies about six months to one year. In a meta-analysis of adverse events after facial thread lifting temporary swelling was the most common with an incidence of 35%. Other adverse events were skin dimpling (10%), paresthesia (6%), thread visibility or palpability (4%), infection (2%), and thread extrusion (2%).

Non-absorbable threads and patient age above 50 years increased the rate of adverse events compared to absorbable threads and younger patients [2]. Another Chinese study listed the following adverse events: skin dimpling (40.5%), contour irregularity (16.8%), visible threads (16.3%), thread extrusion (5.3%), infection (8.9%), swelling (4.7%), incomplete facial paralysis (2.6%), hyperpigmentation (2.1%), hematoma (2.1%), and allergy (0.05%) [3].

Fig. 1: Viability of facial threads in relaxation (White arrows).

Fig. 2: While smiling fine lines develop in the perioral region and on upper lip (Red arrow).

On the other hand, threads have limited impact on volumetric loss during ageing. Therefore, often combined procedures with adjunct fat transfer or filler placement are used [4, 5].

Viability of threads can be due to poor technique (procedural error) but also after of weight loss of the patient. We demonstrate a patient with only 6 kg weight loss. However, subcutaneous adipose tissue on the cheeks seems to be more sensitive to weight loss than subcutaneous adipose tissue on trunk and buttocks. Viability of threads is often more pronounced by facial expressions (Fig. 1 and 2).

Discussion

The disadvantage of facial thread lifting techniques is the disruption of anti-gravitational, supportive orientation of the retaining ligaments. Placing the weight of soft tissue solely on the fixation limits longevity of the lift [6]. This could alter the mobility of the upper soft tissue layers, leading to fine lines in the untreated neighboring areas.

The tissue tightening by threads is superior to volumizing in contrast to dermal fillers which work three-dimensional. Aesthetic improvement over time of durability of rejuvenating effect is not superior to facial fillers [7]. Bioactive facial fillers may volumized up to two years. If the patients is a candidate for a later surgical face lifting the surgery could be somewhat compromised by previous minimal invasive techniques such as facial threads.

Facial thread lifting has become part of the minimal invasive procedures in facial rejuvenation. In the hand of the experienced user, the procedure is quite safe, and the down time is minimal. Patient selection is critical for a successful thread lift. If the patient is on diet for a controlled weight loss, facial threads are not recommended to avoid thread visibility. Although viability is no serious medical complication, aesthetically it is significant and counteracts the therapeutic goal.