The main factor causing the effect of aging on appearance is gravity, which causes ptosis of the facial soft tissue that creates hollowness of the mid-facial and areas under the eyes. Consequently, facial rejuvenation should be performed in a vertical direction lifting these tissues to its original level. This can be undertaken very well through a facelift surgery to achieve a youthful face. Until now lifts were only possible through surgery but with the advent of absorbable and non-absorbable threads, tissue lifts are possible non surgically. When barbed threads are placed under the skin, they can be used to tighten the tissue and add volume to the area of application.

The appreciation and understanding of the vectors that need to be applied for proper soft tissue elevation have optimized the results of facial rejuvenation by repositioning ptotic soft tissues in a more logical vertical direction. People prefer minimally invasive procedures and are willing to trade a more modest degree of cosmetic improvement in exchange for decreased morbidity.

Nonsurgical rejuvenation by volume addition using various types of injections with a variety of fillers or fat has added the ‘‘third dimension’’ to facial rejuvenation. However, though aesthetically pleasing results have been reported and may be achieved when performed by experts such as Dr. Mohan Thomas and Dr. James Dsilva having an artistic flare, rejuvenation with soft tissue fillers in general may result in puffiness. Absorbable suspension sutures are the ¬most minimally invasive, entirely absorbable treatment option for tissue repositioning and recontouring that can be performed under local anesthesia and which demands very little patient downtime.

B. Types of Thread

The types of thread can be divided into three main categories.

1. Mode of Absorption

a. Absorbable threads including Polydioxanone thread (PDO), Silhouette Soft thread (Poly-I-lactic acid or sculptra in solid form), and fine thread with bi-directional absorbable cone. For absorbable threads there are polydiaxone (PDO), poly-L-lactic acid (PLLA) and Polycaprolactone (PCL). They vary in collagen induction and duration of effect.

b. Non-absorbable thread including APTOS thread, Contour thread, Silhouette lift thread (Polypropylene).

2. Barbed and Non-Barbed Thread (Smooth Threads)
a. Barbed Thread - There are 3 types of barbed thread18

i. Bi-directional thread (Long suture) are inserted into a hollow needle and then placed in the treated area. Bi-directional thread cannot move in either direction because of the two-way fixation provided by the barbs.

ii. Uni-directional barbed threads (Long sutures) are designed to be anchored to a fixed structure, such as the deep temporal fascia.

iii. Cogged Threads (Short sutures): Examples include PDO Uni-directional cogged thread, PDO Bi-directional cogged thread, and PDO Multi-directional cogged thread. The cog threads are barbed with different types of barbs and they are used for lifting the tissue and inducing collagen. They come in sharp needle and blunt cannula types.

b. Non-Barbed Threads (Smooth Thread) The Plain thread or Mono are used for collagen induction and applied in a grid pattern or mesh pattern. There are two types of Non-barbed thread:

i. Monofilament Plain: Examples include Miracu plain thread and TR lift thread.

ii. Monofilament Screw or Spiral: Examples include K2 screw lifting and T Screw lifting thread.


The biostimulation treatment with PDO threads causes neocollagenogenesis. This results in improved skin appearance due to the retraction effect it produces. So, we are faced with biostimulation whose primary results are aesthetic improvement. When absorption of the threads is completed, the stimulation effect also stops, and at 18 months we witness a full recovery with a slight increase of fibrous type I collagen.

Threading targets the dermis and subcutaneous tissue.

The plane of insertion for barbed threads is the superficial musculoaponeurotic system, commonly referred to as SMAS. Remaining in this plane diminishes tissue distortion, bruising and discomfort. Most importantly, this area is risk adverse to facial artery and vein damage.

Anaesthesia of the area

For superficial Plain threads we apply a 2% lidocaine and Prilocaine cream (EMLA) 45 minutes before the procedure. For cog thread and any long thread (more than 90 mm), local anesthesia, such as 1-2% solution of Lidocaine with Epinephrine (1/200,000), is injected at the insertion as well as along the thread area as shown in the Picture.

Figure: A and B showing injection of anaesthesia along the thread tract and at the distal most point of the thread.

Needle Insertion

Technique of Cog thread insertion for tissue lift: Superficial dermal or subcutaneous plain threads are inserted with a sharp needle but barbed threads of 19G have to be inserted via a cannula in order to reduce the risk of facial nerve trauma and large blood vessel trauma (such as the facial artery). Correct injection technique is critical to the success of the treatment in achieving the desired results. These structures provide ample anchoring points for maintaining the mechanical lift. Threads for the lower face and jowl lift are inserted from the strong tissue in the pre auricular area.

For the neck rejuvenation, the threads are inserted in the fibrous tissue of the sternocleidomastoid.

  • Aspirin consumption should be stopped 3 days before the procedure. May increase bruising.
  • Antibiotic prophylaxis is important.
  • Prophylactic Acyclovir is prescribed to patients who are prone to herpes infection.
  • Smoking has a detrimental effect on healing and it is a good idea to reduce the amount of smoking for a few weeks.

  • Mild asymmetry, ecchymosis, erythema, bleeding, swelling, and discomfort were the minor complications.
  • Pricking from within is the most common complication and is temporary.
  • Migration of the thread is possible along with Extrusion of the threads.
  • Skin dimpling and / or palpation of the thread is possible when the barb of the thread is present very close to the skin. Gentle massage of the area will correct the deformity.
  • Transient paresthesias and rarely injury to vessels, nerve branches and parotid capsule/duct are possible

Patient Benefits (When compared to traditional surgical approaches)
  • Minimally invasive approach with minimal scarring
  • Reduced procedural and recovery time
  • Patient satisfaction is more immediate
  • No General Anesthesia required- local anesthesia and sedation is preferred

Threads is a quick minimally invasive option for those people where gravity has started to take hold of their face and the skin has started to sag; but who are not willing to undertake a surgical procedure to rejuvenate their face. Using a needle and either barbed or smooth sutures your skin on cheeks, brows, jaw line and neck can be lifted without the need to cut your skin.

This procedure does not produce changes as drastic as the traditional facelift and is not permanent, lasting a few months to a year; therefore, it is best suited to younger patients (generally 30 to 50 years old) who require only moderate facial rejuvenation.

Why Choose CSI?

We offer this procedure for people who are dead against surgery and being Surgeons we are able to place these threads choosing the correct facelift vectors thus preventing injury to the vital structures.

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Figure: A, C: Pre-treatment photographs of a patient who came for a thread lift. B, D Post treatment photographs 4 weeks after thread lift.

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