Extrafacial Loose Areolar (XFLA) Thread Lifting (A Novel Technique)

Thread lifting is one of the widely chosen procedures for minimally invasive facial rejuvenation. Traditional facial thread lifting has nearly inevitable side effects e.g. facial edema, facial bruising, prolonged recovery, skin puckering, and visible and/or palpable threads, as well as less common complications e.g. damage of facial vital structures. Applying the extrafacial loose areolar (XFLA) thread lifting technique by using loose areolar connective tissue, the fourth layer of the scalp, as insertion medium for the threads to be anchored to the layer above (epicranial aponeurosis or galea aponeurotica) and the layer below (pericranium), could help minimize most of the previously mentioned side effects. In this manuscript, technique steps will be detailed to prove its novelty.


Introduction
Thread lifts, like all non-invasive procedures, are widely spread. No official statistics are there to estimate their precise popularity. However, the American So- hand, thread lifts are thought to be an effective minimally invasive procedure that can be employed solely or combined with other procedures for temporary facial rejuvenation purposes with less complications and shorter recovery periods [2] [3] [4].
On the other hand, thread lifting is seen as a nearly useless procedure, depending more on the fake plumping effect induced by the immediate post-procedural swelling with poor short termed results and serious complications, especially that it is done under incompletely aseptic measures by practitioners who received few hours of training according to authors who adopt that opinion [5] [6] [7] [8].
A third party, occupying the middle zone of opinions between both extremities, states that thread lifting is fairly effective as a minimally invasive procedure, amplitude and duration wise, and should not be presented as an alternative to surgical facelift. The procedure has variable results according to the practitioner, technique, technology and the case, with a promising future that will follow the innovation regarding technology and techniques [9] [10] [11] [12]. Like any procedure, thread lifting has complications: 1) Edema, bruising, prolonged recovery, pain, discomfort and ecchymosis.

Innovation
Applying the extrafacial loose areolar (XFLA) thread lifting technique by using loose areolar connective tissue, the fourth layer of the scalp, as the anchorage medium for the threads could help minimize most of the side effects as well as augment results. The technique can be detailed as follows: 1) Disinfect and drape the patient's face. Make sure the technique is sterile.        Figure 6). Immediate homogenous lifting should be noticed (Figure 7). 9) Disinfect entry points and cover them by adhesive wound closure strips.

Relevant Anatomy
Danger zones related to the described procedure can be classified into: A) Entry points (Figure 8, Figure 9)  • Checking if there is blood backflow from the needle.
• Avoiding points with visible, palpable or detectable pulse through a handheld doppler. • Being aware that there is no fixed surface anatomy for the above structures that can be pinpointed by a ruler. Several studies show that surface anatomy of such structures is variable [14] [15].

B) Insertion and anchorage tracks
There are five layers to the scalp: the skin, connective tissue layer, galea aponeurotica, loose areolar connective tissue, and the pericranium [18].
In the extrafacial loose areolar (XFLA) thread lifting technique, loose areolar connective tissue, the fourth layer of the scalp, is used as the insertion medium for the threads to be anchored to the layer above (epicranial aponeurosis or galea aponeurotica) and the layer below (pericranium) (Figure 10).
The loose areolar tissue layer has no vital structures running through it, except that certain emissary veins traverse it to connect the scalp veins to the diploic Figure 10. In the extrafacial loose areolar (XFLA) thread lifting technique, loose areolar connective tissue, the fourth layer of the scalp, is used as the insertion medium for the threads to be anchored to the layer above (epicranial aponeurosis or galea aponeurotica) and the layer below (pericranium).

Conclusion
Classic facial thread lifting is done by inserting threads into the face. It has nearly inevitable side effects such as facial edema, facial bruising, prolonged recovery, skin puckering, and visible and/or palpable threads, as well as less common complications e.g. damage of facial vital structures ( Figure 11).  Facial layers have a sophisticated structure, variable thicknesses even for the same layer in different spots and variable landscape. This makes it easy to unnoticeably change the plane of cannula insertion.
Most of the cannula tracks made by classic thread lifting will be interrupted in most cases by facial retaining ligaments ( Figure 12). This will, in my opinion, hinder homogenous lifting effect and encourage puckering and dimpling.
As mentioned before there is a chance of injuring vital facial structures using the classic facial thread lifting technique e.g. facial vessels, nerves and parotid duct (Stensen duct).
Using the extrafacial loose areolar (XFLA) thread lifting technique solves the above-mentioned challenges with significantly positive results. However, the following prospects and suggestions need to be taken into consideration: 1) Results longevity needs to be estimated.
2) Thread design needs to be modified: • Cannula: to be longer, already curved and completely blunt rather than L-shaped ended cannula.
• Thread: to be longer (with more cogs in the direction on the outer end side to enhance anchorage) and thicker (2 or 3 instead of 2/0 or 1/0 as the loose areolar tissue layer is 1 -3 mm [23], and cogs need to be in contact with the layer above (epicranial aponeurosis or galea aponeurotica) and the layer below (pericranium) to enhance anchorage.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.