1. Introduction
The use of threads in Aesthetic Medicine (AM) has been a practice employed both for the face and body since 1956, when Buttkewitz published a correction for the nasolabial fold using Nylon thread [1].
In 1964, Dr John Alcamo introduced the first patent related to a suspension suture with barbs. Meanwhile, in the late 1960s, Dr. Cauz in France developed a technique for implanting gold threads at the subdermal level on the facial surface, from the ear to the nose, mouth, or chin, in areas where wrinkles appeared a certain flattening compared to those in untreated areas [1]. In 1966, Galland and Clavier described a new methodology using local anesthesia [1]. In 1975, J. Conley and D. Baker described a new technique for gold thread implants based on the implantation of the tread directly under the wrinkles and complementing in with two vertical lines [1]. In1992, this technique was improved by Dr. P. Orenes, who began applying it to the neck as well. Thanks to his work, the Spanish company Loca Marin, started industrial production of a gold thread implantation kit [1].
Until that point, all the sutures presented were made from non-absorbable materials [1], until 1992 when Gregory Ruff developed an absorbable polydioxanone suture with microscopic projections arranged in a spiral along the entire thread [1].
In 1999, a Russian surgeon, Salamanidze, who is credited with applying suspension sutures for facial rejuvenation, developed sutures with bidirectional angled hooks [1]. In 2002, the first experience using suspension sutures with antiptosis action was published, leading to the naming of APTOS threads, the first generation of suspension sutures, which were fundamental for the development of facial rejuvenation techniques using tension threads [1].
In 2004, the U.S. Food and Drugs Administration (FDA) authorized the use of unidirectional sutures, initially made from polypropylene and later made with polylactic acid, making them absorbable [1]. The evolution of materials led to treatments being performed with absorbable thread, such as polydioxanone (PDO) fist and then polylactic acid (PLA) with bidirectional cones [2]. Continuous research improved the anchoring system from barbs to cones, giving rise to the third generation of suspension sutures [1].
Today the culture ingrained in people’s mings regarding external image care has been experiencing significant growth recently, leading to an increased demand for facial and body treatments without surgery. Among the most in-demand treatments are the use of tension threads [3].
Facial rejuvenation techniques using tension threads are part of non-surgical procedures; they are capable of repositioning the soft tissues of the face that descend along a vertical vector, a process determined by structural changes, microcirculatory, and metabolic alterations. The use of tension threads aims to “help individuals improve their self-esteem, give them more confidence in social contexts, and ultimately achieve harmony: a word that embodies the concept of beauty” [1] [2]. This innovative technique, which does not require hospitalization, is outpatient, and performed quickly and safely with minimal or no risk. Its goal is to improve skin quality, reduce sagging, and increase collagen production around the implanted thread. Currently, these threads are made of biocompatible and absorbable materials, acting as an artificial extracellular matrix, providing both a chemical and mechanical effect [3].
Tension threads represent an aesthetic technique for men and women who seek to improve their physical appearance without needing surgery, avoiding the risks of surgery and long recovery periods [3].
Nowadays, suspension sutures can be classified depending on: [1]
1) Suture Desing: Smooth, Barbed, or with Cones.
2) Orientation of Barbs or Cones: Bidirectional or Unidirectional.
3) Material Composition and Duration in the Body: Non-absorbable and permanent or Absorbable and temporary.
4) Mechanism of Action: Tensioning, Lifting, Suspension, or Delayed Revitalizing Action.
5) Implant Technique: Floating Threads or Anchored Threads.
It is essential to understand the biological effect produced by the induction of threads. There is a stimulation of type I and III collagen and a fibroblastic reaction around the threads, which helps maintain the results. What is novel is the use of the threads into an atraumatic needle, which greatly facilitates the technique, also making it minimally painful. It can be performed with only topical anesthesia, such as EMLA or COLD [1].
It is also a simple and sage technique, in which with minimal training and a well-planned thread implantation design good results can be achieved. The technique is commonly known as the Japanese lifting, since the most commonly use threads (PDO) are manufactured in JAPAN or South Korea, and from these countries they are distributed worldwide [1].
Despite having multiple advantages, there are contraindications for their use, such as in pregnant or breastfeeding women, people with skin infections, or those with open wounds. Additionally, there are disadvantages, the main one being the duration of the effect over time, which leads to the recurrence or sagging [3] [4].
2. Objectives
To develop a review study of various medical studies according to the score of the Canada Task Force on Preventive Health Care (CTFPHC) from I, II1 and II2, on the use of Thread Lifts in facial rejuvenation within aesthetic medicine. The aim is to assess the study results and provide a global perspective on the use of thread lifts, considering their therapeutic effects, patient satisfaction levels, as well as possible complications and adverse effects.
3. Materials and Methods
To carry out this research, a search was conducted in the following database: PubMed, Cochrane Library, LILACS, Embase, Ebsco, Scielo, and the National Library of Medicine (NIH). Using keywords: Tension Threads, Suspension Sutures, Face Lift, Non-surgical Lift, the search was initiated, yielding 1268 medical articles. These articles filtered using the following search according to the Canada Task Force on Preventive Health Care (CTFPHC) from I, II1 and II2 and studies with lower levels of evidence were excluded. After filtering the articles using the search criteria, 32 medical articles were obtained, of which 15 articles were selected, these 15 articles were selected based on inclusion criteria, with a publication date no older than 10 years. The characteristics of the studies were also taken into account, such as the population studied, the articles analyzed, and the presentation of complications, since this topic is addressed as part of the elements of this study and the selection considered systematic review, meta-analyses, as well as cohort and case-control studies, prioritizing those with the highest levels of evidence.
4. Results
The correction of facial sagging through non-surgical technique has gained popularity in aesthetic medicine in recent years, with thread lifting being one of the most requested procedures. The studies presented below cover a wide variety of approaches, technique, and evaluations of the effectiveness of facial thread lifting. In this comparative analysis, the results obtained in various studies are discussed, ranging from those exploring aesthetic effectiveness to the duration of the effect and associated complications.
1) Aesthetic effectiveness and improvement in Sagging
The significant improvement in facial sagging, reflecting the success of thread lifting in treating in various areas of the face [4] [10]. In Study Tavares J de P [4], which involved 357 patients with facial ptosis, treatment with thread lifting resulted in an improvement maintained for 2 years. This study reports a significant decrease in the WSRS scale (from 3.88 to 1.93), indicating an important long-term aesthetic improvement. Similarly, in study Li YL [9], the aesthetic effects were visible for 2 years, with improvements in the GAIS and GSS scales, which were highly satisfactory for the patients.
On the other hand, other authors [5] [6], although a significant aesthetic improvement in sagging was reported, the effects were less durable, with the effect lasting only 6 months. This suggests that, compared to more invasive treatment, thread lifting may not offer the same long-term durability, although it remains effective in the short term.
2) Comparison with Surgical Techniques
Regarding the comparison with surgical procedures, other authors reveal that surgical lifting combined with blepharoplasty offered longer-lasting improvements in facial sagging compared to thread lifting treatments. Patients who received this combination showed more noticeable aesthetic results, and the durability of the effects lasted at least 12 months, which may represent an advantage over thread lifting that, in some cases, does not exceed 6 months of effectiveness [5].
However, it is important to note that surgical lifting involves a higher risk of complications and longer recovery times, which may lead patients to opt for less invasive option such as thread lifting. In this regard, highlights that major complications were minimal in patients treated with thread lifting, despite the notable long-term aesthetic improvement [4]. On the other hand, indicates that, although complications in surgical procedures were low, the risk of scarring and other side effects was not insignificant [5].
3) Complications and Side Effects
One of the main advantages of thread lifting over surgical procedures is the low rate of serious complications. Tavares J de P. [4] minor side effects such as bruising (39.8%), edema (30%), and tenderness (20.7%) were reported, most of which were short-lived. The rate of serious complications was nil, suggesting that thread lifting is a relatively safe option for correcting facial sagging, especially in patients seeking quick results with minimal recovery time.
Similarly, [6] [7] also report minor complications such as bruising, pain, and slight asymmetry, although these issues were managed without the need for additional intervention. Li YL [9], which compares surgical and non-surgical techniques, mentions that minor side effects such as bruising and swelling are common in both types of procedures, but no serious complications were reported.
Additionally, on the Mint Lift fine (21 patients) showed a similar rate of minor complications, most of which resolved spontaneously [7]. This study also noted that the lifting effect lasted for 6 months, although some patients required touch-ups, highlighting the temporal limitation of thread lifting compared to the more stable long-term results of surgery.
4) Durability of the Effect
A crucial aspect in the evaluation of thread lifting is the durability of the effect. Others authors [4] [8] demonstrated that the aesthetic results, particularly the facial lift, were maintained for 2 years, positioning thread lifting as an effective option for patients seeking long-term correction without resorting to invasive surgery. On the other hand, studies [6] [7] such as showed that, although the effects were evident, they lasted for only 6 months, which could be a limitation for patients desiring more prolonged results.
Li YL [9], which compares different types of facial lifting, revels that both surgical and non-surgical techniques have a durability of between 6 and 12 months, but the effects of surgical lifting tend to be more sustainable. However, thread lifting offers a less invasive option with shorter recovery time, making it attractive to many patients who do not wish to undergo more invasive surgery.
5) Patient Satisfaction
Patient satisfaction was a common point across all studies, and overall, the results showed high satisfaction with thread lifting. Other authors mention that significant percentages of patients reported an aesthetic improvement that was maintained during the 2 years post-treatment, as reflected in an increase in the GAIS score (Global Aesthetic Improvement Scale) [4]. Similarly, Niu Z and Gülbitti HA; mention also showed that, despite the limited duration of the effects, patients were satisfied with the immediate results [6] [7].
In contrast, Li YL mention which compares surgical and non-surgical procedures, highlights that although patients were satisfied with thread lifting, those who underwent surgery reported a greater overall improvement and a more durable effect, albeit at the cost of longer recovery time and a higher risk of complications [9]. For this, review Table 1 where the results are summarized.
Table 1. Summary of the study results.
Author |
No of Patients |
No of Articles reviewed |
Articles Title |
Year |
Complications |
Results |
Tavares J de P, Oliveira CACP, Torres RP, Bahmad F. [4] |
7262 |
18 |
Facial Thread lifting with suture Suspension |
2017 |
The most important complications are bruising; bleeding; edema; erythema; visible threads; asymmetry; discomfort. |
It’s a minimally invasive procedure with a low percentage of complications, providing good short-terms results, but with limited durability of its effects. |
Contreras C,
Ariza-Donado A, Ariza-Fontalvo A. [5] |
Not recorded |
16 |
Using PDO threads: A scarcely studied rejuvenation technique. |
2023 |
Not complications |
This ultrasound-guided technique demonstrated excellent results, avoiding complications with the superficial temporal artery. Additionally, the substitution of polydioxanone threads with polycaprolactone threads seems to provide better Benefit. |
Niu Z, Zhang K, Yao W, Li Y, Jiang W, Zhang Q, et al. [6] |
Not recorded |
26 |
Incidences of Complications Following Facial Thread-Lifting. |
2021 |
Swelling was the most commonly reported; pooled incidence of 35%; Skin dimpling 10%; paresthesia 6%; thread visibility/palpability 4%; infection 2% |
The use of tension threads in older ages (>50 years) yields good results but increases the risk of dimpling (16% vs. 5.6%) and infection (5.9% vs. 0.7%) than their younger counterparts. Absorbable threads were associated with a significantly lower risk of paresthesia (3.1% vs. 11.7%) and thread extrusion (1.6% vs. 7.6%) tan non-absorbable thread. |
Gülbitti HA, Colebunders B, Pirayesh A, Bertossi D, van der Lei B. [7] |
Not recorded |
12 |
Thread-Lift Sutures: Still in the Lift? |
2018 |
No Objective elevation measurement |
Studies on the use of tension threads are limited; however, it has been shown that the main drawback of these threads is the limited durability of their effects in facial rejuvenation. |
Pham CT, Chu S, Foulad DP, Mesinkovska NA. [8] |
14222 |
59 |
Safety Profile of Thread Lifts on the Face and Neck |
2021 |
Facial asymmetry (n = 6143) (43.19%); edema/tumefaction (n = 453) (3.18%); ecchymosis (n = 407) (2.86%) |
The complications of the reads are mild and resolve on their own (paresthesias, alopecia, and injuries to vessels/glands). In severe cases, treatments are required. |
Goldberg DJ. [9] |
25 |
Not recorded |
Stimulation of collagenesis by
poly-L-lactic acid (PLLA) and -glycolide polymer (PLGA)-containing absorbable suspension suture and parallel sustained |
2020 |
No Objective elevation measurement |
The benefits of collagen stimulation, along with the mechanical effects of the tension threads, are essential for facial rejuvenation. |
Li YL, Li ZH, Chen XY, Xing WS, Hu JT. [10] |
190 |
Not recorded |
Facial Thread Lifting Complications in China: Analysis and Treatment. |
2021 |
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 2.5%; hyperpigmentation 2.1%; hematoma 2.1%; allergy 0.05% |
The main complications of these threads are dimpling of the skin, irregularity of the contour, and thread visibility. |
Wanitphakdeedecha R, Yan C, Ng JNC, Fundarò S. [11] |
25 |
Not recorded |
Absorbable Barbed Threads for Lower Facial Soft-Tissue Repositioning in Asians. |
2021 |
No Objective elevation measurement |
The use of long threads in Thain patients is an excellent treatment option with short-term lifting effects and no complications. |
Park JH, Jeong JW, Park JU. [12] |
94 |
Not recorded |
Advanced Facial Rejuvenation: Synergistic Effects of Lower Blepharoplasty and Ultrasound Guided Mid-Face Lift Using Polydioxanone (PDO) Threads. |
2024 |
No Objective elevation measurement |
Facial rejuvenation with the use of tension threads is extensive, including the use of mid-facial lifting guided by ultrasound with blepharoplasty, showing excellent improvement over time, being a safe and effective technique. |
Kim JS, Yang E, Kim W, Lee W, Kim H, Yi K. [13] |
703 |
Not recorded |
Ultrasound-guided thread lifting for the prevention of parotid gland and diagnosing parotid duct complications. |
2023 |
Moderate swelling 11.24%; inflammation and persistent pain (>7 days) 1.14%; dimple and thread protrusion 2.99%; parotid gland perforation 1.14% and diagnosed with parotid duct injury using doppler ultrasound 0.14%. |
Injury to the parotid gland during the placement of tension threads is a rare complication; however, its incidence is reduced with the use of doppler ultrasound. |
Hong GW, Song S, Park SY, Lee SB, Wan J, Hu KS,
et al. [14] |
No recorded |
Not recorded |
Why Do Nasolabial Folds Appear? Exploring the Anatomical Perspectives and the Role of Thread-Based Interventions. |
2024 |
No Objective elevation measurement |
The reverse technique for placing threads promises better support for the structures compared to the conventional technique, taking into account anatomical structures and considering the use of the crossed technique with volumizing threads for better results. |
Santorelli A, Cerullo F, Cirillo P, Cavallini M, Avvedimento S. [15] |
60 |
Not recorded |
Mid-face reshaping using threads with bidirectional convergent barbs. |
2021 |
No Complications 73.3%; Minor and transient complications 26.6%; dermal pinching 11.7%; minor extrusion 6.7%; bruising 5.0%; mild edema 3.3% |
The use of Definisse threads is safe and efficient, presenting few complications, with a high rate of satisfactory results for the mid-facial third. |
Moon HJ, Chang D, Lee W. [16] |
21 |
Not recorded |
Short-term Treatment Outcomes of Facial Rejuvenation Using the Mint Lift Fine. |
2020 |
Postoperative complications 19% all of which were spontaneously resolved within a maximum period of 4 months |
The use of absorbable barbed threads clearly demonstrates superior aesthetic outcomes and a lower incidence of long-term complications when compared to both permanent and non-absorbable threads, with excellent mechanical and biological effects. |
Zhukova O, Dydykin S, Kubíková E, Markova N, Vasil’ev Y, Kapitonova M. [17] |
357 |
Not recorded |
A New Complex Minimally Invasive Thread Lift Method for One-Time Three-Step Fixation of the Face and Neck Soft Tissues. |
2022 |
With no major complications observed in the postoperative period; ecchymosis 39.8%
(up to 2 weeks); edema 30% (5 to 7 days); tenderness 20.7% (1 to 2 days); dimpling 0.8%; asymmetry 0.6% which disappeared after massaging/pressing. |
There is a high degree of effectiveness with the use of this especially when comparing the results two years after the procedures. |
Nanouk van der Sluis N, Gülbitti HA, van Dongen JA, van der Lei B. [18] |
968 |
11 |
Lifting the Mouth Corner. |
2022 |
Hematoma and swelling 14.3% of all patients. |
The surgical procedure within facial lifting has more lasting effects compared to lifting using tension threads for the mouth corners. |
5. Discussion
Facial rejuvenation using tension threads is a minimally invasive technique aimed at tightening the skin while considering certain anatomical structures, providing the ability to deliver immediate and relatively long-lasting results. The use of tension threads for facial rejuvenation offers an immediate effect, as the threads promote the production of collagen, elastin, and provide a lifting effect [10] [14] [16]. However, some authors argue that there are no effects on elastin production [8], and the lifting effect is poor or inversely proportional to the patient’s age [16] [17]. Some studies report a significant improvement in facial contour and skin appearance 6 months post-procedure [15] [17], while others suggest that the effect’s duration is limited, especially in older patients or those with more aged skin [6] [8]. In this regard, evidence suggests that the dual mechanism of absorbable threads, for tissue repositioning and collagen stimulation, contributes to a move durable effect than other conventional threads, such as PDO threads that degrade more quickly [8]. Despite the immediate benefits of tension threads, current literature does not provide Sufficient evidence to support sustained efficacy beyond 12 months [6]. However, depending on the technique used, this effect could last much longer that 12 months [16].
The impact of age on the results of thread lift procedures is another important aspect. Patients over 50 years old have a significantly higher risk of developing complications [5], which could be related to the reduced skin elasticity and lower cellular regeneration capacity [18]. These finding are complemented by results showing that patients with more pronounced skin sagging and loss of subcutaneous by results showing that patients with more pronounced skin sagging and loss of subcutaneous tissue are at higher risk of complications, potentially requiring a more cautions technique and the use of slower-absorbing threads [9]. The technique used is also crucial, as careful attention to thread depth can minimize the risk of complications and reduce adverse effects [17].
The outcomes of thread lift procedures demonstrate a high level of satisfaction immediately after the procedure [15]. Satisfaction varies depending on the technique used, the physician’s skill, and the type of thread chosen [5] [9]. This high satisfaction rate indicates that patients perceive significant improvements in facial contour, skin firmness, and texture, although these improvements are not always maintained long-term [6] [9]. These effects tend to diminish notably after six months [9] [10], with the decrease in the lifting effect directly related to the resorption of the threads.
In addition to the short-term benefits of thread placement, complications may rise, including dimpling of the skin, thread visibility, infections, thread extrusion, and facial asymmetries [5] [9] [14] [15]. The incidence of these complications varies considerably, with some studies reporting rates between 20% - 30% [17], with skin dimpling and thread visibility being the most common complications [7] [9] [10]. These effects are more frequent when threads are placed too superficially or when the technique is not properly followed. It’s important to note that the use of absorbable threads alone reduces the incidence of complications compared to non-absorbable threads, especially in older patients or those with sagging skin [15] [16].
6. Conclusion
The use of tension threads for facial rejuvenation represents a promising minimally invasive option, offering good immediate results and enhanced collagen production, in addition to a lifting effect. However, complications, the duration of the effect, and long-term satisfaction are areas that require further investigation. The technique and the physician’s experience, as well as the patient’s age and the type of thread used, are important factors influencing the procedure’s success. Despite current advances, it is essential to conduct more in-depth research to address existing gaps, particularly in regions such as Latin America and Europe, where research in this field is limited. Furthermore, education and training of professionals should be promoted to minimize complications and maximize long-term outcomes. It is also necessary to conduct more studies on the longevity of the effects of thread lifting, as well as research involving different ethnic groups, which would allow for more generalizable and applicable conclusions to diverse population. Additionally, education and training of professionals should be promoted to minimize complications and maximize long-term results.