Introduction and abstract

Facial lifting treatment stays as one of the main concern among rising demands in all aesthetic treatment arena. For physicians the treatment of choice will be safe, effective, minimal invasive and scientifically proven. We would like to introduce a novel barb suspension thread system, with sharing on the techniques and the concepts of anatomical-aesthetic-clinical correlation approach for the best outcome.

Background

Face-lifting is the 4th commonest surgical procedure globally [1]. Barb suspension thread is minimal invasive, bearing lower risks and less down time. Successful thread use started in 50's [2] and later with the introduction of permanent thread system by Sulamanidze in late 90's [3]. There is an upsurge of thread materials in aesthetic arena and the use are increasingly common [4]. The composition, design and the clinical applications dictate the product design and as a result the treatment outcome specificities. With more understanding on the facial anatomy and the tissue interaction with the physical composition we can define the treatment outcome by the physical traction and biostimulation effects [5][6][7]. In the following discussion we will illustrate our concepts and practice principles with the use of Happy LiftTM (Revitalizing) bidirectional threads (or in Europe DefinisseTM threads).

Relevant clinical anatomy for a successful barb suspension.

Face aging is a complex and multifactorial process with specific characteristics for each patient. It’s mandatory to do a careful assessment of aging process that has determined the anatomical modification of face. This allows an adequate planning of insertion lines of barbed threads that will permit an efficient lifting action on face soft tissues.

The knowledge of anatomy of structures as the superficial and deep fat compartment, the SMAS (Superficial Muscular Aponeurotic System), the main vessels and nerve and parotid gland is necessary to assure an effective and safe use of barbed threads.

The midface fat compartments are classified as either superficial or deep. The superficial fat compartments are located between the skin and the plane of the Superficial Muscular Aponeurotic System (SMAS) [8][9]. The SMAS is a continuous and organized fibrous network connecting the periosteum, the facial muscles, or other fascial types (e.g., parotid fascia), with the dermis. It consists of a three-dimensional architecture of collagen fibers, elastic fibers, fat cells, and muscle fibers. The fat tissue of the superficial compartments is located within this fibrotic network. Under the SMAS plane, and beneath the mimetic muscles, we find the deep fat compartments that reach and adhere to the periosteal plane.

The Happy Lift TM (Revitalizing) threads are able to hook by their barbs the fibrotic network of retinacula cutis of the SMAS and therefore to lift the superficial fat compartments.

The superficial fat compartments of cheek are described below and can be found in:

Figure 1. Superficial fat compartments

The fat compartments undergo specific modifications due to the aging process. In general the aging of the medial and central group of fat compartments in characterized by ptosis, downward volume migration, and hypertrophy. Differently, the only one superficial fat compartment that has a different aging process characterized by hypotrophy with no ptosis is the lateral temporal-cheek fat. It’s evident that usually, the fat compartments which need to be lifted are that of the medial and central group, whereas, to optimize the lifting action of Happy Lift TM (Revitalizing) threads, we have to use the fixity of lateral temporal-cheek fat compartment to assure a strong anchor area.

Aesthetic assessment and selection of right patients

Effective barb thread lifting procedure requires careful patient assessment. We have applied the HappyLiftTM (Revitalizing) system both to Asian population (skin type II to V) and Caucasians (skin type I to II). In general, Asian skin ages with fibrosis and redundancy and thus less wrinkles while Caucasians ages with more thinning and atrophy [10][11][12]. With this we feel that Asians in general may have better anatomico-aeshetic-clincial outcomes. As in any procedure we should exclude candidates from the contra-indication list, and all patient should undergo a proper consenting and counseling of the procedure and aftercare before the surgery.
The typical patient will have good benefit from thread surgery will be:
a. Age 30 to 60 years old (as in these age group their skin still has good potential to recover and respond to the lifting effect)
b. Mild to moderate skin photoageing (Excessive photoageing may affect the wound healing and risk of hyperpigmentation particularly in Asians)
c. Mild to moderate skin sagging in the midface and lower face fat compartment (Excessive sagging may undermine the good clinical results from the minimal-invasive surgery. Formal face lifting may be more appropriate).
d. Does not have excessive skin thinning or lipoatrophy (in whom other aesthetic treatment like fillers is more appropriate)

We highlight the ageing profile on the face like changes in the fat compartment leading to sagging, herniation as well as skin laxity contributing to the ageing disfigurement. The midface as well as the lower face are important in facial aesthetics because perceptions of facial attractiveness are largely founded on the synergy of the eyes, nose, lips, and jaw definitions as an inverted triangle. For aesthetic purposes, this area should be considered from a 3-dimensional rather than a 2-dimensional perspective, and youthful restoration with regard to these areas should be regarded as the primary goal in facial rejuvenation [13][14][15].

Thread design

The Happy LiftTM (Revitalizing) Double Needle threads are a range of absorbable, monofilament, suspension-barbed threads of synthetic origin (poly-L-lactic acid and caprolactone, p(LA-CL). The thread ends have two straight sharp needles 100 mm long with a diameter of 0.462-0.488 mm for the thread with the 12cm barbed section. The thread with the 23cm barbed section has two 150 mm long needle with the same diameter. The barbs distribution is bidirectional and convergent. The sutures interact with the tissues with a double action. The first one is the immediate lifting action for the support and repositioning of the tissues, thanks to the mechanical action determined by the anchoring of threads barbs once inserted in the tissue. The second is the revitalizing action, due the fibrosis and slight inflammation that is determined along the thread [9].

The main insertion techniques of threads can be classify in two groups on the base of the direction of the vectors they use to lift and reshape the face frames.

Surgical techniques

The techniques with lateral vectors are:
- Jawline Reshaping (JLR) that corrects the defects of jawline due to inferior jowl fat ptosis (12cm threads)
- Malar Reshaping (MR) that lifts laterally the malar fat pad (12cm threads)
- Lateral Reshaping (LR) that lifts laterally the midface and lower face fat compartment (23cm threads) combining the actions of previous techniques.

The techniques with vertical vectors are:
- Oval Reshaping - Vertical Reshaping (ORV-VR) that lifts vertically the central and medial fat compartments of cheek (23cm threads)
- Oval Vertical Reshaping-H (ORV-H) that lifts vertically the central and medial fat compartments of cheek (two 12cm threads) The choice of a technique with vertical or lateral vector is based on patients’ clinical needs.

In Caucasian patients the techniques with lateral vectors assure a V shape face with well-defined angles usually appreciate by patients of this ethnic group. Asian patients instead prefer an oval shape face that can be better achieved by techniques with vertical vectors. Generally in patients with a large face are indicated the techniques with vertical vectors, whereas in narrow face patients are more often indicated the techniques with lateral vectors.

All the techniques include an entry point (IN), two exit points (OUTs), sometimes an intermediate point (M) and the reshaping lines (RLs) that indicate the direction of thread insertion. To increase the patient’s safety two safety lines (SLs) are drawn from tragus to external eye cantus and from internal eye cantus to the modiolus. The insertion of the needle beyond these lines requires a higher attention to avoid damaging nerves and vessels that in these areas are more exposed to this risk.

The insertion technique requires the injection of lidocaine with epinephrine 1:100.000 at IN and OUT points and optionally along RLs to reduce the pain during the insertion. Of note, it is important to set a minimal, yet adequate, surgical field, prior to executing the procedure with Happy Lift TM (Revitalizing) threads and maintain these conditions during the entire procedure. The IN point should be created using a 18 gauge needle, inserting it perpendicularly to the skin and making a hole in the continuity of all thickness of dermis. The thread needle is introduced through the main dermal hole. We will slowly run the needle along the RLs in the SMAS plane. Once the tip of the needle reaches OUT, we are safe to pierce the skin with the needle, creating an exit point, and exiting in a perpendicular way. Continue to slowly pull the needle out along the RL until half part of the thread is inserted into the subcutaneous plane. The same insertion modality is used for the other half of thread along the opposite RL. Once the double needle thread is completely positioned underneath the patient's skin, we can promote the lifting action by "pulling" the skin upward along the path of the thread, distributing the tissue toward the entry point. Once both parts of threads are inserted the superficial fat compartments are lifted pulling both extremities of the thread. The five techniques described are shown in figure 2.

Pitfalls and pearls to success

Assessment: Every patient is individualized. The aesthetic assessment thus is the most important part with good anatomical-aesthetic-clinical correlations in designing a successful surgery. During the assessment one should highlight the relevant ageing features, existing asymmetry and important anatomical concerns (such as neurovascular roadmaps and salivary gland) in the thread placement field. The assessment should then be concluded with hypotheses for the treatment strategies.
Surgery: Throughout the surgery, the respect for surgical sterility is essential to avoid infection after placement of durable materials. A relative bloodless field will make the surgery lot easier. We recommend using Lidocaine mixed with Epinephrine to create a vasoconstricted zone for the placement. During the placement of the thread, one has to pay attention to the plane, as 1) it should be consistent for the entire barb thread, 2) avoid being too deep or get superficialized. Though Asians are good candidates for barb thread surgery, Asian skin ages with deposition of melanin and this may have reactions like post-inflammatory hyperpigmentations [16] [17] or flare of melasma particularly around surgical wound or when the thread placement is too close to subdermal layer or superficialized. With this robust thread system one may achieve vigorous pulling effects or drastic over-correction but this should be avoided so as to minimize the downtime.
Aftercare: A good surgery needs meticulous aftercare instructions to bring out the best results and avoid complications. The wound is mainly consisted of the puncture petit wound and that should be covered with antiseptic regularly for few days. Pain is not a major issue but can be readily lessened with simple analgesics. It is important for the first few days to avoid vigorous exercise, smoking and alcohol as in other surgeries for better wound recovery. In order to allow the best suspension effects we recommend patient to sleep facing upright, and to avoid posture needs prolonged jaw opening (as in the dental procedure). We routinely ask the patient for a follow-up assessment on day 3 or 5, and in the later weeks. This will help us to be aware of the treatment outcome and for photographic documentations.
Complications: In the case series for new incoming trainee physicians as well as the thread surgeries performed by trainers during the live demonstrations, the complications are mainly bruising and mild transient asymmetry. Dimpling at the entry point and along the pathway are occasionally seen particularly in Asian skin due to more fibrotic thickening. We believe this is more technique dependent issue. All complications resolve with massage and time.

Happy lift TM (Revitalizing) threads in combination with other minimally invasive procedures

Happy Lift TM (Revitalizing) threads can be combined and integrated with other procedure to optimize the facial rejuvenation. The age-related modifications of the face have different causes and the aging process is multifactorial and it's due to the face volume reduction, to dynamic action of face muscles, to soft tissue ptosis and to skin sagging. The defects related to volume loss can be correct by fillers, the dynamic defects by botulinum toxin injection and, finally, threads allow the correction of ptosis of soft tissue, completing the treatment portfolio at disposition for face rejuvenation. They can be combined with laser, HIFU, microneedling fractional radiofrequency or other similar technologies to optimize the lifting effect correlated with these treatments.

Conclusion

Barb thread suspension procedure provides an effective means of facial lifting and tightening treatment in current aesthetic arena. With the use of threads, we can achieve results close to surgical face-lift, albeit the usage of thread is by no means a replacement of it. With good anatomical-aeshetic-clinical correlations through a standardized training platform we think barb thread surgery can provide good and versatile clinical use in future.

References
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