Expert Shares Start-to-Finish Thread Lift Pearls : Procedure's success depends on identifying and correctly marking the area of facial 'descent.'

WILLIAMSBURG, VA. — Thread lifts produce pleasing results because the procedure corrects the downward shift of facial skin with age, something that excisional face-lifts don't address, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

"Standard face-lifts tend to move the face posteriorly. … The problem [with the aging face] is a vertical descent," said Dr. Mandy, professor of dermatology at the University of Miami.

The descent of the malar fat pad creates the nasolabial folds, the hollow underneath the malar eminence, the jowl, and the prejowl sulcus, Dr. Mandy explained. He estimates that half of his patients have already had a face-lift but are still unhappy with the nasolabial folds and jowls.

Good candidates for this procedure have soft tissue facial ptosis and moderate soft tissue thickness. Without adequate subcutaneous tissue, there is nothing for the barbs to hook into. The threads can also be seen if there is not enough subcutaneous tissue, he said.

The most important portion of the procedure is marking where the threads will be placed. This should be done with the patient in a seated position. Determine where the facial descent is located. "If you have a heavily malar descent, you're going to put two threads to that malar fat pad," Dr. Mandy said. The threads will exit at the nasolabial folds and jowls, improving these two areas, unlike what occurs with a standard face-lift.

There are two types of threads. The two-sided Articulus 400 series (part of the Contour Threads family made by Surgical Specialties Corp.) has two straight needles with a single thread. The barbs face in the opposite direction to the needle on each end, with no barbs in the center of the thread. No knots need to be tied with this thread type. Contour Threads are single threads with barbs facing in the opposite direction to the needle. They are approved for midface, brow, and neck suspension.

The second type of thread, the Featherlift extended-length Aptos thread (Kolster Methods Inc.), has bidirectional barbs and is approved for use in midface suspension surgery to fix the cheek subdermis in an elevated position.

Dr. Mandy has received compensation as a Contour Threads instructor.

For a brow lift, one double thread (Articulus 400 series)—or two single threads (Aptos)—is fixed on each side just behind the hairline, and the ends exit at the eyebrow. A third double thread (or two single threads) comes from behind the hairline at the central forehead to the medial brow on each side. Dr. Mandy said that he always performs Botox injections at the brow 1 week prior to the thread lift. This prevents patients from pulling against the threads and allows healing in the correct position.

For the midface and lower face area, thread placement is highly variable, depending on the individual patient's degree of ptosis. Typically, two single threads or one double will go from the temporal fascia to the angle of the ala and to the corner of the mouth, skewering the malar fat pad. "If there's a significant jowl, [another] thread will come down to the top of the jowl and one to the apex of the jowl—right to the deepest point of the jowl," Dr. Mandy explained.

If a patient has mild ptosis, he will use only one double thread, running from the temporal fascia to the midpoint of the nasolabial fold and to the jowl.

Up to four single threads (or two double) may be used on each side of the neck to tighten this area, but most patients need only two singles (one double). Dr. Mandy frequently performs neck liposuction just prior to thread placement.

The average patient will require six single threads: two on each side for the midface and lower face, and one on each side of the neck.

In terms of sedation, "I use less and less sedation with this procedure," he said. For most patients, he simply administers oral diazepam. If patients are "a little too jittery, I might give them Tylenol with codeine along with that," he said. Local anesthesia is used: 1% lidocaine with epinephrine in a 25-gauge spinal needle. Dr. Mandy typically uses bupivacaine at the entry and exit sites, where the patients have discomfort.

The procedure starts with a 1.5- to 2.0-mm punch biopsy to open the entry point. For the double thread, the threaded needle grabs the fascia and is then passed through the subcutaneous tissue. A sinusoidal placement pattern—moving the needle back and forth while advancing it subcutaneously—will improve strength by increasing the number of barbs anchoring the thread. When the thread is positioned, pull back from the entry point to allow the barbs to "bite" into the tissue, he said.

Next, the tissue between the arms of the threads is bluntly dissected with a sharp-point dissector. The technique is similar to that used with a liposuction cannula. "The beauty of it is that when you do that, you're now creating a biplane face-lift … so that when you lift that skin, you're basically moving the top plane over the bottom plane," Dr. Mandy said. In addition, the tissue healing process occurs all along the "giant flap" of skin.

Finally, the tissue is contoured by basically "walking" the tissue up the threads. The wider the U-bend of the double thread, the better the thread will stay in place.

With the single threads, one end is threaded through a straight needle while the anchoring end is threaded through a curved needle. The curved needles are used to "bite" the fascia, to hold the thread. "The beauty of those is that they really anchor the fascia," he said.

The barbs of the suture will grab gauze, so dental cotton rolls are used around the exit and entry points. After the procedure, Dr. Mandy trims the threads and tapes them in place. This way, he can recorrect if necessary in the first 72 hours.

He uses a chin strap for moderate support and lots of ice postoperatively. He also has patients take 20 mg of prednisone that night and again the next morning. "That greatly reduces facial swelling," he said

Although a thread lift is not a surgical procedure, there is still considerable recovery time involved. "This is not a weekend face-lift. These patients have to anticipate [that it will be] 1 week before they look relatively normal," Dr. Mandy noted.

Don't be concerned if patients look weird with rolls of excess skin immediately after the procedure. "The worse they look post-op, the better they're going to look a month later," he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

WILLIAMSBURG, VA. — Thread lifts produce pleasing results because the procedure corrects the downward shift of facial skin with age, something that excisional face-lifts don't address, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

"Standard face-lifts tend to move the face posteriorly. … The problem [with the aging face] is a vertical descent," said Dr. Mandy, professor of dermatology at the University of Miami.

The descent of the malar fat pad creates the nasolabial folds, the hollow underneath the malar eminence, the jowl, and the prejowl sulcus, Dr. Mandy explained. He estimates that half of his patients have already had a face-lift but are still unhappy with the nasolabial folds and jowls.

Good candidates for this procedure have soft tissue facial ptosis and moderate soft tissue thickness. Without adequate subcutaneous tissue, there is nothing for the barbs to hook into. The threads can also be seen if there is not enough subcutaneous tissue, he said.

The most important portion of the procedure is marking where the threads will be placed. This should be done with the patient in a seated position. Determine where the facial descent is located. "If you have a heavily malar descent, you're going to put two threads to that malar fat pad," Dr. Mandy said. The threads will exit at the nasolabial folds and jowls, improving these two areas, unlike what occurs with a standard face-lift.

There are two types of threads. The two-sided Articulus 400 series (part of the Contour Threads family made by Surgical Specialties Corp.) has two straight needles with a single thread. The barbs face in the opposite direction to the needle on each end, with no barbs in the center of the thread. No knots need to be tied with this thread type. Contour Threads are single threads with barbs facing in the opposite direction to the needle. They are approved for midface, brow, and neck suspension.

The second type of thread, the Featherlift extended-length Aptos thread (Kolster Methods Inc.), has bidirectional barbs and is approved for use in midface suspension surgery to fix the cheek subdermis in an elevated position.

Dr. Mandy has received compensation as a Contour Threads instructor.

For a brow lift, one double thread (Articulus 400 series)—or two single threads (Aptos)—is fixed on each side just behind the hairline, and the ends exit at the eyebrow. A third double thread (or two single threads) comes from behind the hairline at the central forehead to the medial brow on each side. Dr. Mandy said that he always performs Botox injections at the brow 1 week prior to the thread lift. This prevents patients from pulling against the threads and allows healing in the correct position.

For the midface and lower face area, thread placement is highly variable, depending on the individual patient's degree of ptosis. Typically, two single threads or one double will go from the temporal fascia to the angle of the ala and to the corner of the mouth, skewering the malar fat pad. "If there's a significant jowl, [another] thread will come down to the top of the jowl and one to the apex of the jowl—right to the deepest point of the jowl," Dr. Mandy explained.

If a patient has mild ptosis, he will use only one double thread, running from the temporal fascia to the midpoint of the nasolabial fold and to the jowl.

Up to four single threads (or two double) may be used on each side of the neck to tighten this area, but most patients need only two singles (one double). Dr. Mandy frequently performs neck liposuction just prior to thread placement.

The average patient will require six single threads: two on each side for the midface and lower face, and one on each side of the neck.

In terms of sedation, "I use less and less sedation with this procedure," he said. For most patients, he simply administers oral diazepam. If patients are "a little too jittery, I might give them Tylenol with codeine along with that," he said. Local anesthesia is used: 1% lidocaine with epinephrine in a 25-gauge spinal needle. Dr. Mandy typically uses bupivacaine at the entry and exit sites, where the patients have discomfort.

The procedure starts with a 1.5- to 2.0-mm punch biopsy to open the entry point. For the double thread, the threaded needle grabs the fascia and is then passed through the subcutaneous tissue. A sinusoidal placement pattern—moving the needle back and forth while advancing it subcutaneously—will improve strength by increasing the number of barbs anchoring the thread. When the thread is positioned, pull back from the entry point to allow the barbs to "bite" into the tissue, he said.

Next, the tissue between the arms of the threads is bluntly dissected with a sharp-point dissector. The technique is similar to that used with a liposuction cannula. "The beauty of it is that when you do that, you're now creating a biplane face-lift … so that when you lift that skin, you're basically moving the top plane over the bottom plane," Dr. Mandy said. In addition, the tissue healing process occurs all along the "giant flap" of skin.

Finally, the tissue is contoured by basically "walking" the tissue up the threads. The wider the U-bend of the double thread, the better the thread will stay in place.

With the single threads, one end is threaded through a straight needle while the anchoring end is threaded through a curved needle. The curved needles are used to "bite" the fascia, to hold the thread. "The beauty of those is that they really anchor the fascia," he said.

The barbs of the suture will grab gauze, so dental cotton rolls are used around the exit and entry points. After the procedure, Dr. Mandy trims the threads and tapes them in place. This way, he can recorrect if necessary in the first 72 hours.

He uses a chin strap for moderate support and lots of ice postoperatively. He also has patients take 20 mg of prednisone that night and again the next morning. "That greatly reduces facial swelling," he said

Although a thread lift is not a surgical procedure, there is still considerable recovery time involved. "This is not a weekend face-lift. These patients have to anticipate [that it will be] 1 week before they look relatively normal," Dr. Mandy noted.

Don't be concerned if patients look weird with rolls of excess skin immediately after the procedure. "The worse they look post-op, the better they're going to look a month later," he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

WILLIAMSBURG, VA. — Thread lifts produce pleasing results because the procedure corrects the downward shift of facial skin with age, something that excisional face-lifts don't address, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

"Standard face-lifts tend to move the face posteriorly. … The problem [with the aging face] is a vertical descent," said Dr. Mandy, professor of dermatology at the University of Miami.

The descent of the malar fat pad creates the nasolabial folds, the hollow underneath the malar eminence, the jowl, and the prejowl sulcus, Dr. Mandy explained. He estimates that half of his patients have already had a face-lift but are still unhappy with the nasolabial folds and jowls.

Good candidates for this procedure have soft tissue facial ptosis and moderate soft tissue thickness. Without adequate subcutaneous tissue, there is nothing for the barbs to hook into. The threads can also be seen if there is not enough subcutaneous tissue, he said.

The most important portion of the procedure is marking where the threads will be placed. This should be done with the patient in a seated position. Determine where the facial descent is located. "If you have a heavily malar descent, you're going to put two threads to that malar fat pad," Dr. Mandy said. The threads will exit at the nasolabial folds and jowls, improving these two areas, unlike what occurs with a standard face-lift.

There are two types of threads. The two-sided Articulus 400 series (part of the Contour Threads family made by Surgical Specialties Corp.) has two straight needles with a single thread. The barbs face in the opposite direction to the needle on each end, with no barbs in the center of the thread. No knots need to be tied with this thread type. Contour Threads are single threads with barbs facing in the opposite direction to the needle. They are approved for midface, brow, and neck suspension.

The second type of thread, the Featherlift extended-length Aptos thread (Kolster Methods Inc.), has bidirectional barbs and is approved for use in midface suspension surgery to fix the cheek subdermis in an elevated position.

Dr. Mandy has received compensation as a Contour Threads instructor.

For a brow lift, one double thread (Articulus 400 series)—or two single threads (Aptos)—is fixed on each side just behind the hairline, and the ends exit at the eyebrow. A third double thread (or two single threads) comes from behind the hairline at the central forehead to the medial brow on each side. Dr. Mandy said that he always performs Botox injections at the brow 1 week prior to the thread lift. This prevents patients from pulling against the threads and allows healing in the correct position.

For the midface and lower face area, thread placement is highly variable, depending on the individual patient's degree of ptosis. Typically, two single threads or one double will go from the temporal fascia to the angle of the ala and to the corner of the mouth, skewering the malar fat pad. "If there's a significant jowl, [another] thread will come down to the top of the jowl and one to the apex of the jowl—right to the deepest point of the jowl," Dr. Mandy explained.

If a patient has mild ptosis, he will use only one double thread, running from the temporal fascia to the midpoint of the nasolabial fold and to the jowl.

Up to four single threads (or two double) may be used on each side of the neck to tighten this area, but most patients need only two singles (one double). Dr. Mandy frequently performs neck liposuction just prior to thread placement.

The average patient will require six single threads: two on each side for the midface and lower face, and one on each side of the neck.

In terms of sedation, "I use less and less sedation with this procedure," he said. For most patients, he simply administers oral diazepam. If patients are "a little too jittery, I might give them Tylenol with codeine along with that," he said. Local anesthesia is used: 1% lidocaine with epinephrine in a 25-gauge spinal needle. Dr. Mandy typically uses bupivacaine at the entry and exit sites, where the patients have discomfort.

The procedure starts with a 1.5- to 2.0-mm punch biopsy to open the entry point. For the double thread, the threaded needle grabs the fascia and is then passed through the subcutaneous tissue. A sinusoidal placement pattern—moving the needle back and forth while advancing it subcutaneously—will improve strength by increasing the number of barbs anchoring the thread. When the thread is positioned, pull back from the entry point to allow the barbs to "bite" into the tissue, he said.

Next, the tissue between the arms of the threads is bluntly dissected with a sharp-point dissector. The technique is similar to that used with a liposuction cannula. "The beauty of it is that when you do that, you're now creating a biplane face-lift … so that when you lift that skin, you're basically moving the top plane over the bottom plane," Dr. Mandy said. In addition, the tissue healing process occurs all along the "giant flap" of skin.

Finally, the tissue is contoured by basically "walking" the tissue up the threads. The wider the U-bend of the double thread, the better the thread will stay in place.

With the single threads, one end is threaded through a straight needle while the anchoring end is threaded through a curved needle. The curved needles are used to "bite" the fascia, to hold the thread. "The beauty of those is that they really anchor the fascia," he said.

The barbs of the suture will grab gauze, so dental cotton rolls are used around the exit and entry points. After the procedure, Dr. Mandy trims the threads and tapes them in place. This way, he can recorrect if necessary in the first 72 hours.

He uses a chin strap for moderate support and lots of ice postoperatively. He also has patients take 20 mg of prednisone that night and again the next morning. "That greatly reduces facial swelling," he said

Although a thread lift is not a surgical procedure, there is still considerable recovery time involved. "This is not a weekend face-lift. These patients have to anticipate [that it will be] 1 week before they look relatively normal," Dr. Mandy noted.

Don't be concerned if patients look weird with rolls of excess skin immediately after the procedure. "The worse they look post-op, the better they're going to look a month later," he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.