This emerging procedure follows the trend toward less-invasive facial rejuvenation
An effective, minimally invasive alternative to the aggressive and potentially risky facelift operation has long been one of the holy grails of plastic surgery, promising its inventor riches and fame. Creams, potions, lasers, radiofrequency, and ultrasound have all been tried and have fallen short of full acceptance.
The newest player is the barbed thread lift. Suture lifts without barbs have been used successfully for more than a decade, but the general complaint about these procedures is that over time the suture tends to act like a “cheese wire”; it cuts through the tissues, diminishing the effect. The advantage of the barbed suture is its ability to hold and support the tissues along its entire length, instead of just the tip or loop.
In its simplest form, the suture is scored to cause barbs or cogs to project from it. This makes the suture very easy to move in one direction and very difficult to move in the opposite direction.
Once a suture is in place, tissues can be lifted or repositioned in one direction and will be supported by the expanded cogs and prevented from dropping back into their former position. This is somewhat analogous to a small umbrella that can be pushed easily through sand, but to reverse this motion and pull the umbrella is considerably more difficult.
How Barbed Sutures Began
The first recognizable invention that incorporated the idea of a one-way suture was patented in 1964.1 A New Jersey physician, JH Alcamo, MD, patented a suture with a “roughened” surface that offered resistance in only one direction. It was designed to be used in a surgical sewing machine, but no references could be found for its actual use. His goal for developing the suture was to allow surgeons to make a “tighter seam.”
The next, and probably most significant, patent did not come until 1994.2 The inventor was Gregory L. Ruff, MD, formerly an assistant professor of plastic surgery at Duke University (Durham, NC). His patent describes not only a unidirectional barbed suture, but also a hollow insertion device for placement.
Many subsequent patents, including one of Ruff’s,3 have demonstrated the evolution of this device to a barbed suture that does not require a separate insertion device but instead has needles on each end. One needle is used for positioning the suture, and the other is used for anchoring it to deeper structures. When placed correctly, the barbed suture lifts 1 pound for each inch of its length. This was the first, and, as of this writing, the only barbed suture to achieve US Food and Drug Administration (FDA) certification.
A thread that was developed in Russia4 has been widely used internationally, but it has not yet been cleared by the FDA. It is a bidirectional, free-floating thread that is placed through a hollow needle. After the needle is placed, the tissues are compressed over the needle, which is then withdrawn, causing the cogs to engage the tissues and support them.
Theoretical advantages include very rapid placement of the threads. The disadvantages, which are related to the thread’s free-floating nature, include more frequent migration with exposure, reduced duration of the effect, and sometimes inappropriate bunching of the tissues being lifted.
Another “international” thread was developed by Woffles Wu, MD, in Singapore.5 It is a very long suture that is also bidirectional, with the cogs converging toward a central 8-cm nonbarbed section. It is inserted through a very long hollow needle and turned; the second half is reinserted roughly parallel to the first half. The long nonbarbed section in the middle is the point of maximum lift, and it can again act like a cheese wire.
This suture can be difficult to place because of its length and its tendency to act like two barbed anchors with a cheese-wire suture in the center. Once the upside-down loop is placed and the barbed ends are pulled, there is no further tissue positioning. Again, this suture has not received FDA approval.
Nicannor Isse, MD, developed a semisurgical thread as a modification of the suture developed in Russia.6 It was designed originally to be used in an open incision to support the malar fat pad in a midface suspension. Isse subsequently developed a semiclosed placement method, but this still requires a 2-cm incision in the hairline. This suture is placed from posterior to anterior through a hollow needle, where it engages the malar fat pad. The proximal smooth ends of the sutures are then anchored to the fascia in pairs. Although in its closed usage it is less invasive than the facelift, it still requires a significant incision in the scalp. This suture, like the previous two, has not been approved by the FDA.
Because of the difficulty of interpreting off-label usage, the dangers of non-FDA-approved devices in informed consents, and the litigious nature or our society, it is important to emphasize that the Ruff barbed thread is the only FDA-approved product.
Following the Trend
With the “megatrend” in current plastic surgery toward less-invasive procedures—with less downtime, absence of pain, and more subtle outcomes—the barbed thread lift is “just what the doctor ordered.” It is an ideal procedure for younger patients who are just beginning to show the signs of facial aging, such as increasing prominence of the nasolabial and melolabial grooves, descent of the malar fat pad, and some skin laxity. It can also be very useful for the patient afraid of anesthetics, surgical incisions, or the downtime associated with the more aggressive procedures.
Very underweight and very overweight patients tend to be poor candidates because they are more likely to have tissues that will not move or to have no safe layer through which to pass the sutures. The lift combines well with other noninvasive procedures—such as botulinum toxin Type A, hyaluronic acid, or laser treatments—to intensify the results.
I have also had several excellent results with patients who had facelifts 5–7 years previously and were beginning to exhibit relapses in some areas of the previous surgeries. I used threads to lift only the problem areas, and they were quite happy until it was time to repeat their facelifts. These procedures have been featured on the television programs The Oprah Winfrey Show and Good Morning, America, and in People magazine, among others.
How It’s Done
The barbed thread lift can be performed in the physician’s office using only small quantities of local anesthetics. If no sedation is used and the lift is conservative, some patients can drive themselves home after a brief recovery period in the office. The full thread lift most commonly consists of two threads to lift each brow, four threads per side to lift the cheeks and jowls, and two on each side to lift the neck.
The anchor points are inside the hairline region that is appropriate for each of these locations. In the cheek, it is very important to place the threads in the subcutaneous tissues to avoid getting too close to the deep dermis, which tends to cause grooving of the surface. In the neck and forehead, the insertion needle undoubtedly penetrates the sheet muscles, but this does not cause problems and probably helps with suspension.
The unidirectional (Ruff) suture consists of a barbed 25-cm 2-0 polypropylene suture with a 7-inch straight needle on one end for insertion and a small, curved needle on the opposite end for fixation. The number, position, and size of the barbs have been optimized for holding strength without compromising breaking strength.
The procedure begins by giving the patient a hand mirror and probing the facial vectors to establish the paths of the sutures. The paths are then marked with a surgical marker. Patients can participate in this process, and it helps them feel that they are directing the suture-placement decisions. The paths for the brows begin in the hairline and terminate just below the brow. The paths for the neck can begin either behind the ear or farther posterior in the hairline. They terminate just short of the midline of the neck.
The cheek sutures, which have the greatest variability, generally begin in the hairline just above the ear and terminate just short of the nasolabial or melolabial lines, with one centered on the bulk of the jowl. It is a good idea to check the width of the smile and to avoid placing a suture that might interfere with the lateral extent of the smile. The movement of the face could increase the risk of exposing the thread over time. The highest cheek thread should avoid the arcus marginalis and orbital structures because there is no fat layer in the lid proper and because getting too close to the orbit can cause prolonged edema. See Figure 1 for an example of patient markings.
The paths are then anesthetized locally. I use 0.5% lidocaine with bicarbonate and a 25-gauge spinal needle. After an appropriate period of time and a sterile preparation, a small puncture is made in the hairline with the point of a scissors or a small (1.5-mm) punch biopsy. A third punch is made a short distance posteriorly for every two threads used.
Sutures are placed first with the long needle. It is threaded in a serpentine fashion through the subcutaneous tissues to the marked exit point, and it is brought abruptly to this point instead of with a gradual rise. The thread entries and exits should be nearly perpendicular to the skin. The thread is pulled into the wound until the barbs disappear, and then for 1 additional centimeter. The long needle is removed, and a second suture is placed in a similar manner. Figure 2 illustrates needle placement.
Before the larger needle is removed from the exit point, it is essential to carefully feel the tissues that overlie the needle. If there are any shallow areas, the needle should be withdrawn and repositioned before removal. Once the threads are in place, the smaller needle is used to anchor the thread to the deep fascia by passing it deeply, catching the fascia, and exiting through the third punch area. When both sutures have been placed, they are carefully tied and trimmed.
Here are two important points:
The most common early mistake is to place the sutures too superficially, leaving grooves through the cheeks.
The knots must be square and must not involve any barbed portions of the sutures.
Keeping hair out of the knots can be challenging at times, but it is essential. At this point, the distal ends of the sutures are still protruding from the exit points. After I place all of the sutures, I usually ask the patient to sit again and hold the mirror. We “set” the threads together by lifting the tissues, simultaneously holding the distal ends of the threads.
As the tissues are lifted, the barbs engage and prevent the tissues from descending. A symmetrical overcorrection is appropriate, more in the cheeks and neck than in the forehead. Finally, the protruding threads are trimmed and allowed to retract into the skin.
Very gentle ice compresses and a brief recovery period are appropriate. Consideration should be given to taping the thread areas to restrict movement or simply cautioning the patient against vigorously eating, talking, or making facial expressions. I generally ask patients to sleep on their backs with their heads elevated for 3 days.
During the first 3 days, the risk for dislodging the cogs and diminishing the effect of the thread lift is especially high. After the 3 days, patients still need to be cautious with facial cleansing and makeup removal. After 3 weeks, the threads have become much better anchored by the accumulation of connective tissue in the crotches of the barbs, and patients may safely engage in more vigorous activity.
Despite the temptation to call this a “lunchtime lift,” that term isn’t realistic. Immediately following the procedure, there is grooving along the cheeks, small dimples near the exit points, an accumulation of excess skin near the hairline and behind the ears, and possible bruising. Most of this is socially acceptable within days, but the excess skin can take up to 4 weeks to reposition itself.
The placement relaxes by as much as 40% over the first few months. The remaining gains are long-lasting. One Canadian pioneer in barbed threads tells his patients that the thread lift is characterized by “half of the lift of a facelift, half of the cost, and half of the duration”—not bad for less than 1 hour in the office.
Complications caused by threads are rare. The threads are removable, replaceable, and repeatable. The threads can break, become exposed at the tip, cause bruising, irritate cutaneous nerves, become dislodged, or become infected. They can be treated symptomatically or removed to be replaced at a later time.
Except for occasionally having to deal with a persistent dimple, patients find the complications easy to manage. Patient satisfaction has been very high when they are realistic about their gains. As more threads are approved by the FDA, thread lifts will undoubtedly become increasingly popular. PSP
Donald W. Kress, MD, PA, FACS, is a private-practice board-certified plastic surgeon with his principal office in Frederick, Md. He has more than 25 years of experience in the field; his practice has been limited to aesthetic surgery for more than 10 years. He is currently one of only 23 FDA-approved investigators for the high-strength gel implant. He has been featured on television, radio, and print media. His philosophy is to keep his practice at the very front edge of new technology. He can be reached via his Web site, www.plasticsurgeryone.com.
1. Alcamo JH, inventor and assignee. Surgical suture. US Patent 3 123 077. March 3, 1964.
2. Ruff GL, inventor; Dermagraphics Inc, assignee. Inserting device for a barbed tissue connector. US Patent 5 342 376. August 30, 1994.
3. Ruff GL, inventor; Quill Medical Inc, assignee. Barbed bodily tissue connector. US Patent 6,241,747. June 5, 2001.
4. Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze GM. Removal of facial soft tissue ptosis with special threads. Dermatol Surg. 2002;28: 367–371.
5. Wu WTL. Barbed sutures in facial rejuvenation. Aesthetic Surg J. 2004;24: 582–587.
6. Isse NA, Barbed polypropylene sutures for midface elevation. Arch Facial Plast Surg. 2005;7:55–61.