Aging of face is an unavoidable process. While there are multiple traditional procedures for facial rejuvenation, thread lift has become an increasingly popular procedure all over the world. At present, one of the most promising dissolvable thread lift uses polydioxanone (PDO) material that has been in use for many years. The thread itself not only provides lifting benefits, but the material stimulates collagen regeneration as well.
Here we reviewed an innovative technique combining absorbable thread lift with small incision rhytidectomy for patients with excess skin. Performing thread lift on the patient alone could not achieve the desired results. Management for complication was also reviewed.
A 52-year-old male presented facial ptosis and static crows-feet wrinkles. He also had skin laxity and deepening nasolabial fold (Figure 1). Considering skin laxity, he was recommended the innovative technique combining thread lift with small incision rhytidectomy. This is the patient’s first aesthetic procedure.
Figure 1: A 52-year-old male presenting with skin laxity, mid-face and mandibular jowl ptosis, static crows-feet wrinkles, and deepening nasolabial fold.
Before the procedure, thread lines were designed and marked on the patient. The surgical procedure was performed under local anaesthesia. Following the markings, a small needle knife was inserted at superficial muscular aponeurotic system (SMAS) layer to break ligaments and make pilot tunnels for thread cannulas. Absorbable PDO threads with the following specifications: bidirectional barbed, 19 gauge, 150 mm length, were used with blunt needle.
Five threads were inserted on each side between the lateral aspect of nasolabial fold and laterally preauricular aspect in at an angle. Before removing the cannulas, minimal pressure was applied over the skin to anchor the barbed thread inside the tissues.
A small preauricular incision was made to remove the excess skin. It was then closed with 6-0 polypropylene suture. The results were assessed objectively with photograph taken and subjectively based on the patient's satisfaction.
Following the procedures, improvements of the crow's feet, nasolabial fold, and mid-face and lower face ptosis were observed. However, 10 days after the procedure, patient complained of subcutaneous nodule with palpable knot on the left side of his face (Figure 2). He did not feel any pain or discomfort on other areas. After discussing the options to minimise the discomfort, a minimally invasive approach was attempted. Under local anaesthesia, a small needle knife was inserted into the affected area, to break the fibrosis around the knot without cutting the thread.
Figure 2: Ten days after the procedure, the patient presented with subcutaneous nodule and palpable knot at the left side of his face.
The fixation knot was preserved and 1 month later, the nodule was flattened and the knot was no longer noticeable (Figure 3).
Figure 3: One month after the procedure, the nodule and knot were corrected after small needle knife dissection with almost invisible scar.
The patient handled the procedure well, without bleeding or any other complications. The incision of rhytidectomy and small needle knife healed with nearly invisible scar. The cosmetic effect of thread lift remained and the quality of the skin improved 3 months after the procedure (Figure 4).
Figure 4: The cosmetic effect of thread lift remained and the skin quality was improved 3 months after the procedure.
As we all know, aging is a progressive and inevitable process. Various surgical and nonsurgical procedures have been adopted for facial rejuvenation. But for patients with ptosis and facial laxity, surgical face-lift was the only solution to facial rejuvenation. Despite its effectiveness, surgical face-lift has multiple disadvantages like obvious scarring, great trauma, nerve damaging risks, and long recovery period.
As the demand for less invasive procedure increases, thread lift gained a reputation as an alternative to surgical face-lift. However, even when the non-absorbable poly-polypropylene threads were proved to have long-term efficacy, complications such as thread migration and exposure, nerve involvement and foreign body reactions appeared. Hence, the safety on the use of a non-absorbable thread in the long run was doubtable.
Until recently, absorbable threads made of PDO were available and applied in facial rejuvenation. It was also indicated in histopathological studies that there was collagen deposition when PDO thread lift was performed, improving the skin quality and fibrotic reaction of long-term lifting effect.
Thread lift is able to achieve ideal rejuvenation and contouring results for patients with mild ptosis and skin elasticity. Whereas patients with moderate to severe ptosis and decreased skin laxity, thread lift with small incision rhytidectomy is the ideal procedure to achieve aesthetic improvements. Performing thread lift alone may cause the skin to remain saggy or even exaggerated as excess skin may bunch at the lateral side of the face.
Compared with traditional face-lift surgery, this technique is easy to perform and less traumatic. It also leave almost invisible scar and has a faster recovery time.
Used to release fibrosis and an adhesion in fat grafting, the small needle knife is used for soft tissue dissection before inserting the threads. It is also used to break the fibrosis around the knot when nodule complication happens.
This innovative technique combining absorbable thread lift with small incision rhytidectomy is safe and effective for facial rejuvenation with appropriate patient selection. Small needle knife could be used to assist thread-lifting and correct nodule complication, leading to a better cosmetic outcome.
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