Thread lifting: choosing the right patient

Skin aging is a complex biochemical process characterized by metabolic, structural and functional changes in the cells of all its layers and surrounding tissues, which occurs due to the depletion of the body's bioresources. The aging process affects all layers of the skin, as well as muscles, fascia and bones. Most often, injection methods of introducing hyaluronic acid, vitamins, amino acids, peptides, micro- and macroelements, homeopathic medicines, as well as peelings, lasers, ultrasound, etc. are used for rejuvenation. The rejuvenation effect of these technologies is insignificant and lasts no more than a few months over a period of time. by activating blood circulation, stimulating metabolism and skin regeneration, especially when doctors use multicomponent drugs and combined techniques. The synthetic activity of keratinocytes, fibroblasts and other skin cells increases, resulting in renewal of the epidermis and restructuring of the dermis, where no more than 1.5% of new collagen is synthesized. This amount of the main reinforcing component is not enough for obvious skin rejuvenation, but this is quite suitable for doctors for the prevention of aging and correction of early age-related changes.

The threadlifting technique is now successfully used in different countries and is an alternative to surgery.

Tread lifting (translated from English as “thread lifting”) is a skin rejuvenation technique that is based on placing self-absorbable threads under the skin in order to create a microframework that supports the skin, as well as increasing its firmness and elasticity.

Despite the conflicting opinions of many specialists, threadlifting as a technique is successfully used by many doctors in different countries and is an alternative to surgery. Today, manufacturing companies offer cosmetologists threads made from polydioxanone, polylactic acid, caprolactone with L-lactic acid and polypropylene.

Polydioxanone - most often used for the manufacture of mesothreads, hypoallergenic, non-pyrogenic, non-toxic, and has been used as a suture material in surgery for many years.

Polylactic acid has been used in cosmetology for more than 20 years due to its unique properties of triggering natural skin regeneration mechanisms. It is produced by polymerization of lactic acid and is an absolutely biologically compatible substance with living tissues.

Polypropylene is used to make non-absorbable threads, which are used by surgeons in their practice.

For visible rejuvenation results, it is necessary to include pathological stimulation of collagen synthesis, which will ultimately more significantly renew the skin structure through neocollagenesis.

One such skin rejuvenation method is polydioxanone (PDO) threads. This is a new approach that harmoniously complements existing methods in aesthetic medicine. The effectiveness of this procedure has been confirmed by my many years of experience, and I am ready to share it with readers.

Polydioxanone is a linear polymer formed during the catalytic polymerization of the heterocyclic compound p-dioxanone: O = CH -CH2- O-CH2- CH = O (C4H6O3).

The breakdown of PDO occurs through hydrolysis of the polymer and forms two monomers of 2-hydroxyethoxyacetic acid (C4H8O4), which then breaks down into water and carbon dioxide and is absorbed by the skin.

A synthetic fiber is created from this material, consisting of one monofilament thread, which dissolves in tissues after 4–6 months, depending on the thickness, triggering reparative processes in the skin and stimulating pathological neocollagenesis. The uniqueness of the technology lies in the fact that a polydioxanone thread is inserted into the injection needle or cannula, which acts as a conductor, the free end of which comes out of the needle and is attached to it with a sponge. The injection needle is made of special steel and laser sharpened, is flexible and does not break in tissues. This allows you to control changes in direction (up-down and left-right) and ensures high quality reconstruction of skin contours and volumes. After inserting a needle or cannula with thread, they are easily removed, and the thread remains inside the tissue.

Velancia is a high-quality PDO thread from KORU Pharmaceuticals Co., Ltd, whose products are used by leading dermatologists, plastic surgeons and skin care specialists in more than 40 countries. Company Max E sthetics is the exclusive representative of TM Velancia in Ukraine, offering a wide range of threads for tightening the skin of the face and body: Mono, Screw, Cannula Cog, Smart Cog, Twin Screw. Velancia threads are indicated for the correction of age-related skin changes, such as gravitational ptosis, sagging, decreased tone, folds, wrinkles, as well as for the effective correction of the facial oval, modeling and creating clear facial contours.

EFFECTS OF PDO

Over the past three years, manufacturers of PDO threads have introduced a large number of different types of threads. They are twisted, woven into braids or collected into bundles, laser notches are made on them, welded to anchor threads, wound on a needle or attached to it, and thick threads are inserted into atraumatic cannulas.

Depending on the modification of PDO threads, they cause three main effects in tissues.

The revitalizing effect is achieved through the reconstruction of the epidermal matrix due to injury and the effects of biodegradation of polydioxanone through hydrolysis, which leads to improved trophism and regeneration of the skin, increased tone, and improved structure. The tissue response is an increase in the pool of dividing cells in the basal layer of the epidermis, improvement in the condition of the basal membrane of the epidermis due to the focal appearance of perpendicular elastic fibers, restoration of type IV collagen around the vessels, and the appearance in the area of ​​the dermoepidermal junction of the expression of dermal papillae and epithelial ridges.

The lifting effect is achieved due to the formation of soft fibrosis around the implanted thread. Macrophages, fibroblasts and single leukocytes form a cellular infiltrate around the thread with mild cellular reactions. In the outer part of the infiltrate, due to individual activated fibroblasts, a primary connective tissue sheath is formed from thin collagen fibers, which gradually thicken and mature. This process continues until the thread is completely absorbed. Thus, at first, the thread is gradually replaced by loose connective tissue, which gradually turns into fibrous tissue, thickening the skin due to the ordered synthesis of collagen and elastin fibers in the dermis. This is what causes the delayed lifting effect.

The effect of true (mechanical) lifting is a rapid process of anti-gravity fixation of tissues due to their reposition using thread fixing elements, notches or anchors. Subsequently, the process of neocollagenesis also starts in the epidermal structures of the skin, which causes long-term lifting.

INDICATIONS AND CONTRAINDICATIONS

Indications for the introduction of direct PDO threads on the face, neck, décolleté:

• horizontal and vertical forehead wrinkles (sleep wrinkles);
• increased mobility and laxity of the soft tissues of the forehead;
• wrinkles of the bridge of the nose and nose;
• drooping of the eyebrows or the outer edge of the eyebrow;
• flabby and sagging tissues of the upper eyelid (sleep wrinkles);
• flabby temple tissue (sleep wrinkles);
• wrinkles at the corners of the eyes (crow's feet);
• painting bags;
• smile wrinkles around the eyes;
• early cheek ptosis;
• smile wrinkles on the cheeks;
• nasolabial folds;
• folds of the corners of the lips (“marionette lines”);
• lip contour modeling;
• perioral wrinkles;
• preauricular wrinkles;
• wrinkles and porosity of the chin;
• minor changes in the contour of the lower jaw;
• increased mobility and laxity of the soft tissues of the lower jaw contour;
• wrinkles and sagging neck skin;
• wrinkles and sagging skin of the décolleté.

Indications for direct PDO threads on the body:

• rejuvenation of the skin of the mammary glands, abdomen, arms, legs and buttocks;
• stretch marks on the chest, abdomen, arms, legs and buttocks;
• skin unevenness after liposuction;
• cellulite;
• local fat deposits on the arms, chest, abdomen, legs.

Indications for PDO threads with notches and anchors:

• gravitational ptosis of the forehead, eyebrows, cheeks, submental area;
• severe nasolabial and labiomental “marionette folds”;
• violations of the oval line of the face with the formation of “jowls”;
• sagging and sagging skin of the neck, chest, arms, abdomen, back, buttocks, inner thighs;
• to give a new shape and additional volume to certain areas of the face (for example, cheekbones or cheeks) and body.

Contraindications for insertion of PDO threads:

• very pronounced hypodermis;
• severe excess skin;
• autoimmune diseases;
• feverish conditions;
• various acute infectious diseases (ARVI, etc.);
• inflammation of the skin in the area of ​​the procedure;
• non-absorbable implant (silicone) in the area where the threads are inserted;
• oncology and severe somatic diseases;
• tendency to form hypertrophic and keloid scars;
• hemophilia, bleeding tendency and some blood diseases;
• pregnancy and lactation;
• neurotic and psychological disorders.

ADMINISTRATION TECHNIQUES

The principles of working with PDO threads are constantly being improved, which expands the possibilities of their application.

Fan technique

PDO threads are introduced subcutaneously parallel to the surface of the dermis from one point in different directions in the form of a fan. The fan technique is most often used for threads with notches and anchors.

Sandwich technique

PDO threads are introduced subcutaneously, sometimes intramuscularly, parallel to the surface of the dermis from one point in the same direction, but to different depths of the hypodermis or muscle, that is, the threads are inserted one under the other, which resembles a sandwich.

Linear vector technique

PDO threads are injected subcutaneously and intramuscularly parallel to the surface of the dermis in the selected direction. Distance between thread injections: minimum 0.2 mm, maximum 1 cm. This technique is used for all threads, including filler threads and barbed threads. This technique is also used in acupuncture. Needles with PDO threads are inserted perpendicular to the skin into acupuncture points and leave the needle in the skin for 15–20 minutes, periodically twisting the needle holder. Then the needle is removed, and the thread, remaining at the acupuncture point, stimulates it for a long time.

Reinforcement technique, or mesh

PDO threads are introduced subcutaneously, parallel to the surface of the dermis from different points, forming vertical and horizontal vectors, that is, the threads intersect, forming a strong mesh. Distance between threads: minimum 0.2 mm, maximum 1 cm. This technique restores and enhances the elasticity of the entire skin area and supports the surrounding tissue, gently and evenly distributing loads throughout the mesh.

Suture technique

PDO threads are inserted at an angle to the surface of the skin, then the needle is lowered to the deep layers of the hypodermis and even muscles and again raised to the upper layers of the hypodermis, forming a zigzag or wave, that is, from top to bottom and back, capturing different layers of the hypodermis and pulling them together. A zigzag can be done horizontally inside the fat compartment, repeating the movements of a crawling snake, stitching it in different directions. This technique helps tighten and lift sagging skin tissue. The end of the thread should always remain deep in the fabric. This technique is used for long and thick threads, including threads with notches and anchors.

Combined technique

PDO threads of different configurations are administered subcutaneously and intramuscularly in different directions, combining techniques.

Principles of introducing PDO threads

For the correct exposure of the threads, it is necessary to remember the thickness of the skin in different areas of the face, described by Mario Gonzalez-Ollua in 1957.

When working in different areas, it is necessary to solve the tasks assigned to the doctor:

• change skin quality;
• tighten the hypodermis and associated muscles;
• reduce the activity of facial muscles;
• limit the mobility of the skin-muscle layer.

Each task has its own solutions and its own types of thread insertion.

SIDE EFFECTS

Facial rejuvenation using PDO threads is a safe and effective procedure, but it is also associated with minor side effects and complications that develop in 90% of cases for iatrogenic reasons and in 10% due to the characteristics of the client’s body. Post-procedural adverse reactions and complications are collected in the table.

THREAD WITH NOTCHES

Threads with notches or anchors have become especially popular recently. They are called kogi. They mechanically tighten the soft tissues of the face, neck and body and fix the displaced areas of sagging skin “in a new place.” For this purpose, it is very important how the threads of the notches or anchors are directed and arranged around the circumference, since they should open like an umbrella when the thread is pulled in the tissues and cling with the notches to the connective tissue structures of the skin, moving it to a higher position and thereby providing lifting fabrics.

Kogami can also be used to reinforce the skin in order to strengthen and thicken the hypodermis through subsequent neocollagenesis. The threads can be inserted in any direction, but preferably as vertically and horizontally as possible. The grid technique can be used for these purposes. The location of the notches and their number do not play a role, because the tissues do not move, but are only reinforced.

An important point when installing cogs is knowledge of the anatomical and physiological characteristics of the ligamentous apparatus of the face, because these are stable structures that can be used as a point of fixation. In fact, these are not exactly ligaments, but skin-bone fixing points of the face, which represent a fusion between the dermis and the periosteum. There are about 15 of them, but only 4 of them are basic:

• the zygomatic point is located lateral to the zygomaticus major muscle;
• the mandibular point is located on the anterior third of the lower jaw, above its edge, crossing the platysma;
• the orbital point is located on the lateral edge of the orbit, passes through the orbicularis oculi muscle;
• the masticatory point passes along the anterior edge of the masticatory muscle to the zygomatic fossa.

Skin-fixing points play the role of nails that fix the SMAS in facial expression and gravitational ptosis. For greater fixation of the soft tissues of the face, the ends of the threads should be located in the areas of projection of the main ligaments or connective tissue septa.

Another important structure of the face is the fat compartments, which are also influenced by gravity and gradually shift downward, changing the volume and contours of the face and neck.

When correcting the volume and position of compartments using barbed threads, it is necessary to alternately reinforce each compartment separately using the mesh technique. The direction of insertion of the threads into the compartment is not particularly important. Typically, four cogs per compartment are sufficient for these purposes. The length of the threads should be slightly larger than the size of the compartment. It is necessary to enter the needle through the fascial boundaries into and out of the compartment, followed by tightening it by the ends of the threads. It is possible to simultaneously compress several nearby compartments, as if connecting them with each other using the same technique. To lift sagging fat bags, we use longer threads with notches using a vector-linear technique. The direction of the vectors should correspond as much as possible to the anti-gravity vectors or change the position of the compartment as much as possible in the desired direction. The entry or exit of the ends of the threads should fix the fat compartment to the main skin-osseous fixation points or ligaments of the face. The number of threads is determined by the degree of PFA degradation and is decided individually with each client. But for longer and more stable results, the minimum number of threads is 4–8 threads per zone.

Advantages of the lifting procedure using PDO threads with notches and anchors:

• has low morbidity;
• does not require excision of excess skin;
• does not require incisions, since the needle is inserted and withdrawn through small punctures that quickly and imperceptibly close;
• performed under local anesthesia;
• does not require hospital stay and complex dressings;
• does not leave scars on the skin;
• gives an effect comparable to that of a surgical facelift;
• gives a natural result;
• has a long-lasting rejuvenating effect;
• well developed injection techniques.

INDIVIDUAL APPROACH

It is fundamental to develop a rejuvenation program with PDO threads for each patient. That's why I developed step-by-step approaches to rejuvenation.

At the first consultation, I develop a treatment plan with the patient. We begin the work with the most significant areas for the patient, for example, the jowls. The number of threads installed during the procedure is determined individually depending on the area and its condition.

The first procedure can be performed without prior preparation, on the day of the patient’s application. The next day after the procedure, a follow-up visit to the clinic for examination and rehabilitation is recommended. After about 1–2 weeks, we move on to the next zone, thereby gradually covering the entire face, neck and décolleté, and then the body.

It is easier to work with young people; to prevent skin aging, I recommend that they undergo the PDO thread procedure once every year or two. For patients with tissue ptosis, the procedure for introducing PDO threads in one area, without the development of swelling and bruising, is repeated every 2–4 weeks (depending on the patient’s wishes) to achieve the required therapeutic effect. This tactic is optimal for them. The results develop gradually and change the contours of the face and body. The patient understands what is happening in the tissues and patiently waits for results, which are always present earlier in some, later in others, and last up to 1.5–2 years.

Of course, in individual protocols for correcting age-related changes in the face and body, options are possible, since each patient is unique. PDO threads are a safe and timely tool in the practice of an aesthetic medicine doctor and should be included in the rejuvenation program at the right time according to indications. Only an integrated approach to rejuvenation will give a complete and long-term effect, because there is no one magic remedy.

The disadvantages of the thread lifting technique are the presence of swelling and temporary retractions and folds in the area where the threads are placed in patients with severe tissue ptosis, however, these nuances resolve themselves and disappear within 2-4 weeks.

For the patient, the key to a successful thread lifting procedure is the correct choice of a qualified doctor who can select the required number and type of threads, correctly prepare the skin and perform the procedure technically correctly.

This article is part of the special project Injection anti-aging

You can read all the articles on this topic:

SPECIAL PROJECT. And injectable anti-aging

Literature:

Irina Lopadina, dermatovenerologist, cosmetologist (Cyprus)

Tamara Semenovich, dermatovenerologist, chief physician of the Estet Doctor clinic, international trainer and speaker of the II European Congress on injection techniques

Cosmetologist No. 6, 2018

​​​​"Les Nouvelles Esthétiques Ukraine" No. 1 (113) 2019