Non-Surgical Face Lifting: Addressing Nasolabial Folds with Absorbable Thread Procedures

Facial aging represents a dynamic and intricate process that unfolds across multiple dimensions, involving the intricate interplay of various facial tissues, namely bone, ligaments, muscles, and fatty tissue. The structural metamorphosis associated with aging extends to bony resorption, exerting a notable impact on critical facial structures such as the maxilla and zygoma. This resorption leads to a discernible loss of maxillary angle and projection, subtly altering the overall facial architecture. Similarly, in the mandible, bone resorption contributes to anterior recession, resulting in a reduction of lower facial tissue tone and an increase in ligament laxity. The intricate dance of aging and gravity orchestrates a soft tissue descent, compelling the need for a nuanced evaluation to distinguish between genuine ligament laxity and the perceived laxity of overhanging, deflated tissue originating above these ligaments.

The realm of age-related modifications extends to facial muscles, a topic that has sparked considerable debate. Magnetic resonance imaging studies unravel a distinctive curvilinear contour in youthful faces, sculpted by facial mimetic muscles with an anterior surface convexity, a consequence of underlying fat pads. However, aging introduces a gradual straightening and shortening of these muscles due to repetitive contractions and a reduction in deep fat volume. Intriguingly, midface aging studies present a conundrum, as they do not consistently reveal significant differences in mimetic muscle characteristics between young and old subjects, challenging prior assumptions and adding layers of complexity to our understanding of facial aging.

The tapestry of aging is further woven with diverse fatty tissue changes, impacting distinct facial areas and depths of fat compartments. Soft tissue fullness undergoes reduction in regions like the malar, mandibular, mental, and perioral sites, while superficial fat finds refuge in the submentum, labiomental crease, lateral nasolabial fold, jowl, and malar fat pad regions. Notably, the lower face bears the brunt of age-related signs, prominently manifested in the development of jowls, emphasizing the profound impact of aging on facial aesthetics.

In the realm of interventions for moderate to severe skin laxity, the traditional approach involves SMAS (Superficial Musculo-Aponeurotic System) rhytidectomy. However, due to the inherent complications associated with surgical procedures, a growing number of patients are turning to nonsurgical alternatives. The evolving landscape of skin laxity treatments has witnessed the introduction of less invasive procedures, with thread lifting emerging as a promising option. Initially employing nonabsorbable barbed sutures, complications prompted a shift toward the development of absorbable threads. These threads, crafted from materials like polydioxanone, poly-l-lactic acid, polyglycolic acid, or poly-l-lactic acid and caprolactone, showcase the dynamic evolution of aesthetic interventions, reflecting a delicate balance between efficacy and patient safety.

In this blog, we will specifically discuss how to address nasolabial folds with non-surgical alternative using threads.

Challenges around Nasolabial Folds

Nasolabial folds, colloquially referred to as smile lines or laugh lines, are the distinct facial furrows that traverse the skin, originating at the sides of the nose and gracefully extending to the outer edges of the mouth. These lines, though a common and natural consequence of the aging process, embody a complexity of factors that contribute to their appearance and prominence.

At a fundamental level, the aging journey manifests in the skin's structural changes, where the reduction of collagen and elastin fibers heralds a decline in skin elasticity. This depletion, a hallmark of the aging epidermis, paves the way for nasolabial folds to emerge as the skin becomes less adept at resisting the gravitational pull and loses its ability to bounce back from expressions and movements.

Facial morphology undergoes a dynamic transformation with time, and alterations in fat distribution further influence the depth and visibility of nasolabial folds. As facial fat shifts or diminishes, the contours of the face evolve, contributing to the nuanced topography of these facial lines. Simultaneously, the incessant activity of facial muscles engaged in repetitive expressions, such as smiling and laughing, leaves an indelible mark on the skin, as the continuous folding and unfolding exacerbate the formation of these lines.

Delving deeper into the structural underpinnings, modifications in the underlying bone structure, particularly in the maxilla, can exert a substantial impact on the prominence of nasolabial folds. Changes in bone density and volume alter the framework on which the skin rests, further influencing the topographical landscape of these facial creases.

While nasolabial folds are inherently woven into the fabric of aging, their manifestation can be influenced by an interplay of genetic predispositions, lifestyle choices, and environmental exposures. The genetic blueprint one inherits may dictate the inherent resilience of their skin, predisposing some individuals to more pronounced folds than others. Lifestyle choices, encompassing skincare routines, sun protection practices, and dietary habits, can either mitigate or exacerbate the progression of these lines. Environmental exposures, such as prolonged sun exposure and pollution, contribute to the oxidative stress that accelerates the aging process and may intensify the appearance of nasolabial folds.

In essence, nasolabial folds, while emblematic of the inexorable march of time, embody a tapestry of biological, structural, and environmental influences that converge to shape the unique contours of each individual's face over the course of their life.

Absorbable Threads for Nasolabial Folds Improvement

In this meticulous thread implantation procedure, designed to address lower facial laxity, patients underwent a single session featuring the strategic utilization of either short (12 cm) or long (23 cm) absorbable barbed threads. These specialized threads, measuring 10 cm in length and characterized by distinct barbed sections, employed straight, cut-edge needles. A noteworthy aspect of these absorbable threads was their intentional design, featuring barbs exclusively within intermediate areas while maintaining smooth surfaces at both ends and midsections.

During the implantation process, the skilled application of barbed threads allowed for the creation of a "J stitch" — an innovative technique aimed at fortifying anchoring and support. This unique stitch involved the reintroduction of the needle into the exit hole, executed at a precise 20°–30° angle, reaching a depth of 2 cm before removal. This specialized maneuver significantly increased the holding force of the thread, bolstering resistance to slipping and enhancing tissue compression, thereby elevating the overall efficacy of the procedure. The choice between short and long threads was contingent on individual facial dimensions, with the length determined by the distance between entry and exit points, favoring the longer 23-cm threads when this distance exceeded 7 cm.

The primary objective of thread placement was the repositioning of lower face fat compartments, encompassing the inferior jowl fat, middle cheek fat, and lateral cheek fat, with a simultaneous focus on restoring jawline definition. Preoperatively, meticulous planning involved marking entry and exit points along specific facial landmarks, delineating the precise path the thread would traverse during implantation.

To optimize patient comfort, 1% lidocaine with adrenaline was injected at both entry and exit points before the procedure. Entry points, created with an 18G needle, penetrated 5 mm into the subcutaneous tissue, with exit points located strategically 4–6 cm away. The thread path meticulously followed the mandibular angle, ensuring the precise placement of barbs within the soft tissue.

Post-procedure, a regimen of fusidic acid ointment application twice daily for a week was prescribed to promote optimal healing and minimize potential discomfort. Patients were provided with comprehensive guidance on gentle post-treatment care, including instructions on makeup application and specific restrictions. Additionally, patients received self-assessment tools to gauge their experience, incorporating parameters such as pain levels measured on a visual analog scale. Rigorous monitoring of adverse reactions throughout the post-operative period was integral, ensuring a comprehensive assessment of safety and comfort and reinforcing the commitment to patient well-being throughout the entirety of the treatment process.

Who will be a great candidate for this procedure?

The meticulous selection of patient for this procedure involved stringent exclusion criteria to ensure the robustness and accuracy of the findings. Pregnant or lactating individuals were excluded due to the potential hormonal fluctuations during these periods, which could introduce confounding variables.

To delineate the specific effects of absorbable threads, patients who had undergone recent treatments, such as botulinum toxin, mesotherapy, or laser therapy within the last 6 months, were excluded. This temporal window was crucial to capture the independent influence of absorbable threads without interference from the residual effects of these other treatments.

Individuals with concurrent dermatological diseases, autoimmune disorders, or infections in the targeted area were excluded. This careful selection aimed to create a cohort with consistent baseline conditions, allowing for a more precise evaluation of the effects of absorbable threads.

The deliberate prohibition of certain medications in patients, including antibiotics, anticoagulants, vitamin C or E supplementation, steroids, and nonsteroidal anti-inflammatory drugs, was implemented to minimize extraneous variables that could affect the outcomes. This approach ensured a controlled environment, where the impact of absorbable threads could be isolated and accurately assessed.

Beyond this, the exclusion of individuals with a history of allergy to p(LA-CL), local anesthesia, or adrenaline was a necessary precaution. Allergic reactions in this context could confound the evaluation of treatment efficacy and safety, potentially skewing the results. Furthermore, the restriction on including patients with a history of smoking was rooted in the acknowledgment of the well-established detrimental effects of smoking on skin health and wound healing.

Results & Past Research

A study in 2021 discovered that among the initial cohort of 27 patients enrolled in their study, an impressive 92.6% (25 individuals) successfully completed the comprehensive follow-up visits. Unfortunately, two patients were unable to attend the 12-month follow-up, resulting in their exclusion from the final analyses. The detailed demographic profile of the 25 patients included in the analysis is thoroughly presented, ensuring a comprehensive understanding of the study population. To gauge the subjective evaluation of lower face laxity, measured on a robust 6-point scale, the picture above provides a visual representation. Immediately post-implantation, 32% of patients exhibited a mild lifting effect in comparison to baseline, and this trend persisted at subsequent follow-ups, with the majority displaying a mild lifting effect at 1 week and 1, 2, and 3 months (40%, 48%, 56%, and 40%, respectively). However, a notable shift occurred at 6 and 12 months, where a substantial proportion (40% and 56%, respectively) showed no lifting effect compared to baseline, shedding light on the longevity and dynamics of the treatment outcomes.

The clinical enhancement in lower facial laxity following the implantation of both 23-cm (long) and 12-cm (short) absorbable barbed threads is thoughtfully delineated, presenting valuable insights into the comparative efficacy of different thread lengths. The study highlighted a positive and immediate impact on the nasolabial fold area and submental volumes. Remarkably, volumes in the submental area stabilized at a level higher than baseline by 1 month post-procedure, a notable finding that adds depth to our understanding of the treatment's multifaceted effects. Subgroup analysis not only confirmed these trends but also indicated a numerically higher difference in submental volume with long threads throughout the study period compared to short threads, suggesting potential considerations for personalized treatment approaches.

Patient self-assessments, a crucial component of understanding the treatment experience, were meticulously recorded at all follow-ups. The data revealed intriguing trends, showcasing the rapid onset of positive perceptions as early as 1 week post-treatment, with a majority (51.9%) reporting excellent lifting effects. While scores showed a decline in subsequent follow-ups, the nuanced observations included a substantial percentage (48.1%) reporting marked lifting effects at 1 month, and a notable 60.9% expressing a moderate lifting effect at 2 months. At 3 months, a significant proportion (53.8%) still reported a marked lifting effect, with this number decreasing to 32% at 6 months. Importantly, a minority (28%) reported no lifting effects at 12 months, offering valuable insights into the persistence and variability of patient perceptions over time.

Turning attention to the safety profile, adverse reactions to the thread implantation procedure are meticulously outlined in Table above. All patients reported a mean pain score of 3.91 ± 1.79 (on a scale of 0–10), with an average duration of 3.15 ± 2.27 days. This level of discomfort was considered reasonable for thread procedures, aligning with established expectations and not necessitating clinical intervention. Notably, all reported adverse reactions, including edema (33.3%), bruising (81.48%), dimple formation (22.22%), and palpable nodules (11.1%), were classified as mild and resolved spontaneously without the need for medical intervention. This robust safety profile adds significant credence to the viability of the procedure, emphasizing its clinical applicability and patient tolerance.

Reference:

Absorbable Barbed Threads for Lower Facial Soft-Tissue Repositioning in Asians (2021)

Application of Nonsurgical Modalities in Improving Facial Aging (2022)

Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation (2012)

Silhouette instalift: benefits to a facial plastic surgery practice (2019)

Facial rejuvenation and improvement of malar projection using sutures with absorbable cones: surgical technique and case series (2011)

Thread-lift sutures: anatomy, technique, and review of current literature (2020)

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