World Academy of Science, Engineering and Technology

International Journal of Medical and Health Sciences

Vol:10, No:12, 2016

Thread Lift: Classification, Technique, and How to

Approach to the Patient
Panprapa Yongtrakul, Punyaphat Sirithanabadeekul, Pakjira Siriphan

 not relevant to our study topic. We then gathered and read all
Abstract—Background: The thread lift technique has become related full-text research articles and summarized them within
popular because it is less invasive, requires a shorter operation, less this topic review.
downtime, and results in fewer postoperative complications. The
advantage of the technique is that the thread can be inserted under the II. LITERATURE REVIEW
skin without the need for long incisions. Currently, there are a lot of
thread lift techniques with respect to the specific types of thread used A. Facial Aging
on specific areas, such as the mid-face, lower face, or neck area.
Objective: To review the thread lift technique for specific areas Facial aging reflects a combination of skeletal and
according to type of thread, patient selection, and how to match the connective tissue changes. Alteration in the position of the soft
most appropriate to the patient. Materials and Methods: A literature tissue and overlying muscles causes the appearance of aging
review technique was conducted by searching PubMed and [1]. Signs of aging include poor definition of the mandibular
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MEDLINE, then compiled and summarized. Result: We have divided margin, wrinkles of the forehead, vertical wrinkles in the
our protocols into two sections: Protocols for short suture, and
glabellar area, drooping of the zygomatic malar region, and
protocols for long suture techniques. We also created 3D pictures for
each technique to enhance understanding and application in a clinical deepening of the naso-buccal fold. Another main factor in the
setting. Conclusion: There are advantages and disadvantages to short effect of aging on appearance is gravity, which causes ptosis
suture and long suture techniques. The best outcome for each patient of the facial soft tissue, such as the downward shift of the
depends on appropriate patient selection and determining the most malar fat pad that creates hollowness of the mid-facial and
suitable technique for the defect and area of patient concern. infra-orbital area. Consequently, facial rejuvenation should be
performed in a vertical direction [2]-[4].
Keywords—Thread lift, thread lift method, thread lift technique,
thread lift procedure, threading. B. Types of Thread
The types of thread can be divided into three main
I. INTRODUCTION categories.

T HREAD lifting is a cosmetic procedure that lifts and

realigns sagging tissue, while adding definition to facial
contours by using threads that are manufactured from the same
1. Mode of Absorption
1.1 Absorbable threads including Polydioxanone thread
materials used in surgery to close wounds. When placed under (PDO) [5]-[7], Silhouette Soft thread (Poly-I-lactic acid or
the skin, they can be used to tighten the tissue and add volume sculptra in solid form), and fine thread with bi-directional
to the area of application. Even though there are many thread absorbable cone [8].
lift techniques used in clinical practice, there has not been a 1.2 Non-absorbable thread including APTOS thread, Contour
comprehensive literature review about thread lift techniques. thread, Silhouette lift thread, Woffles thread
Therefore, we propose to review the use of thread lift (Polypropylene).
techniques for facial rejuvenation, focusing on the type of 2. Barbed and Non-Barbed Thread (Smooth Threads)
thread, patient selection, and how to choose the appropriate
technique for the selected patient. We employed the PUBMED a) Barbed Thread
and MEDLINE website search engines to retrieve the relevant There are 3 types of barbed thread [9]-[11]:
literature by inputting the following keywords: Thread lift, 1) Bi-directional thread (Long suture) are inserted into a
thread lift method, thread lift technique, thread lift hollow needle and then placed in the treated area.
rejuvenation, and thread lift procedure. We included clinical 2) Uni-directional barbed threads (Long sutures) are
trials, comparative studies, controlled clinical trials, and designed to be anchored to a fixed structure, such as the
clinical reviews from January 1970 to October 2015. We read deep temporal fascia.
all of the abstracts of the studies and filtered those that were 3) Cogged Threads (Short sutures): Examples include PDO
Uni-directional cogged thread, PDO Bi-directional
P Yongtrakul is with Division of Dermatology, Chulabhorn International cogged thread, and PDO Multi-directional cogged thread
College of Medicine, Thammasat University, Khlong Luang, Pathumthani, [12].
Thailand 12120 (phone: 66909012222; e-mail: bummt@hotmail.com).
P Sirithanabadeekul was with Division of Dermatology, Chulabhorn b) Non-Barbed Threads (Smooth Thread)
International College of Medicine, Thammasat University, Khlong Luang,
Pathumthani, Thailand 12120 (e-mail: punyaphats.cicm@gmail.com). There are two types of Non-barbed thread:
P Siriphan is with Pan Rajdhevee Suphannahong Foundation, Bangkok,
10330, Thailand (e-mail: docnong_2000@hotmail.com).

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1) Monofilament Plain: Examples include Miracu plain the lower border of the zygomatic bone, extending
thread and TR lift thread. down to the superficial musculoaponeurotic system
2) Monofilament Screw or Spiral: Examples include K2 (SMAS) plane [16], [17]. Follow this line until you
screw lifting and T Screw lifting thread. meet the end-points shown in Fig. 1 (B).
The value of Bi-directional thread over Uni-directional Step 3. Insert two to five Mono Plain or Screw threads in
thread, and Non-barbed thread, is that Bi-directional thread another three directions, as shown in Fig. 1 (C). This
cannot move in either direction because of the two-way step creates a meshwork relative to Steps 1 and 2.
fixation provided by the barbs. However, if there is asymmetry
of the face from the thread insertion, Uni-directional threads
or Non-barbed threads allow easier postoperative correction
[13], [14].
3. Length of Threads
We suggest classifying the thread based on its length,
because different lengths are used for different lift techniques
such as the Short suture technique and Long suture technique.
3.1 Short suture is defined by any thread shorter than 90 mm
in length.
3.2 Long suture is defined by any thread longer than 90 mm
in length.
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C. Treatment Algorithm
First, design the treatment technique with a marker or
pencil-based drawing. Prescribe prophylactic antibiotics 1
hour before treatment. Use an anti-bacterial product such as
chlorhexidine prior to thread insertion. For superficial Plain
threads, apply a 7-15% lidocaine cream 45 minutes before the
procedure. For cog thread and any long thread (more than 90
mm), local anesthesia, such as 1-2% solution of Lidocaine
with Epinephrine (1/200,000), should be injected at the
insertion area. Ensure that the threads are cut at the insertion
point and the cog ends are submerged underneath the skin,
otherwise protrusion may occur. Clean the area and apply ice
packs to the thread-treated area following the procedure to
minimize edema and bruising.
D. How to Apply the Thread Lift Procedure
The thread insertion technique can be distinguished into two
approaches by the difference in thread length, including a
protocol for short suture and a protocol for long suture
techniques.
1. Protocols for Short Suture
The protocol for threads shorter than 90 mm, such as
Polydioxanone thread (Plain, Screw, Spiral and Cog thread),
involves the use of the free floating method. The guidelines
below provide the minimum number of threads required for
each treatment area. If severe skin laxity or excess adipose Fig. 1 Short suture techniques for lower face lift: (A) Mono Plain or
Screw threads insertion; (B) Cog threads insertion; (C) Mono Plain or
tissue is present, more threads can be inserted [15].
Screw threads insertion in another three directions to create a
a) Lower Face Area and Jawline meshwork
Step 1. Insert five to 10 Mono Plain or Screw threads for each b) Mid-Face and Cheek Area
side as shown in Fig. 1 (A). For skin tightening and Step 1. Insert four to six cog threads for each side, down to the
rejuvenation, insert the needle into the dermis plane. SMAS plane as shown in Fig. 2 (A).
For lipolysis, insert the needle deeper into the Step 2. Insert five to 10 Mono Plain or Screw threads for each
subcutaneous plane. side as shown in Fig. 2 (B).
Step 2. Insert four to six cog threads for each side at insertion Step 3. (Naso-labial fold) Insert 3-5 Mono Screw threads for
point (A), located 1.5 cm pre-auricular and 1 cm below each side. Insert the 1st screw thread into the Naso-

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labial fold straight, and then insert the 2nd to 5th thread 4th and 5th threads in a vertical direction to create a
in a zig-zag fashion [18] (Fig. 2 (C)).  meshwork (Fig. 3 (C)).
 Tear trough lift: Select and insert five Mono Plain threads,
30 mm in length using a 31-G needle, into the sub-dermis
of the lower eyelid on each side (Fig. 3 (D)).
d) Neck Area
Insert 10-15 Mono Screw threads horizontally and 10-15
Mono Plain threads vertically for each side, deep into the sub-
dermis [2], [16], [19], [20] (Fig. 4).
2. Protocols for Long Suture
The protocol for thread longer than 90 mm, such as APTOS
2/0, 4/0, Silhouette Lift, Silhouette Soft, or Contour thread.
Most long sutures are barbed, including bi-directional and
uni-directional threads. The procedure technique that is
usually applied for uni-directional thread is the fixed method
(with an anchoring point), while the procedure technique for
bi-directional thread is the free-floating method (without an
anchoring point). A third type of procedure is a double needle
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technique that also uses the free-floating method (without an

anchoring point). All procedures can be performed under local
anesthesia.
For the Fixed method (with an anchoring point), 3-4 mm
incisions for insertion of a straight needle are necessary. The
incision point should be located at the deep temporal fascia or
periosteum so that it can be used as an anchoring point. For
lower face and cheek lifting, the anchoring point is made
posterior to the frontal and temporal hairline [20], [21]. For
neck lifting, the anchoring point is made posterior to the
sternocleidomastoid muscle.
a) Lower Face Area and Jawline
Technique 1 Lower Face Thread Lift [22], [23]
Uni-directional threads are recommended. Select two long
barbed threads for each side. Tie a knot in the thread at the
deep tendon fascia. Insert the needle at the incision point, deep
to the SMAS, and at the 2nd halfway point the needle should
be more superficial, as it moves into the subcutaneous plane.
Fig. 2 Short suture techniques for mid-face and cheek area: (A) Cog At 1.5 cm medial to the marionette lines, the needle is brought
threads insertion; (B) Mono Plain or Screw threads insertion; (C) out, leaving the thread in the tissues. Pull the thread lightly
Mono Screw threads insertion into the naso-labial fold and then trim the excess thread (Fig. 5 (A)).
c) Peri-Ocular Area Technique 2 Lower Face Thread Lift
 Medial and Lateral eyebrow lift: Insert two to four Cog Bi-directional threads are recommended. Select two bi-
threads at insertion point (A), located 1 cm below the directional threads for each side. Make a puncture wound in
hairline. Insert the 1st Cog thread through sub-dermis the pre-tragus area (point A). Insert “a flexible hollow needle”
ending at point B, 1 cm above the brow, in order to avoid deep to the papillary dermis and then follow the line,
trauma to the temporal branch of the facial nerve. maneuvering the needle in a slight zigzag pattern until the tip
Once the Cog thread is anchored, slowly retract the cannula of the needle passes through the exit point (point B). Insert the
and clamp the Cog thread. Insert the 2nd Cog thread sub- thread into the needle and carefully withdraw the needle
dermally towards end-point C, 1 cm above the brow and leaving the thread positioned in the dermis. Pull the thread
parallel to the lateral canthus line. Clamp both Cog threads lightly and then trim the excess thread (Fig. 5 (B)).
together and trim them close to the skin (Figs. 3 (A) and (B)).
 Crows feet: Insert five Mono Plain threads, 30 mm in Technique 3 Redefinition of the Mandibular Contour
length using a 31-G needle, into the dermis for each side. Select one double needle thread for each side. Insert both
Insert the 1st to 3rd threads in a horizontal direction and the straight needles into the sub-dermal layer through two
adjacent inlet holes. Follow the line as shown in Fig. 5C. Pull

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both ends of the thread and then trim the excess. No sutures until half of the thread has been inserted. Re-insert the
are necessary. introducer from point C upwards until it exits at point B again.
Introduce the other half of the Woffles thread into point B
Technique 4 Woffles Lift
until it exits at point C. Remove the needle, pull the end of the
Choose three to four Woffles threads for each side. Make a thread firmly while pushing the skin upward in a vertical
small incision at point B. Insert the introducer from point A direction, and then trim the excess thread (Figs. 5 (D)-(F)).
upwards until it exits at point B. Then, remove the stillete and
insert one Woffles thread from point B downward to point A
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Fig. 3 Eye brow lift: (A) Medial eyebrow lift; (B) Lateral eyebrow lift; (C) Crow's feet; (D) Tear trough

b) Mid-Face and Cheek Area: Malar Fat Pad Lifting

Technique 1 Straight Needle with Anchoring Point [2], [3],
[8], [24]-[27].
Choose 3-4 long barbed threads for each side. Make a 1 cm
incision. Tie a knot of the thread at the deep tendon fascia.
Insert the needle at the incision point. Angle the needle
upward from the periosteum to the malar fat pad area. At 1 cm
lateral from the naso-labial crease, the needle is brought out,
leaving the thread in the tissues. Pull the end of the thread
firmly and push the skin of the cheek back over it. Then trim
the excess thread (Fig. 6 (A)).
Technique 2 Curved Needle with Anchoring Point (5 cm or
6 cm Needle with 45 cm Thread)
Make a 2 mm to 3 mm incision along the “crow’s feet”
wrinkles (Point 1). Insert the needle at the incision point. Pass
the needle through the subcutaneous area along a triangular
path to Points 2 and 3 and return to Point 1. At Point 1, the
Fig. 4 Short suture technique for Sub-mental fat pad, Double chin, needle is brought out, and threaded back into the wound again.
and Skin tightening Both ends of the thread are brought together and attached to
the orbital periosteum with several knots (Fig. 6 (B)). 

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Technique 3 Double needle without anchoring point direction of the malar fat pad, moving to the surface at the
technique. marked points, and then return to the temple area where the
Insert two needles in a single puncture and then separate threads are anchored to the zygomatic periosteum. No sutures
them from each other. Advance the needles medially in the are necessary (Fig. 6 (C)).
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Fig. 5 Lower face lift: (A) Uni-directional thread technique; (B) Bi-directional thread technique; (C) Double needle technique; (D), (E) and (F)
Woffles lift technique

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ends lightly and trim the excess thread. No sutures are

necessary (Fig. 7 (C)).
d) Neck Lifting
Technique 1 Straight Needle with Anchoring Point
Make a 1 cm incision in the retroauricular area. Tie a knot.
Trace the threads medially and exit at the midline (Fig. 8 (A)).
Technique 2 Long Straight Needle with Anchoring Point
Make a 1 cm incision bilaterally in the retroauricular area.
At the incision area make a “Holder” thread with 2/0 Prolene
and anchor it on the periosteum to support the other threads.
Trace the thread along the first marked line until it appears on
the other side. The needle is brought to the surface, turned
around, and reinserted at the point it is brought out. Finally,
trim the excess thread (Fig. 8 (B)).
Technique 3 Double Needle without Anchoring Point
Insert both straight needles into the aponeurosis of the
platysma. Follow the line to the area of the
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sternocleidomastoid muscle. Pull both ends of the threads

lightly and then trim the excess thread. No sutures are
necessary (Fig. 8 (C)).
Fig. 6 Mid-face lift: (A) Uni-directional thread technique; (B) Curved
needle technique; (C) Double needle technique
c) Eyebrow Lifting
Technique 1 Straight Needle with Anchoring Point
Make four to six incisions, 2 cm above the hairline [28].
Introduce the thread into the subgaleal plane up to the superior
eyebrow margin, where it passes outside the skin and over the
eyebrow via a 1 mm cutaneous incision. The eyebrow anchor
is made and the thread is passed across laterally, after which it
is turned upward toward the scalp area. Apply traction and
make a knot, creating a rectangle (Fig. 7 (A)).
Technique 2 Double Needle without Anchoring Point
Insert both straight needles at the hairline. Follow the line
within the subcutaneous tissue, advancing both needles
downward until reaching the central eyebrow. Using the same
exit hole, reinsert the medially positioned needle and follow
the contour of the eyebrow toward the nasal edge, while the
lateral needle follows the contour of the eyebrow laterally.
Both needles are then advanced upward until reaching the
hairline, forming a symmetrical pattern. No sutures are
necessary (Fig. 7 (B)).
Technique 3 Double Needle without Anchoring Point
In a single puncture, insert both straight needles into the
temple area and then trace the needles downward toward the
temporal muscle. Separate the needles from each other and
insert them deep into the temporal fascia before withdrawing
into the subcutaneous space. Follow the line to the highest
point of the brow. At this time, the needles are moved to the
surface, turned around, and reinserted to trace medially in the
direction of the glabella. In the middle of the upper glabella,
both needles are brought out together. Pull the four sutures

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Fig. 7 Eyebrow lift: (A) Uni-directional thread technique; (B) and (C)
Double needle technique Fig. 8 Neck lift: (A) and (B) Uni-directional thread technique; (C)
Double needle technique
E. How to Choose the Appropriate Technique for the
Selected Patient
Patients who are suitable for lifting operations have a
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slightly unclear mandibular margin, sagging of the zygomatic

malar region, naso-buccal deepening, forehead wrinkles, eye
wrinkles, lax neck skin, a double chin, or a fat pad in the neck
area. Patients with advanced facial lipoatrophy, excessive
laxity of the skin that requires removal, or advance cutaneous
or muscular prolapse, as well as those who request immediate
results, or exaggerated lifting similar to traditional lifting, are
not suitable for the thread lift procedure. To select the
appropriate thread and suture technique for each patient, the
physician should focus on the specific patient defect and
primary area of patient concern. In accordance with this
viewpoint, we suggest utilizing the patient-based algorithm
shown in Fig. 9.

III. DISCUSSION
The thread lift procedure has been popularized over the past
10 years. Presently, there are several techniques that have been
developed to help meet patient expectations and improve
patient satisfaction, as summarized in the two protocols
presented in this topic review (Short and Long suture
technique protocols). The primary focus should be the area of
patient concern, the physician assessment of the physical
problem, and selection of the most appropriate technique for
the patient (as suggested in the patient-based algorithm (Fig.
9)). Moreover, the physician should explain all the advantages,
disadvantages, limitations of the selected technique, and
potential complications [18], [23], [29]-[34] to the patient.

IV. CONCLUSION
According to the collected data that has been summarized in
this review, several techniques of the thread lift procedure
have been indicated. However, positive results depend on the
process of patient selection (good candidates), as well as
selection of the most appropriate technique for the patient.
Based on our current knowledge of thread lifting, we
hypothesize that future trends will include thread lift with
growth factors that can enhance the wound healing process

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and thread lift with substances that could induce lipolysis to

enhance a V-shaped face.
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Fig. 9 Patient-based algorithm *Mild aging signs include: slightly unclear mandibular margin, need for V-Shaped lifting, naso-buccal
deepening, and relaxed neck and chin skin. *Moderate to severe aging signs include: marked unclear mandibular margin, downward slope of
the zygomatic malar region, facial lipoatrophy, severe naso-buccal deepening, and a double chin or excessive fat pad under the neck.
*Silhouette soft: We recommend that long suture technique to be applied with Silhouette soft absorbable, bidirectional thread (not required to
be fixed and easy to apply) for patients who require a heavy lifting effect

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