An effective procedure fills the gap between noninvasive facial rejuvenation and facelift surgery is thread lift. Thread lift procedures use variations of temporary sutures to lift portions of loose skin on the jawline, cheek, neck, and elsewhere. Rather than removing skin in a typical surgical lift, this process lifts and repositions the skin, resulting in noticeably lifted and refined facial features. In addition to the immediate aesthetic improvement, this procedure initiates a healing response by creating large surges of collagen production in the treatment area.

Recently, members of the Portrait collective had the opportunity to train with one of our distinguished Medical Directors, Dr. Sheila Barbarino, MD, FAAO, FAACS, FACS, on one particular type of PLLA thread lift: Silhouette InstaLift^Ⓡ Today, we're sharing with you what we've learned!

Background 

Silhouette InstaLift^Ⓡ uses threads that biologically degrade slowly over time, a process that results in new collagen and elastin. These sutures are made of polyglycolic acid (PGA) and poly-L-lactic acid (PLA or PLLA), both degradable sugar materials. 

Each long thread, made up of only PLLA, contains eight tiny cones, which are a combination of 82% PLLA and 18% PGA. Four of these cones are meant for lifting, while the other four are used for anchoring.

When to use threads 

There are the three R's of facial rejuvenation: 

• Resurface: lasers, chemical peels, microneedling, neurotoxins 
• Refill underlying tissues: injectable fillers 
• Reposition midface: threads and lifting procedures 

Typically, a client will experience the best results with a combination of threads and filler. As a provider, you might have a preference on when to use threads or not. Dr. Barbarino mentions, "One area that I really love using threads is in the nose because you don't need to worry about vascular occlusion, which is a huge bonus."

As patients become more informed about aesthetics and learn more about threads, they may start to come in requesting the procedure. A provider should plan to perform a full consultation to recommend the treatment they feel is best based on the patient's unique features and desired goals. Threads are an excellent option for the jawline and cheek area, especially for someone who has already received many filler treatments in these areas.

Prepping for treatment 

When unpacking the tools for a Silhouette InstaLift^Ⓡ, a provider will need two needles and two sets of four cones. To perform this procedure, providers should use 18 gauge needles. Dr. Barbarino reassures providers not to worry about any hyperpigmentation of patient skin with this needle type. 

If providers look at the threads themselves, you'll notice an alternating pattern between a cone and a knot. "“The cones engage on the knots and then engage on the skin tissue,” explains Dr. Barbarino. “The first thing you want to do is ensure the cones are locked in before starting the treatment. You can do this by adding tension to both sides of the thread, pulling away from the middle. By doing so, the cones should pop into a more solid, triangular shape.”

In addition to the threads and needles, a ruler comes with every set, which is used to determine cone placement. There is a focal, or ‘Zero,’ point in the center of the ruler, with measurements of the four cones on either side. “First, you want to identify the areas that will benefit from thread lifting. Then, you want to plan out the placement of the cones, with four being on either side.”

The ‘Zero’ point represents where the needle will enter the skin, which providers will want to denote with a marker. Providers will also want to mark the two exit points, being sure to extend well past the 4th cone on each side. The extra room ensures plenty of space for all cones within the area, yielding maximum results. Providers can even draw a guideline through each marker as a reference later on. Once it is determined, apply numbing medication to the treatment area, focusing on the entry and exit points.

When assessing a jawline thread, providers should look to lift the bottom portion of the face. The entry point will be right behind the heavy portion of the skin, where you want to see the most lift happen. Exit points for the jawline will typically be back behind the ear and down towards the chin.

Dr. Barbarino provides a tip for threads in the upper cheek area in terms of placement. She shares that “one rule, in general, is to always end the thread before or after the nasolabial fold. When placed in this area, the end can become visible when the patient smiles.” InstaLift^Ⓡ threads also allow the capability to anchor much closer to the eye area. Still, be mindful of the conjoint tendon, where the skin becomes much thinner, for anchoring in this area will not hold as tight.

The amount of lift desired will determine the number of threads used on each side of the face. Every provider has their personal preference for how close to put the threads together, but most tend to place them about one finger width apart. Be sure to avoid crossing threads, as cones can become tangled.

A common misconception is that thread placement is more important than cone placement. Dr. Barbarino shares that cone placement is critical to executing this procedure. “You should always be asking, “where do I need the lift?” and lining up the cones to that area.”  

Performing a Silhouette InstaLift^Ⓡ

The angle in which the provider works is crucial when administering this procedure, so be sure to find a comfortable position from the start. Before beginning, stress to the patient that they cannot touch anything on their chest or face during the treatment. It’s critical to keep the area sterile and ensure the tools used are not interfered with. The second needle and hanging thread can be rested on the patient’s chest when you’re ready to begin.

The provider can choose to go up or down the face first — whatever is more comfortable. Traveling up the face first tends to be a little trickier, but results will be the same no matter how you start.

Providers should plan to insert the needle, using their hands to pinch the skin to help determine the proper depth, and then direct the needle up or down the face. A good rule of thumb for appropriate needle depth is feeling the needle between your fingers as you guide it through the desired plane. Since patients' skin texture and thickness can vary greatly, providers should use their consistent feel as a standard. Also, be mindful to stay in the same plane of skin depth and avoid being too superficial. If providers see the silver of the needle as you go, they’re too shallow in the skin for threads and need to reposition. With PLLA threads, if you go too deep, the results will not offer as much of a lift. The complications, however, are close to none. If any minor skin irregularities or depressions appear after thread placement, they will typically disappear within a few days.

After inserting the needle, the provider should guide it down the marked path. When it reaches the exit point, the needle should be brought straight into a cap, and the thread should continue to be shimmied through. The exit point will be more shallow than the entry point because you’re both on the way out of the skin, and the area is generally thinner.

When pulling the thread through, ensure you get all the cones into the skin before stopping. Providing counter traction with the opposite hand will help guide the thread more easily. Once all the cones are in place, providers should run a finger in one big sweep over the area to lock the cones. For best results, be sure to apply tension to the thread and accordion the skin as much as possible around the cones. At this point, a lubricant, such as arnica or vitamin K gel, can be applied to the skin to assist with the sliding motion.

When ready to cut, providers should pull tight and ride the thread down to flush with the patient’s face before cutting; otherwise, excess material will pop out.

Treatment aftercare 

More times than not, patients will be able to go out the next day without any lingering side effects of treatment. Post-procedure, a short course of steroids can be prescribed to help alleviate any excessive swelling or pain, but it is typically unnecessary. Sometimes a prophylactic course of antibiotics may be prescribed. During the day following the procedure, patients should avoid any movement that pulls the facial skin, like biting into an apple, lifting heavy weights, and washing the face.

Results

With PDO threads, it’s essential to sit the patient up and have them smile and animate to see if there are any ripples or threads popping out, but this is not necessary with the Silhouette InstaLiftⓇ threads. The needles were likely dropped in different planes if you see dimples appearing between thread placements. The dimples do go away, but it’s good to work towards dropping both needles into the same plane within the skin.

Overall, the Silhouette InstaLift^Ⓡ is a low-risk procedure that can provide quick and incredible results to patients. This process may feel lengthy when first learning, but it will become a quick and effective procedure with practice!

Talk to a Portrait specialist today to learn more about incorporating this procedure into your practice.