Vertical Lifting: A New Optimal Thread Lifting Technique

for Asians
Seung Hoon Kang, MD,* Eun Jung Byun, MD,† and Hei Sung Kim, MD, PhD†

BACKGROUND With the evolution of facial rejuvenation methods, thread lifts have gained popularity among
patients who seek cosmetic improvement. Absorbable wedge-shaped polydioxanone (PDO) sutures are cur-
rently available, and they are extremely popular in the aesthetic clinics in Korea. In case of midface and
mandibular jowl lift, threads are most often inserted in an oblique manner with vectors of rejuvenation
directed toward the temple. However, specific characteristics of skeletal anatomy should be considered when
deciding which technique to use in Asians. Herein, the authors introduce a vertical lifting technique most
suitable for Asians, in which short (6 cm in length), wedge-shaped PDO sutures are inserted vertically
downward in the anterior malar and submalar areas.

OBJECTIVE To describe a novel technique adopted to counteract the descent and laxity of the Asian face.
The authors also aimed to assess the overall safety and efficacy of wedge-shaped PDO thread lift in facial
rejuvenation.

METHODS A retrospective chart review was performed on cases of facial laxity treated with vertical thread
lifting. A total of 39 Korean patients were included. All participants underwent a single treatment session. The
results were assessed objectively using serial photography and subjectively based on the patients’ satisfaction
scores. Complications were also recorded.

RESULTS Most patients (89.7%) considered the results satisfactory. Consensus ratings by 2 independent
dermatologists showed that the objective outcomes at the 6-month follow-up were largely categorized as very
much improved (10.3%), much improved (43.6%), and improved (33.3%). The incidence of complications was
low, and the complications were minor.

CONCLUSION Thread lifting with short, wedge-shaped PDO sutures is safe and effective for facial rejuve-
nation. The authors’ vertical lifting technique has several advantages over the current approaches. First, the
vectors directly oppose the vertical sagging of the face, which makes the technique highly efficient. The
technique also carries a lower risk of accentuating the cheekbones, a feature which most Asians do not prefer.

Supported by a grant of the Korean Healthcare technology R&D project, Ministry of Health & Welfare, Republic
of Korea (Grant No.: HN15C0105). The authors have indicated no significant interest with commercial
supporters.

A n increasing demand for reversal of the aging face

has led to the evolution of various rejuvenation
techniques, and with a trend shift toward minimally
Facelift suture,4 and Silhouette suture5), developed
primarily for use in facial rejuvenation, were non-
absorbable. Patients do not wish to undergo insertion of
invasive treatments, thread lifting has become materials that remain permanently in the facial soft
extremely popular. tissue, and for this reason, absorbable, barbed suture
designs (e.g. wedge-shaped polydioxanone [PDO]
The evolution of wedge-shaped suture technologies and thread) have become newly available.1,6
their application in the field of aesthetic surgery is now
in its third decade.1 Previous suture designs (e.g. Aptos Although the use of thread lifting for facial rejuvenation
Thread,2 Woffles thread,3 Isse’s Endo Progressive has increased worldwide, most consensus statements do

*Four Seasons Dermatology Clinic, Seoul, Korea; †Department of Dermatology, Incheon St. Mary’s Hospital, College of
Medicine, The Catholic University of Korea, Seoul, Korea

© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2017;43:1263–1270 DOI: 10.1097/DSS.0000000000001169

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 VERTICAL THREAD LIFTING FOR ASIANS

not distinguish between ethnic populations. There are, 2016. The authors compiled and analyzed the data
however, significant differences in the ideal faces from consecutive patients who underwent thread lift-
between whites and Asians, reflecting not only cultural ing with a medical grade PDO thread at 4 SEASONS
disparities but also distinctive treatment goals. Dermatologic Clinic. The authors reviewed the
patients’ sex, age, and preoperative and postoperative
Unlike the West, high cheekbones (a prominent malar clinical photographs. The results were assessed
eminence) are considered masculine and unattractive in objectively using serial photography and subjectively
Asia. They are therefore considered neither necessary according to patient assessments. The principles of the
nor appreciated. A more rounded “apple” cheek with- 1975 Declaration of Helsinki were followed.
out zygomatic emphasis is generally preferred. Cur-
rently, in cases of midface and mandibular jowl lift, Treatment efficacy was assessed by comparing pho-
threads are routinely inserted in an oblique manner with tographs at the 6-month follow-up with those taken at
vectors of rejuvenation directed toward the temple. baseline using a 5-point Global Aesthetic Improve-
Here, threads inevitably traverse the malar eminence ment Scale (GAIS) (5- “very much improved,” 4-
resulting in an accentuation of the cheekbones (Figure 1).4 “much improved,” 3- “improved,” 2- “no change,”
This unintended effect may be favorable to whites, but it and 1- “worse”). The grading was performed by 2
has caused significant dissatisfaction in Asians. independent, blinded physicians. Side effects were
recorded. Patients were followed up after surgery, and
To overcome this problem, the authors have devel- their outcomes were evaluated by asking them to rate
oped a vertical lifting technique in which short (6 cm in their overall satisfaction using the following scale:
length) wedge-shaped PDO sutures are inserted verti- “excellent,” “very good,” “good,” “fair,” or “poor.”
cally downward in the anterior malar and submalar All statistical analyses were conducted using PASW
areas. The authors’ aim was to evaluate the effective- version 18.0 (IBM, Armonk, NY). Descriptive statis-
ness and safety of this novel technique in counteracting tics are presented as both numbers and percentages of
the descent and laxity of the Asian face. the patients or as means and SDs.

Materials and Methods Polydioxanone Thread

A retrospective chart review was performed over Bidirectional wedge-shape PDO threads (VOV-LIFT,
a period of 2 years from October 2014 to September GLK International, Seoul, Korea) with the following

Figure 1. Malar enlargement following conventional thread lift: (A) baseline and (B) after thread lift.

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 KANG ET AL

Figure 2. The short (6 cm), bidirectional, wedge-shaped polydioxanone thread.

specifications were used: VOV-LIFT 19 G 6 cm/2 to 0. against gravity. In cases with significant marionette
The product contains a 45° blunt needle (Figure 2). lines or jowls, additional threads (4–5 short wedge-
shaped PDO sutures) were inserted in a fanning pattern
Surgical Technique with vectors directed against the sagging folds, below
the level of the malar eminence (Figure 5).
The procedure was performed by a single dermato-
logic surgeon (Dr. Kang, one of the authors) with the
To minimize edema and bruising, ice packs were
patient under local anesthesia. Topical anesthetic
applied. Oral cephalosporin was given up to 5 days
cream (EMLA, eutectic mixture of 2.5% lidocaine and
after the procedure, and patients were encouraged to
2.5% prilocaine; Astra USA Inc., Westborough, MA)
sleep in the supine position for the first 2 to 3 weeks
was applied to the target area 1 hour before the pro-
after surgery.
cedure. After painting the operating field with Beta-
dine, 2% lidocaine with epinephrine (1: 100,000)
(Yuhan, Seoul, Korea) was injected at the entry points.

The authors marked the skin preoperatively where

vertical lines were drawn on the anterior malar and
submalar areas taking care to avoid involvement of the
malar eminence (Figure 3). Short (6 cm in length), 2 to 0
bidirectional wedge-shaped PDO sutures were inserted
according to the markings after placing the patient
in a 45° head-down tilt position (Figure 4). For the
anterior malar area, the point of needle insertion was 1
cm below the lower eyelid margin and in between the
inner canthus and the lateral canthus. The aimed depth
of insertion was the layer immediately below the
superficial muscular aponeurotic system. The needle
was inserted vertically downward to the level of the Figure 3. The vertical thread lift: short wedge-shaped
polydioxanone threads are inserted vertically in the ante-
marionette lines. Six to 8 threads were inserted sub- rior malar and submalar areas taking care to avoid
cutaneously into each cheek, with the vector directed involvement of the malar eminence.

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 VERTICAL THREAD LIFTING FOR ASIANS

Figure 4. Patient positioning for thread lift: the patient is placed in a 45-degree head-down tilt position.

Results patients considered the outcomes to be excellent, 20

patients (51.3%) considered the outcomes to be very
Patients’ characteristics and outcomes are summarized
good, and 5 patients (12.8%) considered the outcomes
in Table 1. A total of 39 patients who underwent
vertical thread lifting with short, wedge-shaped PDO
sutures and made regular follow-up visits were TABLE 1. Patients’ Characteristics and
included in the study. All were female except 1 patient. Postoperative Outcomes and Complications
The mean age of the study population was 45 years
Mean 6 SD
with a range of 31 to 70 years.
Age, yrs 45 6 10.6

At the 6-month follow-up, 35 patients (89.7%) consid- No. of patients (%)

ered the results satisfactory, among which, 10 (25.6%) Total 39 (100)
Sex
Female 38 (97.4)
Male 1 (2.6)
Physician assessment (Global
Aesthetic Improvement Scale)
Very much improved 4 (10.3)
Much improved 17 (43.6)
Improved 13 (33.3)
No change 5 (12.8)
Worse
Patient satisfaction
Excellent 10 (25.6)
Very good 20 (51.3)
Good 5 (12.8)
Fair 3 (7.7)
Poor 1 (2.6)
Complications
No 33 (84.6)
Figure 5. Vertical thread lift (variant form): in cases with Yes 6 (15.4)
significant marionette lines or jowls, additional threads are
SD, standard deviation.
inserted in a fanning pattern with vectors directed against
the sagging folds, below the level of the malar eminence.

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 KANG ET AL

to be good. The objective outcomes measured by tissue undermining, and as the name implies, it
comparing the baseline (preoperative) photographs with boasts an exceptionally short recovery time.8,9
those taken at the 6-month follow-up were categorized Although substantially mentioned in the popular
as “very much improved” (10.3%), “much improved” press, the authors found surprisingly little infor-
(43.6%), “improved” (33.3%), and “no change” mation in the plastic surgery or dermatologic liter-
(12.8%). Representative preoperative and ature regarding its safety, efficacy, and
postoperative photographs are presented in longevity.8,10
Figures 6 and 7.
With the addition of barbs to the suture material,
Treatment was well tolerated, and it caused minimal the load-bearing ability of facial suspension sutures
discomfort. Six patients (15.4%) were found to have has increased.8 The latest generation of barbed
procedure-related complications. Dimpling was the sutures designed for soft tissue approximation is
most common side effect (2 patients, 5.1%), followed available in the form of both absorbable and non-
by bruise (1 patient, 2.6%), facial asymmetry (1 absorbable materials with various suture lengths
patient, 2.6%), thread extrusion (1 patient, 2.6%), and needles attached. 1 For this particular study, the
and malar eminence accentuation (1 patient, 2.6%). authors used self-retaining bidirectional 6-cm
Significant adverse events such as nerve damage or for- wedge-shaped PDO sutures which are able to pro-
eign body granuloma were not observed in this study. vide strong traction in freely mobile tissues. With
respect to PDO, it is a polymer which gradually
hydrolyzes. Its strength degrades in an inverse
Discussion
fashion to the increase in the strength of the healing
Suture suspension of the face, although not a new wound (or lax skin).11 Currently, absorbable bidi-
technique, has gained prominence with the advent rectional wedge-shaped sutures are only approved
of the so-called “lunch-time” face-lift.7 To for approximation of the wounds and soft tissue,
counteract the descent and laxity of the tissues, but this study results suggest that the suture mate-
this procedure entails the passage of sutures under rial may also be favorably used in facial
the facial skin. It does not require an incision or rejuvenation.

Figure 6. Preoperative and postoperative clinical photographs of the patients who underwent vertical thread lifting:
(A) initial and (B) 6-month follow-up.

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 VERTICAL THREAD LIFTING FOR ASIANS

Figure 7. Preoperative and postoperative clinical photographs of a patient who received vertical thread lifting: (A) initial; (B)
6-month follow-up; and (C) 12 month-follow-up.

The purpose of barbed sutures is not only to apply enable significant lifting of the cheek and jowl by fully
but also to maintain tension without sagging or opposing the direction of malar skin sagging. For those
slipping.12 A study on barbed threads indicates that with significant marionette lines or jowls, a variant
cogs induce a fibrotic reaction through myofibro- form is available (Figure 5), and it can be further
blasts, lifting the aging face.13 However, until the added.
suture is enveloped by a supportive sheath of fibrotic
tissue, the suture alone has to bear the load of the As mentioned earlier, the authors’ technique specifi-
lifted skin.12 The holding strength of barbed sutures cally adopts short (6 cm) threads. The use of short
may be improved by less traumatic needles (i.e. threads is based on the cultural disparities in beauty
a blunt needle with a narrow diameter),11 but the between whites and Asians. Unlike the West, high
technique (or vector) of thread insertion is assumed cheekbones (a prominent malar eminence) are con-
to strongly influence the results.7 sidered unattractive in Asia and have rarely been
appreciated. With the traditional technique, threads
In cases of midface and mandibular jowl lift, threads traverse the malar eminence resulting in an accentua-
are conventionally inserted in an oblique manner with tion of the cheekbone.4 For Asians, the problem has
vectors of rejuvenation directed to the temple. The been quite common and extremely troublesome. Short
authors have long questioned why vectors which threads used in the authors’ new technique typically
directly oppose gravity are not used, and the authors spare the malar area. Naturally, the risk of malar
have developed a vertical lifting technique where eminence accentuation (also recognized as malar
threads are inserted vertically downward (Figure 3). widening) is low, which makes the technique well
The authors postulated that the technique would suited for Asians.

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 KANG ET AL

In clinical practice, the authors generally perform objective evaluation and patient satisfaction with
a thread lift with the patient placed in a 45-degree surgical results.
head-down tilt position (Figure 4). Such type of
positioning (by neck extension) enables a natural The study results suggest that vertical lifting with
face-lift which enhances the efficacy of thread wedge-shaped PDO sutures is an effective and safe
insertion and will come in handy to those who procedure for facial rejuvenation in Asians, but
practice thread lifting. appropriate patient selection is necessary for
achieving optimal outcomes. The procedure is
Overall, the efficacy of vertical thread lifting with indicated in those who are relatively young and
short, wedge-shaped PDO was favorable with have a modest degree of facial soft tissue laxity.15 It
both patients (89.7%) and physicians (87.2%) is certainly not suited for patients with significant
claiming satisfaction and improvement at the dermatoheliosis or more prominent rhytides. Pref-
6-month follow-up. Although the longevity of erably, the patient should have a less prominent
thread lift cannot be discussed here using the malar eminence. Although best suited for Asians,
authors’ limited data, the lifting effect was found to the technique may also be successfully used in
persist over 1 year in a number of their patients whites as an adjunct to the conventional technique
(Figure 6). that is currently being practiced.

The procedure was well tolerated under local To gain recognition as a novel alternative method for
anesthesia and none of the patients asked for further midface rejuvenation in Asians, further investigation
sedation. In terms of complications, dimpling was into the use of vertical lifting and long-term evalua-
the most common side effect (5.1%), and it was tions are required.
treated with soft tissue massage and subcision.
The authors also had a patient with malar emi-
nence accentuation (2.6%), despite use of the ver- References
tical technique. Adverse events most commonly 1. Paul MD. Barbed sutures in aesthetic plastic surgery: evolution of
thought and process. Aesthet Surg J 2013;33:17S–31S.
reported with use of barbed sutures are pain,
2. Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze GM.
dimpling, visible threads, and foreign body
Removal of facial soft tissue ptosis with special threads. Dermatol Surg
reactions.14 2002;28:367–71.

3. Wu WT. Barbed sutures in facial rejuvenation. Aesthet Surg J 2004;24:

582–7.
No conclusive consensus is available with respect to
the number of threads and optimal location for 4. Isse NG, Fodor PB. Elevating the midface with barbed polypropylene
sutures. Aesthet Surg J 2005;25:301–3.
placement of threads in thread lifting. However,
5. Isse N. Silhouette sutures for treatment of facial aging: facial
a better understanding of the critical vectors and rejuvenation, remodeling, and facial tissue support. Clin Plast Surg
consideration of cultural disparity may produce the 2008;35:481–6.

desired results more successfully than the original 6. Savoia A, Accardo C, Vannini F, Di Pasquale B, et al. Outcomes in
thread lift for facial rejuvenation: a study performed with happy lift
placement.7 Thus, the authors’ vertical lifting tech- revitalizing. Deramtol Ther (heidelb) 2014;4:103–14.
nique has several advantages over the current 7. Atiyeh BS, Dibo SA, Costagliola M, Hayek SN. Barbed sutures “lunch
approaches. First, the vectors directly oppose the time” lifting: evidence-based efficacy. J Cosmet Dermatol 2010;9:
132–41.
vertical sagging of the face, which makes the technique
8. Villa MT, White LE, Alam M, Yoo SS, et al. Barbed sutures: a review of
highly efficient. The technique also carries a lower risk the literature. Plast Reconstr Surg 2008;121:102–8.
of accentuating the cheekbones, which makes it ideal 9. Hudson DA, Fernandes DB. Caveats for the use of suspension sutures.
for Asians. Aesthet Plast Surg 2004;28:170–3.

10. Suh DH, Jang HW, Lee SJ, Lee WS, et al. Outcomes of polydioxanone
knotless thread lifting for facial rejuvenation. Dermatol Surg 2015;41:
The strength of this study is the introduction of 720–5.
a novel vertical lifting technique, together with
11. Ruff G. Technique and uses for absorbable barbed sutures. Aesthet
the evaluation of efficacy and safety including Surg J 2006;26:620–8.

43:10:OCTOBER 2017 1269

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 VERTICAL THREAD LIFTING FOR ASIANS

12. Rashid R, Sartori M, White LE, Villa MT, et al. Breaking strength of 15. Lycka B, Bazan C, Poletti E, Treen B. The emerging technique of the
barbed polypropylene sutures: rate-blinded, controlled comparison antiptosis subdermal suspension thread. Dermatol Surg 2004;30:41–4.
with nonbarbed sutures of various calibers. Arch Dermatol 2007;143:
869–72.

13. Jang HJ, Lee WS, Hwang K, Park JH, et al. Effect of cog threads under Address correspondence and reprint requests to: Hei Sung
rat skin. Dermatol Surg 2005;31:1639–43. Kim, MD, PhD, Department of Dermatology, Incheon
14. Rachel JD, Lack EB, Larson B. Incidence of complications and early St. Mary’s Hospital, The Catholic University of Korea, 56
recurrence in 29 patients after facial rejuvenation with barbed suture Dongsuro, Bupyeong-gu, 150-713 Seoul, Korea, or e-mail:
lifting. Dermatol Surg 2010;36:348–54. hazelkimhoho@gmail.com

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