The use of absorbable or non-absorbable sutures has long been the basis for repositioning and supporting subcutaneous tissues.11 Suspension techniques together with traditional rhytidectomy incisions are generally used to achieve better facial rejuvenation results. Skin and SMAS suspension, or deep subperiosteal suspension, can be performed with autologous tissue, such as tendons or fascia, or prosthetic materials, including sutures, slings, or mesh.6,9 Several types of suture material have been used for this purpose, particularly polytetrafluoroethylene (Gore-Tex™), polyglactin (Vicryl™) and polypropylene.9 Among the many suspension techniques, two general concepts of facial rejuvenation are currently being developed.12 The first is subcutaneous suspension using SMAS as the fixation basis, with tissue elevation using posterolateral vectors, and the second is based on the subperiosteal detachment and en-bloc repositioning of all structures using purely vertical vectors.12 Suspension techniques have also been incorporated into minimally-invasive procedures of the middle and lower facial thirds using the endoscope. Thus, it is possible to reposition and anchor the facial soft tissues to the temporal fascia or the periosteum through minimal incisions.13

Simple transfixation of smooth threads through the skin can be a suitable option to elevate the eyebrows or the middle third of the face with low morbidity.7,14 Several techniques have been described that achieve a subtle facial lifting with the use of suture threads that hold the area of the face to be suspended, ultimately fixing it to the scalp (Curl Lift, Arch Lift).15 The results of these procedures may be unpredictable. The threads tend to easily cut the tissues and the wrinkles and folds of the skin tend to disappear along with the results.7,14

With the advent of polypropylene barbed sutures, the capacity of the sutures to withstand loads increased very much.9 The first to mention the concept of barbed sutures was Alcamo in 1964,7 followed by Fukuda in 1984 and Ruff in 1994.16 These pioneers used the barbed sutures to close wounds without the need for knots. However, they did not anticipate their esthetic applications.7 The suture they described had barbs placed sequentially along its length. The barbs changed direction at a point near the center of the thread to create a mirror image of the barbs in the opposite direction. When wrapped around the tissues, one extremity anchored the other and closed the wound or moved the tissues toward the center of the thread, creating new gradients of tension and compression.16,17

Tissue suspension with barbed sutures was first reported in the late 1980s by Russian authors Sulamanidze et al.5,18 With little or no soft tissue dissection, the sutures are placed in the subcutaneous tissue.3,18 Both the design and the way they were placed have changed since their introduction. The original APTOS (Anti-Ptosis Suture) was a multi-toothed thread that was later modified to become bidirectional, with the barbs directed to attach the tissues to the central region of the thread, without the need for anchoring at the extremities. It was subsequently redesigned to allow one-way traction and suspension.18 With the one-way barbs, the fixation methods were once again modified.3,18 Although several techniques have been used over the years, all of them involve the interposition of the soft tissues to the suture barbs, with consequent triggering of inflammatory response and production of fibrosis around them.19

The latest generation of barbed sutures for soft tissue support is available as both non-absorbable and absorbable material with several lengths and different types of inlaid needles.3 The varied current presentations allow different applications, including self-fixation, curved passages that embrace the ptotic tissue, loops, and fixation of the two extremities of the thread at a single point, with anchoring at the temporal fascia or other deep points.7,15,19

The mono-filament, double-convergence polypropylene threads used in Brazil, known as Beramendi or Russian threads, are approved by ANVISA, but not by the FDA.18,20 In general, permanent strands are approved for correction of facial and cervical ptosis, while absorbable threads are approved only for soft tissue approach and suturing of incisions.17 The most common absorbent material used to produce the threads is polydioxanone (PDO), a polymer that is gradually hydrolyzed.16

Barbed sutures can be applied to both the forehead and the middle and lower thirds of the face, as well as the neck. Regardless of where the threads are used on the face, incisions, however small, should be made in locations where they can be camouflaged, followed by dissection of the subcutaneous tissue, passage of the threads and their proximal anchoring. Finally, the soft tissues should be shaped so that a smooth and harmonious contour is achieved.3

It is important to emphasize that long-term studies and reviews on the duration of results and the satisfaction of patients undergoing facial rejuvenation procedures with support sutures are rare.6,21 The few existing clinical studies have a level of evidence III, at the most.9

Sulamanidze et al. stated that elevating facial tissues with APTOS is simple, effective, and fast, and it prevents scarring and the need for implants.18 The authors also stated that both immediate and late outcomes are good and long-lasting (follow-up from 2 months to 2.5 years).18,22 Lycka et al. also reported good results in a series of 350 patients in a retrospective study based on “patient interviews and surgeon observation.”23 They also defended the use of threads in replacing traditional surgical interventions citing minimal complications and high patient satisfaction.23,24 For them, APTOS would be a safer alternative to the current facelifts, suggesting that the well-positioned barbed sutures have the effect of making the face look more harmonious and thinner.7 Regarding the duration of the results, 117 patients were followed up for a period of 12–24 months and maintained 70% of the initial correction, determined by blind photo evaluation.23 Others have found that facial tissues seem stronger, firmer and rejuvenated, and, more importantly, patients seem happy with the results, although very little persistent elevation can be observed.24 This reported improvement may have occurred due to the production of fibrotic tissue around the sutures, combined with the effect of soft tissue structuring also promoted by suturing. It is known that fibrosis increases the collagen matrix of the dermis and subcutaneous tissue.7

The enthusiasm for the so-called “thread lift” in treatment of the nasolabial, bucco-mentonian grooves, eyebrows, and platysmal bands has been disseminated by patients themselves.19,23,24 In the short term after the procedure (1–3 months), many state they seem to have undergone a “perfect face lift” and, like their doctors, are delighted with the quality of the results obtained.6 Published data from an anonymous satisfaction survey of 20 consecutively treated patients and based on the pre- and post-procedure photo evaluation of 7 patients by 7 independent dermatologists concluded that the unidirectional, permanent and anchored barbed sutures (Contour Threads®) placed in subcutaneous tissue can produce long-lasting ptotic facial tissue suspension.6 Based on these results, the hypothesis is that the correction lasts at least a year or a little longer than that.6 The thread advocates also mention the rapid recovery of their patients after the procedure.22 Although there are many advantages in using the barbed sutures for minimally-invasive facelift procedures,6 its long-term effectiveness may be disappointing, leading to a decline in its popularity.24 Overall, the results obtained are subtle and have a short duration.11

Some plastic surgeons have questioned the allegations of predictable, long-lasting, low-morbidity results with a minimal complication rate, made by thread use advocates.22 They argue that the results are disappointing and that tissue repositioning is not maintained in the long term, and threads can often be visible, extruded, broken, or traction lines can appear at rest or with facial mimicry.11 Despite reported cases of successful treatment of the mandibular line and neck,11 it can be observed that the skin of the lower third of the face tends to sag over time.6 Even when the techniques are modified to tie the fascia that covers the platysmal muscle, the results in the neck are still inferior to those observed in the malar region.6

Poor and short-term results may not be the only risks of this noninvasive facial rejuvenation procedure. Permanent insertion of a foreign body can cause unexpected reactions with considerable morbidity and negative esthetic effects, and even the most stable alloplastic material may fail and break down under repeated stress and flexion, such as occurs in the moving face.11 Reports on side effects of a wide variety of alloplastic materials applied to the face for this purpose have increased, and a more stringent monitoring of these effects is necessary.19,25 Although immunological or chemical reactions to an inert implant are very unlikely, such foreign bodies can infect or fragment25 Because these procedures are commonly performed on relatively young patients and complete surgical suture removal is virtually impossible, residual fragments can remain for decades, worsening symptoms over time.25

There have been no major complications reported in most studies on the use of barbed sutures.5,8,18,23 Minor and transient complications include facial asymmetry, bruising, erythema, hematoma, edema, and discomfort.11 Thread migration, extrusion, and scar formation at their sites of entry and exit are the late complications described.11,26 Complications of APTOS were more recently reported in a series of 102 patients: 11 palpable thread tips with pain, 8 thread migrations, 5 infections or granulomas, and 5 skin irregularities.7,9 More severe complications, such as Stensen's duct rupture, facial nerve injury, chronic foreign body sensation and scarring have been reported by other authors.25,26

In addition to the previously reported transient bruising and edema, some patients may still have irregularities in the skin overlying the threads. Although transient, they may persist for days or weeks. The patient generally cannot return comfortably to his/her daily activities until the resolution of such irregularities. Thus, the time required for recovery after the “thread lifting” may be the same for the recovery after a rhytidoplasty.24 Additionally, the rate of surgical revision after the thread lifting procedures is high. In all, 11% of patients require removal of the threads because they are palpable, extruded, or due to patients’ dissatisfaction with their appearance.24

The data of the studies evaluated in this review are summarized in Table 1 below, which is an extended version of the table published by Villa et al. in their review.9