Since the early 1990’s, surgeons have been evaluating new surgical techniques for lifting the cheeks and jowls. After the arrival of thread-lift techniques for the face, many aesthetic practitioners learnt the technique to offer their patients an alternative option for facial rejuvenation. The thread lift is a minimally invasive procedure that utilizes sutures to mechanically lift the skin. According to data from the American Society for Aesthetic Plastic Surgery (ASAPS), during the last 20 years the number of non-surgical procedures increased by more than 12 times compared to surgical procedures, which increased by two times in the same time.
First, is a completely non-invasive method of rebuilding collagen in the skin, resulting in an overall tightening and lifting effect. The original facelift technique does not require any incisions.
Second, no special preparation is required prior to the treatment there is no need for hospitalization, general anesthesia or long-term rehabilitation. They are called “weekend procedures”, which is especially important for active and young women and men.
First threads for thread lift were mainly considered for plastic surgeons. They were composed of silicone and polypropylene and were inserted through incision and general anesthesia. A long downtime and other specific features did not make them popular.
The crucial step for future success was the appearance of absorbable threads on the market. Being used for more than 30 years, it proved its safety and reserved prominent position in surgery. The threads consist of L-polylactic acid in combination with Σ- caprolactone (P(LA/CL)) in ratio - 3:1.
In addition, the main component L- polylactic acid is responsible for rejuvenation effect. It stimulates the natural revitalization of tissues and prolongs the ageing process:
During thread biodegradation L-lactic acid is released into surrounding tissues, stimulating neocollagenesis and their rehydration.
Σ-caprolactone, the second component of the thread, slows down its biodegradation, increasing the duration of tightening effect, and serves as a lactic acid delivery system to surrounding tissues.
The overall percentage of degradation of the material from day one to 72 weeks was 41.2% Full reabsorption period for the PLA threads takes between one and a half and two years.
The tissues react to the implantation of the P(LA/CL) threads by formation of collagen type 1 and type 3, and by development of a fibrous capsule. Even after full biodegradation, the fibrous capsule continues to hold soft tissue for 3 to 5 months (Fig.1).
Excellence Visage represents the new series of techniques for lifting and armoring of the face and body tissues with the help of fully absorbable threads composed of P(LA/CL).
The Excellence line appeared in 2013. The main product in this line is Visage. There are 10 threads with multidirectional barbs of 15 cm length in Excellence Visage and 7 cm length in Nano Excellence already placed in atraumatic cannulas; the diameter of threads is USP 2/0.
The main peculiarity of Excellence Visage is disposition of its multidirectional barbs (Fig.2). This configuration gives the opportunity evenly distribute the tension of the tissues along the entire length of the thread, and the three-dimensional arrangement of the barbs allows to achieve the most reliable fixation.
Excellence Visage is universal product. It can be successfully applied both for lifting and reinforcement of almost all areas of the face and neck.
One of the most important characteristic is, that thread is preinstalled in special atraumatic cannula with the rounded tip and a hole aside (Fig.3).
The rounded tip of the cannula does not give the possibility to go beyond the right plane and pushes the tissue without any breaks. Thus, the superficial muscular-aponeurotic system (SMAS) perforation and damage in deeper structures are practically impossible. The risk of the skin retraction is also minimal. Application of Excellence Visage is the least traumatic amongst existing thread lift methods.
The application of Excellence Visage can be combined with other cosmetology procedures and surgical operations.
Excellence Visage is indicated in patients of 25 to 45 years for:
1. Volumization and contouring of the middle third of the face and the
2. Correction of the “wrinkles of sadness” – sagging mouth corners.
3. Elimination of the ptosis of the mental area.
4. Lifting and reinforcement of middle third of the face.
5. Lifting and reinforcement of the middle and lower thirds of the face
Nano Excellence is indicated in patients of 25 to 45 years, for:
1. Lifting of the arch and the tail of the eyebrows.
2. Correction of the forehead wrinkles (works well in combination with
3. Midface and mental area reinforcement.
4. Contouring of the cheekbone area.
5. reinforcement of neck soft with subsequent lifting.
Contraindications are the same as for majority of thread lift procedures and include pregnancy and lactation, acute and chronic infectious diseases, presence of benign and malignant tumors, keloid predisposition, coagulation disorders and serious chronic diseases.
Materials and methods
We conducted 420 thread lift procedures form November 2015 through November 2016 at a Total Charm clinic. 252 (60%) patients received thread lifts alone using Excellence Visage and Nano Excellence. 168 (40%) patients had undergone thread lift using Excellence Visage and Nano Excellence in combination with other threads and surgical methods.
Method of application of Excellence Visage
The procedure is carried out in a sterile treatment room. No special preparation is required prior to the treatment. If the threads are used in combination with botulinum toxin injection, then BTX is recommended 2 weeks prior thread lift. The doctor interviews the patient, determines indications and contraindications, explains the technique, warns about possible complications and instructs for the post-treatment period. Written informed consent should be provided by all patients for the use and distribution of their photographs.
Step by step procedure:
1. Preoperative and postoperative photodocumentation was obtained in 5 standard positions (one frontal view, two oblique views and two lateral views).
2. The marking at injection site and the application area was carried out in an upright position, then the patient was laid horizontally.
3. Treatment area was cleaned by antiseptic solution.
4. The local anesthesia was performed using ultracaine or lidocaine solutions.
5. Pack of threads was opened in the presence of the patient.
6. The cannulas with the rounded tip were introduced into the enter point.
7. Different methods of thread application were used depending on the task: (Fig. 4, 5, 6,7)
8. After application, the thread was trimmed in such a way that the tip was hidden in the subcutaneous tissue.
9. At the end of the procedure the patient returned to the upright position, the doctor evaluated the symmetry, soothed the tissues using light massage along the Langer’s lines and enter point.
10. The patients were instructed post-treatment recommendations and the ice packs were applied to the intervention area for 20 minutes.
The control checkup was planned on the third day. There were slight swelling and minor hematomas along the treatment area. The minor asymmetry was explained by the hypercorrection and swelling during the procedure, which disappeared subsequently. In some patients, we could still observe minor asymmetry 2 weeks after the procedure, but at the end of the first month, asymmetry completely disappeared and redefined face, lifting effect, a clear contour and repositioned volume appeared. The skin became smoother, looked more elastic and moisturized due to biorevitalization.
According to observations of 420 thread-lift procedures performed at our clinic, desired results in all patients were preserved during the year. The following assessments were obtained:
Excellent - 336 (80%)
Good - 76 (18%)
Average - 8 (2%)
According to the assessment, the procedure can be recommended to the patients of appropriate categories in the presence of true indications. In addition, technique could be combined with other cosmetic and surgical methods.
The features of Excellence Visage, arrangement of barbs, threads with different lengths, a cannula with atraumatic rounded end, determine its advantages and effectiveness.
Excellence Visage and Nano Excellence have well proven themselves both in monotherapy and in combination with other aesthetic procedures. They are highly effective for lifting, contouring, volumization and reinforcement. An additional advantage is rejuvenation due to thread biodegradation and stimulation of new collagen synthesis.
1. The American Society for Aesthetic Plastic Surgery - New plastic surgery statistics reveal focus on face and fat. PUBLIC RELEASE: 1-MAR-2017. ASAPS-Stats2016, https://www.eurekalert.org
2. Aptos LLC, Products, http://aptos.global/faq/
3. Ji Hoon Park, et al, Preparation of Biodegradable and Elastic Poly(“-caprolactone-co-lactide) Copolymers and Evaluation as a Localized and Sustained Drug Delivery Carrier. International Journal of Molecular Sciences, 2017
4. JiaolongWang et al. Biodegradable Polymer Membranes Applied in Guided Bone/ Tissue Regeneration: A Review. MDPI, 2016
5. Aptos LLC, Products, http://aptos.global/products/
6. Histocompatibility Study of APTOS threads, 2008
7. Stein P, Vitavska O, Kind P, Hoppe W, Wieczorek H, Süchurer NY. The biological basis for poly-l-lactic acid-induced augmentation. J Dermatol Sci. 2015;78(1):26–33