Complications Following Facial Thread-Lifting

Zehao NIU ,Yudi HAN ,Rui JIN ,Yan LI ,Jianchao LIU ,Nan LI ,Wanheng LI,Dan LI,Youbai CHEN,*,Yan HAN,*

ABSTRACT Background Facial thread-lifting (FTL) is a minimally invasive facial rejuvenation technique.However,to date,no study has focused on the treatment of complications associated with FTL.The purpose of this study was to report on clinical manifestations of complications following FTL and their treatment methods.Methods We retrospectively reviewed the electronic medical records of patients who presented with complications of FTL.Patient demographics,medical history,types and clinical manifestations of complications,imaging,treatment methods,histopathological findings,and follow-up information were collected.Descriptive statistical analysis was performed.Results Our sample included 61 patients,all women,with a mean age of 36.3 ± 8.9 years.The most common reason for consultation was infection (31.2%),followed by dissatisfaction with postoperative facial contour (23%),paresthesia (19.7%),dimpling and irregularity (16.4%),subcutaneous induration (13.1%),thread extrusion (4.9%),and facial nerve injury (3.3%).Fifty-one (83.6%) patients reported alleviated symptoms after receiving pharmaceutical and physical therapies.Surgical interventions,including debridement and thread removal,were required in 10 patients (16.4%).Threads were completely or partially removed in 5 patients within 3 months of the initial FTL.During a median follow-up of 1.7 years,9 patients recovered well and were satisfied with the clinical outcomes,whereas one patient was unsatisfied due to dimpling and scarring.Conclusions The results show that most complications after FTL can be treated nonsurgically.Revision surgery is recommended for patients with recurrent infection,thread extrusion,and subcutaneous induration.Aesthetic surgeons and dermatologists should comply with the indications for FTL and optimize surgical procedures to minimize the risk of complications.

KEY WORDS Complication;Debridement;Facial thread-lifting;Infection;Thread removal

INTRODUCTION

Facial thread-lifting is a minimally invasive technique for facial rejuvenation that involves the insertion of barbed or conical threads through the superficial musculoaponeurotic system (SMAS)[1].Short-term lifting is achieved by soft tissue repositioning that is provided by the threads.The threads continue to stimulate the proliferation of fibroblasts and the overexpression of TGF-β to promote long-term collagen deposition and rejuvenation[2].Since Sulamanidze et al.[3]first used barbed threads for facial rejuvenation,FTL has gained global popularity because it is easier to perform and has fewer complications,shorter downtime,and lower cost than traditional subcutaneous,sub-SMAS,or subperiosteal lifting.

Previous studies have demonstrated that complications of FTL are relatively common[4-6].Reported complications include:1.Short-term complications such as bruising,pain,swelling,bleeding,and hematoma formation;2.Aesthetic concerns,including dimpling,skin irregularities,and abnormal facial contour;3.Neurosensory sequelae,such as tension,numbness,and pruritus;4.Infection,inflammation,abscess,thread extrusion,subcutaneous induration,and granuloma;5.Injury of surrounding structures such as the facial nerves,parotid gland,and duct.Although some of these symptoms disappear spontaneously within weeks,others may require pharmacotherapy or surgical intervention.These factors may significantly impact patients’ aesthetics,function,and quality of life.

Understanding the clinical features and treatment methods of the abovementioned complications will help aesthetic surgeons and dermatologists to better prevent and manage them.To the best of our knowledge,no previous studies have addressed the treatment of complications following FTL.

The purpose of this retrospective study was to analyze the clinical features and treatment methods of complications associated with FTL.The specific aims were to 1.describe the most common complications that lead to consultation and surgery and 2.review their clinical manifestations,treatment methods,and clinical outcomes.

METHODS

Study Design

We conducted a retrospective chart review of consecutive patients who presented to the Department of Plastic and Reconstructive Surgery at the Chinese PLA General Hospital between January 2016 and January 2020 for consultation or treatment of FTL complications.This study was approved by the Institutional Ethics Committee (2020-006).

Participants

The inclusion criteria were:1.Patients who underwent FTL;2.Complications that could be directly related to FTL;3.Complete medical records.The exclusion criteria were:1.Threads used for other purposes,e.g.,augmentation rhinoplasty,or filling the nasolabial groove or lacrimal grooves;2.Patients who underwent other treatments for facial rejuvenation,e.g.,dermal filler and botulinum toxin injections;3.Incomplete medical records.

Data Collection

Patients were identified through the Institutional Patient Data Registry.Data on patient demographics,medical history,types and clinical manifestations of complications,imaging,treatments,histologic evaluation of removed tissue,and follow-up information were collected through the patients’ electronic medical records.

Data Analysis

Continuous variables were expressed as mean ± standard deviation or median (range) depending on their distributions.Dichotomous variables were expressed as percentages and proportions.Descriptive statistics were calculated using Stata v15.1 (StataCorp,College Station,TX,USA).This study is reported in accordance with the Preferred Reporting of Case Series in Surgery (PROCESS Guidelines)[7].

RESULTS

Complications

All 61 patients in our sample were female,with a mean age of 36.3 ± 8.9 years.Infection (Fig.1A-E) was the most common reason for visit (n=19,31.2%),followed by dissatisfaction with changes in facial contour (n=14,23%),paresthesia (n=12,19.7%),and dimpling and irregularity of the skin (n=10,16.4%).Subcutaneous induration and chronic swelling were observed in 8 (13.1%) patients.Thread extrusion,allergic reaction to the threading material (Fig.1F),and scarring were noted in 3 (4.9%) patients,and facial nerve injury occurred in 2 (3.3%) patients (Table 1).

Non-Surgical Treatments

The majority of complications were first treated conservatively by non-surgical methods.Mild infections were treated with povidone-iodine dressings,oral antibiotics,and topical antibiotic ointments.Patients who complained of dissatisfaction with facial contour and paresthesia were often assisted by physiotherapy.Pain was managed using oral analgesics.Numbness and hypoesthesia were treated with oral neurotrophic drugs such as mecobalamin.Dimpling or irregularity of the skin was managed by local massage and the application of heat.Intralesional injections of steroids were performed for subcutaneous induration.Swelling was managed with oral detumescent drugs such as diosmin.Allergic reactions were managed with topical glucocorticoid ointment.Scarring was treated with silicone scar gel and laser therapy.Patients with facial nerve injury received hormone therapy and oral neurotrophic drugs.Of 61 patients,51 (83.6%) showed an improvement in symptoms following non-surgical treatments,whereas the remaining 10 (16.4%) patients required revision surgery that included debridement and thread removal.

Fig.1 Different clinical manifestations of infection (A-E) and allergy (F) after facial thread-lifting

Surgical Treatment

Indications for surgical intervention included recurrent infection,thread extrusion,and subcutaneous induration.Surgery was also performed in patients who demanded thread removal due to dissatisfaction with facial contour or paresthesia.Three patients with infections underwent preoperative ultrasonography and one underwent preoperative magnetic resonance imaging (MRI).Ultrasonography demonstrated a subcutaneous linear hyperechoic focus surrounded by heterogeneous or hypoechoic flow signals,indicating that the thread was surrounded by infection (Fig.2A-B).Infections on MRI presented as multiple high-signal areas within the soft tissues (Fig.2C-D).

Surgery was performed under local anesthesia in 4 patients and general anesthesia in 6 patients.In cases requiring thread removal,a 1-cm incision was made along the preauricular hairline.The end of the thread was exposed by blunt dissection,and the surrounding granulation tissue was removed to reveal the thread.Following thread removal,the site was thoroughly curetted and all necrotic tissue was removed.Thorough irrigation was performed using hydrogen peroxide,povidone-iodine,and saline.The threads were completely or partially removed in 5 patients within 3 months of the initial FTL (Fig.3).Hematoxylin-eosin staining of thedebrided tissue showed chronic hyperplasia of granulation tissues,intensive infiltration of inflammatory cells,increased proliferation of fibroblasts,and angiogenesis (Fig.4).In addition,multifocal unstructured crystalline material was detected,indicating the ongoing degradation of the thread.

During a median follow-up of 1.7 years,nine out of 10 patients reported satisfaction and substantial improvement in symptoms,whereas one patient was dissatisfied due to subsequent dimpling and scarring at the site of the surgical incision.

Table 1 Complications and corresponding treatments

Fig.2 Ultrasound imaging of the infected threads

Fig.3 A 32-year-old female strongly demanded thread removal due to dissatisfaction with facial contour and unbearable strain 3 months after thread-lifting

Fig.4 Pathological findings of the debrided tissue

DISCUSSION

Major Findings

The results of the present study show that infection was the most common reason for consultation and reoperation.Symptoms were alleviated in most of the patients after pharmacotherapy and/or physiotherapy,and revision surgery was required in 10 (16.4%) patients due to intractable infection,thread extrusion,induration,and patient demand.Preoperative imaging was helpful in defining the area of thread infection.Threads could be removed either completely or partially within 3 months of FTL.Most of the patients recovered well and were satisfied with the clinical outcomes.

Short-Term Symptoms

Short-term swelling,bruising and pain are the most commonly reported symptoms after FTL in the literature.Sulamanidze et al.[3]felt that these reversible symptoms should not be defined as complications because they resolved spontaneously within 2 weeks.Distinct from their studies,we found very few short-term symptoms.This likely reflects the fact that patients initially returned to the site where the FTL was performed rather than being referred to a hospital.Thus,only more severe or protracted complications were encountered in our cohort.

Infection

The incidence of postoperative infection following FTL varies significantly in the literature.Sulamanidze et al.[8]noted only one infection in a total of 6,089 patients (0.01%) who underwent FTL with Aptos polypropylene threads.Wu et al.[9]showed that 5 out of 102 patients (5%) had infections after Aptos FTL.Garvey et al.[10]reported that the incidence of infection was 5.6% in 72 patients who underwent FTL using contour polypropylene threads.Fukaya et al.[11]found infection in one of 100 patients (1%) who received Xtosis polypropylene threads.Guduk et al.[12]found one case (0.7%) of infection using Silhouette polylactic acid threads.In a study by Guida et al.[13],one out of 20 patients (5%) developed an infection following Silhouette FTL.Unal et al.[14]used polydioxanone (PDO) threads for FTL in 38 patients and documented an infection rate of 5.3%.Similarly,Bertossi et al.[15]noted an infection rate of 6.2% in 160 PDO threads.

In this case series,infection was the most common reason for consultation and reoperation.Preoperative ultrasonography and MRI are useful tools in the detection of threads and the area/depth of infection for surgical planning.In agreement with Guduk et al.,we found that most infections occurred at the end of the threads.Furthermore,an interesting finding was that the removal of threads from the infected tissue was not as technically difficult as we expected,probably due to the inflammatory reaction surrounding the threads.

Dissatisfaction with Facial Contour

Dissatisfaction with facial contour after FTL has been reported previously,with facial asymmetry the most common type of facial contour issue.Suh et al.[16]noted that 6.5% of 31 patients had facial asymmetry after FTL using PDO threads.Moreover,Kang et al.[17]reported that the incidence of facial asymmetry was 2.6% in 39 patients with PDO threads.In a study by Lee et al.[18],the incidence of facial asymmetry was 3% in 35 cases,while de Benito et al.[19]found that 2 out of 316 patients (0.6%) developed facial asymmetry and underwent revision surgery following FTL with Silhouette threads.

In contrast,we found that convex malar and/or sunk buccal was the most common aesthetic contour concern following FTL,rather than facial asymmetry.This may be because facial asymmetry can be easily corrected by reinsertion of threads in the areas where the initial FTL was performed and,therefore,did not require a visit to an academic hospital.Interestingly,we found that dissatisfaction with facial contour was more common in young females aged <35 years without obvious skin laxity.These women complained that FTL significantly changed their facial contour and demanded thread removal to recover their original appearance.

Paresthesia

Few studies have documented paresthesia after FTL,and as a result,the etiology is poorly understood.We speculated that the feeling of strain might result from the excessive stretching of soft tissue during thread-lifting.Conservative non-surgical methods are first-line therapy because it is challenging to assess these symptoms objectively.Surgery should also be considered in cases of persistent and debilitating neurosensory alterations.

Dimpling

The incidence of dimpling varied from 3.5% to 15% in the literature[9,15,17-20].Guduk et al.[12]noted that 17 out of 148 (11.4%) patients experienced skin dimpling and irregularity after FTL with Silhouette threads.Skin dimpling spontaneously resolved within 1 week in 16 patients.One patient required revision surgery due to long-standing dimpling.We found that dimpling was caused by the superficial insertion of threads and excessive lifting.Therefore,threading in the appropriate layer of SMAS and gentle lifting with constant speed are important to prevent dimpling.Dimpling is commonly managed with local massage and heat application and usually disappears within 2 weeks.Removal surgery,or filling with hyaluronic acid or autologous fat,could be considered to treat long-standing dimpling.

Subcutaneous Induration

A thread-induced foreign body reaction is a common complication of absorbable threads and other implants made of polylactic acid due to an imbalance between degradation and absorption.Pathologically,nanoparticles from the degraded materials are phagocytized by macrophages,leading to sterile inflammation,abscess,and inflammatory granuloma formation,as shown in Fig.4.The clinical manifestation is palpable subcutaneous induration,which is commonly found at sites with less subcutaneous tissue coverage.Garvey et al.[10]reported that 9 patients (11.3%) developed subcutaneous induration and underwent thread removal surgery.Moreover,de Benito et al.[19]noted that the incidence of subcutaneous induration was 0.3% (one in 316 patients),while Yoo et al.[21]described one case with a subcutaneous induration in the temporal region 8 years after FTL using Aptos threads.Of the 8 cases with subcutaneous induration in this study,five occurred in the temporal region and 3 in the buccal region.These nodes ranged from 2 mm to 5 mm in diameter,with clear boundaries and poor mobility.Intralesional glucocorticoid injection was initially performed,and revision surgery was reserved for those without a positive response.

Thread Extrusion

Thread extrusion is a severe complication of FTL and often leads to thread removal.Kang et al.[17]showed that the incidence of thread extrusion was 2.6%,Guduk et al.[12]reported an incidence of 2.7%,and Fukaya et al.[11]noted that 8.3% of patients had thread extrusion.Thread extrusion is commonly associated with infection and inflammation due to a foreign body reaction.All exposed threads were removed in the current study.

Facial Nerve Injury

Facial nerve injury is a rare complication after FTL and has only been reported in a few case studies.In a study by Park et al.[22],one of 102 patients reported transient symptoms of facial nerve weakness after FTL.Two patients presented with transient symptoms of facial nerve weakness in our cohort.These symptoms might be caused by tissue disturbance,edema,or the use of local anesthesia.These symptoms improved within 1 week after dehydration,neurotrophic,and steroid therapy,and did not warrant removal surgery.

Limitations

This study has several limitations.Unlike in a cohort study,the incidence rate of individual complications could not be calculated based on the current data.However,the present study focused on the treatment modalities for FTLrelated complications rather than their incidence rates.Furthermore,the indications for surgical intervention remain controversial,particularly when patients demand thread removal due to dissatisfaction with facial contour and paresthesia.In addition,the sample size was too small to be able to perform an association analysis.Therefore,a randomized controlled study with an adequate sample size and objective evaluation is needed to validate the efficacy of these treatments.Despite these limitations,this pilot study reviewed the treatment methods for complications resulting from FTL and demonstrated the utility of ultrasonic and MRI in delineating areas of infection.To the best of our knowledge,this is the first study to evaluate histopathologic findings at the time of thread removal.These results will help to establish the safety profile of FTL and help aesthetic surgeons and dermatologists better understand the treatment methods for these complications.

CONCLUSION

The results of this retrospective case series show that most complications after FTL can be treated non-surgically,including with pharmaceutical and physical therapy.Debridement and thread removal are recommended for patients with recurrent infection,thread extrusion,and subcutaneous induration.Threads can be completely or partially removed within 3 months of the procedure.Aesthetic surgeons and dermatologists should ensure that they understand the indications of FTL,use officially approved products,and optimize surgical procedures to minimize the risk of complications.

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

This study received ethical approval from the Ethics Committee of the Chinese PLA General Hospital.The requirement for written informed consent was waived due to the retrospective nature of this study.

Consent for Publication

All the authors have consented to the publication of this article.

Competing Interests

The authors declare that they have no competing interests.The authors state that the views expressed in the article are their own and not the official position of the institution or funder.