Chronic Inflammatory Reaction After Thread Lifting

The evolution of dermatologic and plastic surgery has involved a shift toward less invasive procedures. Consequently, numerous noninvasive face-lift techniques have been investigated over the past decade to improve the results of the procedure and to avoid incisional surgery. Thread lifting promises to correct facial aging with limited scarring, rapid recovery, and minimal complications compared with the standard incisional surgery.1 As a result, the thread technique for facial lifting has become increasingly popular with both physicians and patients. For the past several years, the authors have favored the use of nonabsorbable polypropylene thread for lifting because of its durability. However, some authors report several delayed complications after using this thread type, including foreign body granuloma and great auricular nerve neuropathy.2,3 Consequently, many physicians have postulated that absorbable suture materials would be a good option for improving skin texture and for safety concerns. The authors present the case of a 45-year-old woman that experienced complications after nonabsorbable thread lifting. This patient presented with a protruding mass and a chronic inflammatory reaction over the left temporal area 8 years after thread lifting was performed at an outside facility. Although these complications are unusual, as physicians, the authors should be cautious and fully explain the risks of these procedures to patients before surgical procedures. A 45-year-old woman presented to the authors' clinic with a protruding mass with pain and discomfort over the left temporal area that had persisted for approximately 2 years. Over the past 2 years, the size of the mass became progressively larger and was accompanied by oozing and tenderness (Figure 1A). Because this tumor was thought to be vascular in origin, the authors decided to take an initial biopsy. During the biopsy procedure, an object was palpated with the end of the punch; therefore, the authors widened the incision to identify the object and discovered a type of thread (Figure 1B). The patient then reported to the authors that she had undergone a thread-lifting procedure with nonabsorbable polypropylene suture (Aptos thread; Aptos, Moscow, Russia) 8 years previously at a local plastic surgery clinic. Histologic examination of a 3-mm punch biopsy specimen taken from the temporal mass revealed a chronic inflammatory reaction (Figure 2).Figure 1: (A) Photograph of a patient with an erythematous protruding mass in her left temporal area. (B) In an uncovered skin lesion after biopsy, the end of the blue thread was easily observed.Figure 2: Biopsy specimen from temporal mass showed dense acute and chronic inflammatory cells' infiltration in the dermis, but no granuloma formation. (A) H&E stain, ×40 and (B) H&E stain, ×100.During a discussion regarding treatment with plastic surgery consultation, the authors recommended that the patient undergo total thread removal to improve the inflammation and to prevent recurrence. However, the patient declined thread removal because of concerns about a possible asymmetric cosmetic appearance afterward. Consequently, she was treated with systemic and topical antibiotics for a total of 28 days, which resulted in partial reduction of the inflammatory reaction. She promised to revisit the authors' hospital and scheduled a surgery date for thread removal (the authors were unable to take a picture at that time). Unfortunately, she did not return to the authors' hospital for surgical removal because of the associated cost and was lost to follow-up. Discussion Since the invention of the first barbed suture by Sulamanidze in the late 1990s, the use of thread lifting has steadily increased. Furthermore, the theoretical benefits of using thread for face lifting include short recovery time, minimal scarring, good lifting, and high patient satisfaction rates. However, there have also been several complications associated with various thread-lifting procedures. In a 2004 study by Wu and colleagues, 9 of 102 patients experienced palpable thread ends with pain, 8 patients experienced thread migration, 5 patients had infections or granulomas, and 5 patients had skin dimpling or irregularities.4 Other authors have also reported that adverse events occurred in 20 of 29 total patients who underwent facial lifting with polypropylene threads. The most common event was intractable pain, followed by dimpling, visible or palpable threads, thread extrusion, paresthesia, and foreign body reactions.5 According to a report by Kaminer and colleagues, 12 of 20 patients experienced postprocedural side effects, including bruising, swelling, pinching, visibility of threads, and ear numbness. Furthermore, in a report by Horne and Kaminer, the risk of complications was greater as the number of threads used was higher.5 Fortunately, these reactions are predominantly mild or moderate in intensity, and the reactions can be corrected by a relatively simple procedure with no permanent sequelae. Chronic inflammatory reactions in the thread-lifting area, as identified in the authors' case, are an infrequent complication. Some authors have suggested that chronic inflammation of the soft facial tissues may be a result of repetitive trauma and micromovement between the barbs of the suture and the surrounding capsule.6 One way to avoid inflammation may be for physicians to be aware of this problem and to educate patients regarding avoiding trauma after the threads have been inserted. The chronic inflammatory reaction is first treated with antibiotics. Unfortunately, in rare cases, the knot of the thread in the scalp causes granulation tissue formation, and the hair roots can be pushed in deep, which can lead to hair sinuses and inclusion cysts. With these kinds of complications, physicians may have to perform immediate thread extrusion.6 Although the threads used in the authors' patient are no longer available, other permanent lifting threads are still on the market. As a result, the authors predict that problems similar to what affected their patient will continue to be seen for some time. Therefore, consistent and longer-term follow-up evaluations are critical to determine whether thread lifting provides long-lasting and satisfying results.