Introduction:
To evaluate the surgical efficacy and outcomes related to midface,
mandible, neck (and double chin), and nose lifting with APTOS thread lift.

Methods:
In this prospective review chart study, a total of 58 patients were included (from July 2018 to July 2019). All participants underwent facial thread lifting using APTOS. The patients were followed up first week, third, and sixth month after lifting surgery. Outcomes were assessed by two surgeons and patients based on the GAIS score. All data were analyzed by SPSS-17 software with chi-square test.

Results:
A total of 58 patients (Mean ± SD: 52.52 ± 10.58) (F: 45, Mean ± SD:53.13 ± 11.27 years, M:13, Mean ± SD: 50.38 ± 9.43 years) were included in the study. The most common sites for the face-lifting surgery were midface and mandibular (N = 45, 77.5%), neck (N = 10, 17.3%), and nose (N = 3, 5.2%), respectively. The level of satisfaction remained unchanged (after 6 months), about 80%, for the patients, increased from 90.7% (first week) to 94.8% (sixth month) after surgery, and increased from 93.1% (first week) to 94.8% (sixth month after surgery). The highest rate of potential complications after the surgery was related to ecchymosis (17 cases, 30%), followed by complications of pain (N = 10, 17.2%), tumefaction (N = 4, 6.9%), and dimple (N = 1, 1.7%) were reported.

Conclusion:
The results showed that satisfaction in patients and surgeons increased over time (after 6 months). Postoperative (minor) complications were also assessed and ecchymosis was found to be the most common complication. However, the proportion of postoperative complications was relatively low.

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INTRODUCTION

As we get older, our facial soft tissue changes and becoming loose. In aging process, connective tissue of the skin becomes thinner and elastic fibers undergo a collapse. The most influenced parts are mandibular area, cheeks, eyebrows, and neck. In aging process, connective tissue of the skin becomes thinner and elastic fibers undergo a collapse. This dermatochalasis of the facial soft tissues is cause of distinctive aging signs of the face and neck. Some of aging signs are as follows: loose facial skin, sagging cheeks, excess skin hanging from the lower jawline, excess fat in the neck, and platysmal bands visible in the neck.

A substantial amount of cosmetic surgeries, especially facelift and neck lift surgeries, are performed every year around the world. Based on International Society of Aesthetic Plastic sur gery (ISAPS) reports, five countries including the United States, Brazil, Japan, Italy, and Mexico have the highest rates of cosmetic (aggressive and less aggressive) surgeries. Due to these reports, 41.1% of the total plastic surgeries in the world performed in these five countries.

Increased demand for rejuvenation of the aging face leads to evolution of various plastic surgery techniques. Surgeons and patients are seeking less invasive techniques, minimal complications, rapid patient recovery, ease of application to plastic surgery, and quicker functioning time. Thread lifting is a preferred substitute for surgical lifting. Based on the material that makes up the suture and filling threads, thread materials may be classified as absorbable or nonabsorbable. The main advantage of using insoluble threads is their long-lasting effect, although clinical studies on this advantage are scarce. The advantage of using soluble threads made of caprolactone or polydioxanone is that the complications are expected less frequently, especially from the viewpoint of long-term prognosis.

The APTOS threads are manufactured by the APTOS Company (Germany), and it is of the barbed absorbable kind. These threads are divided into different types based on the length, type and caliber of the thread, needle or cannula, and the caliber of the thread and cannula. In this study, we aimed to evaluate the surgical efficacy and outcomes related to midface (zygomatic-malar), mandible, neck (and double chin), and nose lifting with APTOS thread lift.

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METHODS

In this prospective chart review study, a total of 58 patients who were candidates for lifting surgery were included in the study from July 2018 to July 2019. All procedures were performed at a skin and beauty clinic, Tehran, Iran, and a Skin Clinic in Tabriz, Iran. The ethical and research deputy of these clinics approved the study protocol. Informed consent was obtained from all individual participants included in the study. The selected patients had prominent nasolabial fold (NLF), slightly defined mandibular contour, and relaxed neck and chin with multiple skin folds, three participants were candidates for nose tip elevation lifting. During the study based on participant's requests and demands and surgeon experiences, patients were randomly divided into three groups, namely, midface (zygomaticmalar)—mandible, neck (neck and double chin), and nose. The study was conducted to evaluate the outcomes, effectiveness, and safety of thread lifting for head and neck. In this study, thread lifting techniques were performed by different types of APTOS threads. Based on the availability of materials at the time of the surgery, we used different types of visage excellence threads and light lift thread 2G (LLT2G).

The APTOS threads are manufactured by the APTOS Company, and it is of the barbed absorbable kind. These threads are divided into different types based on the length, type and caliber of the thread, needle or cannula, and the caliber of the thread and cannula (Figures 1-4). Visage Excellence is P (LA/CL) thread with barbs USP2/0,EP 3, in classic type (Figures 1 and 2); the length of thread is 190 mm and the caliber of cannula is 20 G and the length of cannula is 150 mm, in soft type (Figure 2); the length of cannula and thread is 100 mm and for Nano type (Figure 3); the length of thread and cannula is 70 mm and the caliber of cannula is 22 G. In LLT2G (Figure 4), the length of thread is 250 mm with two triangle cutting needles GS1, 0X110 mm, straight. Before thread lifting, all patients underwent routine examinations and photographic evaluation.
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Treatment protocol

To modify the nasolabial folds, marionette lines and jowls in the midface-mandibular region, the location of threads will first be determined in two triangles (Figures 5 and 6). The upper triangle's vertex is at the intersection of zygomatic arch and hairline, and its base is between points 3 and 4, as shown in Figures 5 and 6. Point 4 is at the outer edge of the nasolabial fold in the Ala of the nose, and point 3 is approximately defined at the midpoint between the Jaw angle and Chin. The second triangle is defined between points 2 and 3 and the corner of the mouth, where point 2 is at the lower edge of the zygomatic arch and a centimeter in front of the Tragus. To lift in area of the triangle 1-3-4, two classic visages and two soft visages were used and for lifting in the lower triangle according to the soft tissue and its slack needle LLT2G used for heavier and slacker tissue and for lighter texture with less slack, two classic visages were used.

According to Figures 5 and 6, first in the entry points 1 and 2 after injection of anesthetic injection with needle no.18 caliber created and then with cannula 22G lidocaine solution 1% will be injected in specified directions. First classic visage from point 1 to point 3 is inserted into the hypodermis, and point 3 is fixed by the surgeon's finger, and cannula is retracted, and the tip of cannula is retracted up to one centimeter out of place and then anteriorly an chored until the cannula's tip reaches point A and after fixing the thread eventually pulls the cannula to exit from point 1. The second classic visage thread, after entering point 1, directs the cannula tip to point B. After fixing thread, the cannula's tip pulled back, then the cannula's tip is redirected to point C and then the canuula's tip is pulled back to final exit from point 1. The first soft visage thread from point 1 enters the cannula's tip directed to D and threaded into D area and then retracted to 1 cm at point 1 and then directed to point E and retracted after fixing to exit from point 1. The second thread of soft visage is inserted and, as described above, after fixing the thread at points F and 4, the cannula's tip will be pulled out of the number one entry, respectively

For the second hypothetical triangle area, if the soft tissue is heavy and the skin has a high degree of skin slacking a double nee- dle thread (LLT2G) is used. The point of entry will be point 2 and the point of exit will be points A and C. The inlet and outlet points will first be anesthetized by injection of the anesthetic agent, and then, the needles will be coupled to entry point 2 and the upper needle will be directed to point C and the lower needle to point A (Figure 5). Both needles will be removed from the above points, and the threads will be cut off from the surface of the skin. In the case of soft tissue, two soft visages will be used (Figure 6). The first thread is inserted from entry point 2, and the cannula's tip is pushed to point A, and after fixing the thread, cannula is pulled back to 1 cm from exit 2 and then pushed to point B and after fixing the thread; cannula is retracted toward outlet 2 for final exit. The second thread enters from entry 2 and cannula is pushed to point C after fixing the thread at point C; cannula is pulled back to 1 cm from entry 2 after fixing the thread at point D; cannula will be pulled back toward point 2 for the final exit of the cannula tip.

In the neck lifting, if the purpose of lifting is double chin, Nano Visage will use (Figure 7); first, the entry points 1 and 2 are positioned at the midline between the Jaw angle and Chin, and on the midline of the neck, one centimeter of the lower edge of chin and 1 cm above Adam's Apple are designated as A and G points, respectively, and the region between A and G is divided into 6 equal parts. First, the anesthesia injected slightly into points 1 and 2 and incision created by needle no. 18 then by caliber 23 cannula, lidocaine 1% infiltrated. The first Nano Visage will be entered from point 1 the tip of the cannula pushed to point G after fixing, the cannula's tip pulled back to 1 centimeter from point 1 and then redirected to the point F and after fixing the thread, it pulled back for final exit. The second Nano Visage enters from point 1, The tip of cannula will be directed to point E and D and the third Nano Visage will first be directed to point C then to B. On the other side, the first Nano Visage to point F then E and the second Nano visage will enter from point 2 directed to points D and then C and the third Nano Visage after entering from point 2 will be redirected to point B and then A.

The lateral side of the neck lifting (Figures 6 and 9) is indicated by the entry point on the Platysma Auricular ligament (Figure 8). At the midline of the neck, point A is 1 cm behind the edge of the chin and point B is 1 cm above the Adam's apple. Point C and D divide A and B interval into three equal parts. Point 2 is 2 centimeters from B and point 3 is 2 centimeters from C (Figure 9). First, points 1, 2, and 3 are anesthetic by injecting lidocaine and after creating incision with needle no.18, lidocaine 1% was injected by cannula 22 between points 1, 2 and 3, and then 2 needles were inserted in pairs, and the upper needle was directed toward point 2 and the lower needle was directed to point 3 and the needles will be removed from The above points and the thread will be cut off from the surface of the skin.

For nasal tip lift with Nano Visage (Figure 10), first, the nasal tip will be anesthetized with an injection of lidocaine and then by needle no.18 an incision will create on tip of the nose. With cannula 23, lidocaine 1% will be injected between points 1, 2, and 3. The first Nano visage enters from point 1, moves to point 2 and then, after fixing the thread, returns again to 1 centimeter from point 1 and pushed back to point 2 and returns to point 1 for the final exit. The second Nano Visage as explained above put between points 1 and 2. The third Nano Visage travels from point 1 to point 3 and then goes down to point 3 in such a way that the cannula's tip collides with maxilla, sense by the surgeon then the cannula's tip pulled back out of point 1. The fourth Nano Visage as described put between points 1 and 3.
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Outcomes assessment

After surgery, the results were assessed by two surgeon (The sur- geon and independent surgeon) and patients based on the GAIS score (Global Aesthetic Improvement Scale). The patients were followed up first week, third month, and sixth month after lifting; outcomes were evaluated by asking them to rate their overall satisfaction on the following scale: exceptional improvement, very improved patient, improved patient, unaltered patient, and worsened patient (Table 1).
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Statistical analysis

Statistical analyses were performed using SPSS software version 18 for Windows (IBM Inc). To compare response of patients and surgeons satisfaction based on time-points after surgery and their lifting site, we used the chi-square test. Also, to compare side effects after surgery based on sex and lifting location, we used the chisquare test. P values < .05 were considered statistically significant.

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RESULTS

In this study, 58 subjects with mean age of 52.52 ± 10.58 years were included. Of 58 individuals, 45 were female (mean age 53.13 ± 11.27 years) and 13 were male (mean age 50.38 ± 9.43 years). The youngest was 30 years, and the oldest was 76 years (Table 2). The most common location performs the lifting operation in this study was midface and mandibular (n = 45, 77.5%), neck (n = 10, 17.3%), and nose (n = 3, 5.2%), respectively (Table 3). Table 4 summarizes the satisfaction scores of patients and surgeons at different times (first week, third month, and sixth month after lifting) based on the GAIS Score (The Global Aesthetic Improvement Scale). Patients' satisfaction (excellent, very good, and good satisfaction) at different times, 1 week, third month, and 6 months after lifting operation were 81% (n = 47), 88.7% (n = 55), and 79.3% (n = 46), respectively. The highest satisfaction was in group I (Improved) in the first week after surgery (42 cases, 72.4%) and the lowest belonged to group VI (Very Improved) (5 cases, 8.6%).

Eleven cases (19%) at this time reported no significant change, and no cases of E and W status were reported among the subjects. In the third month after surgery, the highest level of satisfaction was related to group I (46 cases, 73.2%) and the lowest was in group U (3 cases, 5.3%). At this time, 9 cases (15.5%) were in group VI; no cases of E or W status were reported among the subjects. In the sixth postoperative month, the highest level of satisfaction was in group I (39 cases, 67.2%) and the lowest in group VI (7 cases, 12.1%). Also, 12 cases (20.7%) were in U group and no cases of E or W status were reported among them (Table 4).

Surgeons' satisfaction (excellent, very good, and good) was also evaluated at different time points in the first week, third month, and sixth month postoperatively. Surgeon Satisfaction was 90.7%, 96.6%, and 94.8% in the first week, the third month, and the sixth month postoperatively, respectively. The highest rate in the first week after surgery satisfaction related to group I (30 cases, 51.7%) and lowest satisfaction related to group E (4 cases, 6.4%). Eighteen cases (31%) in group VI and 6 cases in group U and no cases of W were reported in these subjects. In the third month after surgery, the highest and lowest satisfaction was observed in group VI (27 cases, 46.4%) and group U (2 cases, 3.4%). Also, 26 patients (44.8%) in group I and 3 patients (5.3%) were in group E and no cases of W status were reported in these subjects. The sixth month after surgery also showed the highest level of satisfaction in group I (39 cases, 67.2%) and the lowest in group E (2 cases, 3.4%). At this time, 14 patients (24.1%) in group VI and 3 patients (5.2%) were in group U and no cases of W status were reported in these subjects (Table 4).

For independent surgeon, satisfaction was assessed at three time points in the first week, third month, and sixth month after surgery. The first week, third month, and the sixth month postoperation satisfaction were 93.1%, 96.6%, and 94.8%, respectively. The highest and lowest satisfaction in the first week after surgery for surgeon number 2 related to the group I (25 cases, 43.1%) and group U (4 cases, 6.9%). Twenty-two patients (37.9%) were in group VI and 7 patients (12.1%) in group E, and case of W status among subjects was not observed. In the third month after surgery, the highest rate of satisfaction was in group VI, 27 cases (46.6%) and the lowest in group U, 2 cases (3.4%). Seventeen cases (31%) in group I and 11 cases (19%) in group E and no cases were found in group W. In the sixth month after surgery, the highest level of satisfaction was observed in the group VI and I (43.1%) with the lowest level of satisfaction in group U, 3 cases (5.3%). Five cases (8.6%) in group E and none were in W status (Table 4).

Patients' and surgeons' satisfaction in the first week and sixth month after surgery regarding the location of midface and mandibular, neck, and nose lifting were assessed. According to these results, the highest satisfaction of patients and surgeons was observed in mandibular and I (Improved) status. Also, no significant relationship was observed between the rate of postoperative satisfaction and the location of operation at any of the times studied (P > .05) (Table 5).

The possible complications of postoperative lifting were carefully examined by surgeons. According to Table 6, the highest rate of complications occurred ecchymosis (17 cases, 30%), and then, pain (10 cases, 17.2%), tumefaction (4 cases, 6.9%), and dimple (1 case, 1.7%) were reported. Results showed that there was no statistically significant relationship between complications and gender (P > .05). Findings showed that the relationship between complications and location of lifting operation was significant only for ecchymosis (P = .006) and for other types of complications, there was no statistically significant relationship (P > .05).

After surgery, the complications were carefully evaluated by two surgeons and according to the type of complication, medical interventions were done. These interventions included usage of NSAIDs that continued until the patient was completely remedied. The type of interventions performed according to the type of complication is detailed in Table 7.

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DISCUSSION

This study aimed to evaluate the efficacy of facial lifting (face, neck, and nose) with APTOS threads, and 58 candidates were included in the study. At different time points (first week, third month, and sixth month) after surgery, patients' and surgeons' satisfaction (2 surgeons independently) were evaluated based on GAIS Score. Overall, the results showed that satisfaction in patients and surgeons increased over time (after 6 months). Postoperative (minor) complications were also assessed, and ecchymosis was found to be the most common complication. However, the proportion of postoperative complica- tions was relatively low.

Patients' satisfaction was assessed in the first week and sixth month after surgery, and the results showed that patients' satisfaction decreased slightly from 81% (n = 47) in first week to 79.3% (n = 46) in sixth month after surgery. In the first week after surgery, the highest rate of satisfaction was in Group I (Improved) (42 cases, 72.4%) and the lowest in Group VI (Very Improved) (5 cases, 8.6%). In the sixth postoperative month, the highest and lowest satisfaction rates were observed in groups I (39 cases, 67.2%) and VI (7 cases, 12.1%), respectively.

Surgeon satisfaction was also evaluated in week 1 and month 6, and it was found that satisfaction increased with time, from 90.7% in first week to 94.8% in month 6 after surgery. The highest level of satisfaction for surgeon 1 in the first week after surgery was in group I (30 cases, 51.7%) and the lowest in group E (4 cases, 6.4%). Six months after surgery, the highest and lowest satisfaction rates were observed in group I (39 cases, 67.2%) and group E (2 cases, 3.4%, respectively).

Also, satisfaction for independent surgeon in the first week after surgery and 6 months thereafter showed that postoperative satisfaction increased with time so that satisfaction in the first week after surgery was increased from 93.1% in the first week to 94.8% in the sixth month after surgery. The highest level of satisfaction for surgeon number 2 in the first week was in group I (25 cases, 43.1%) and the lowest in group U (4 cases, 6.9%). In the sixth month after surgery, the highest level of satisfaction was in groups VI and I (43.1% each) and the lowest in group U (3 cases, 5.3%).

In a 2017 study by Hyejeong Lee et al, the results showed that out of 35 patients studied, 33 (94.3%) were satisfied with the operation. The highest rate of satisfaction (surgeon's) was in group VI (very much Improved) with 68.6% followed by Much Improved (25.7%) and Improved (5.7%). Patients' satisfaction was 54.3% for Excellent group, 31.4% for Very Good group, 8.6% for Good group, and 5.7% for Fair group. As in our study, no case of Worse was reported.12 Another study was conducted by So-Eun Han et al in 2016 on 20 women candidates for REEBORN thread lifting. Patient satisfaction was assessed using a questionnaire at 6 and 12 months after surgery. Surveys showed that patient satisfaction decreased from 90% in the sixth month after surgery to 80% in the 12th month after surgery. In our study, patients' satisfaction after 6 months also decreased about 2% (compared to the first week after surgery).

A study by Antonella Savoia et al, in 2014 aimed to investigate the consequences of face lifting with Happy Lift. In this study, 37 people were included in the study. Results of the patients' satisfaction after surgery showed that out of 37 patients, 33 (89%) were satisfied with their outcome, out of which 65% were in Excellent group, 24% in Good group and 11% Of people were dissatisfied with the outcome of their operation. However, in our study, none of the subjects in the study were in the unhappy group at any of the time points (first week, third month, and sixth month).14 In another study by Khrustaleva et al, 2015, patient satisfaction was assessed 1 year after surgery. In this study, patients were divided into two groups according to Backer criteria. Satisfaction was 91% in the first group (with low age changes) and 86% in the second group (with high age changes).15 A study by Kang SH et al (2017) found that 89.7% of those surveyed were completely satisfied with their outcome. Postoperative satisfaction was also evaluated by two surgeons at 6 months postoperatively. Results showed that 10.3% had excellent satisfaction, 43.6% had very good satisfaction and 33.3% had good satisfaction.16 In a previous study by this author (Rezaee), the rate of patients' satisfaction after surgery was evaluated at different times (first week, first month, third month, and sixth month after surgery). The patient's satisfaction rate was 94% in the first week to 99% in the sixth month, the satisfaction of the first surgeon was 94% to 99%, and for the second surgeon it was 83% in the first week and 98% in the sixth month. The study is also in line with the new study.

In the present study, patients' and surgeons' satisfaction in the first week and sixth month after surgery were evaluated according to the region of the lifting (midface and mandibular, neck, and nose). According to these results, the highest satisfaction of patients and surgeons was reported at the time of study at mandibular and mandibular sites. There was no statistically significant relationship between the rate of postoperative satisfaction and the region of operation at any time. In the previous study (Rezaee et al), the highest level of satisfaction was observed between the patients and surgeons at the time of study in the Jawline area, and only for surgeon No. 1, there was a significant statistical relationship between the site of lifting and satisfaction.

Another study was conducted by Rezaee et al In 2019, the study enrolled 151 patients between 2016 and 2017, and the results showed that patient and surgeon satisfaction increased over time. Patients' satisfaction increased from 77.5% in the first week after surgery to 89.4% in the sixth month. For surgeon number one, rates of satisfaction in the end of first week and six month, were 96% (unchanged).

As the same as this study (present study), the highest rate of operative satisfaction was reported in mandibular area and only for surgeon number 2 and in the first week there was a statistically significant relationship between satisfaction with the region of lifting and at other times no statistically significant association was found.

In this study, the possible complications of postoperative lifting were investigated by surgeons. No serious postoperative complications were reported in any of the subjects, and in some cases, minor complications were reported. The most common complications reported after surgery were ecchymosis, pain, tumefaction, and dimple, respectively. Also, there was no significant relationship between complications and gender of the subjects. Regarding the relationship between the complications and the site of lifting, the studies showed that this relationship is significant only for ecchymosis and in other types of complications there is no significant statistical relationship. In a 2009 study by Patrick B. et al, The most common postoperative complications were swelling, ecchymosis, infection, and palpable threads.17 The results of this study showed that in 64.8% of individuals at least one of the above-mentioned complications was observed. The most common complication according to the results of this study was ecchymosis (40.3%) which is consistent with our study results. However, in our study only about 30% of people developed ecchymosis. Another study was conducted in 2017 by Mototsugu Fukaya et al The most important postoperative complications in this study were ecchymosis, local infection, and palpable sensation. It has also been noted that postoperative ecchymosis disappeared spontaneously within a few weeks without any treatment and lifting thread was removed from the operative position in cases of infection. In our study, NSAIDs were used to relieve the side effects that were completely eliminated shortly after taking the drug.8

In the 2017 study by Hyejeong Lee et al, the most important postoperative complications were mild swelling (45.7%), bruising (31.4%), dimple (8.5%), and asymmetry (2.8%). Dimple was observed in only one case (1.7%) in our study.12 Another study by Sarigul Guduk S and his colleague in 2018 showed that dimple, ecchymosis, and pain, respectively were the most common complications after surgery. In this study, dimple was identified as the most common postoperative complication, but in our study dimple was the least postoperative complication, so it was not consistent with the results of our study.18 In a study previously conducted by Rezaee et al, in 2018, it was found that the highest rate of complications was related to ecchymosis (79 cases, 40.9%) followed by dimple (55 cases, 28.5%), tumefaction (35 cases, 18.1%), and pain (10 cases, 5.2%), respectively.

These results were in line with the results of this study in terms of the possible postoperative complications. The only difference was in the frequency of complications, as in the previous study, dimple was the second most com- mon complication after surgery, but dimple in this study was the least reported complication after surgery. The results also indicate that there is a significant relationship between the complications (ecchymosis and dimple) and gender. However, it was found in this study that there was no statistically significant relationship between the complications and the gender of the subjects, which is not in line with the results of mentioned study. Other similar studies have not examined such evidence of the association between complications and the gender of the study subjects.

In the present study, the relationship between the complications and the site of lifting was also shown to be significant only for ecchymosis, and there was no statistically significant relationship between other types of complications. In a study previously developed by Rezaee et al (2019), it was found that there was no significant relationship between postoperative complications and site of lifting, which was not in line with the results of this study. In this study, postoperative complications were evaluated by two surgeons and due to the type of complication, therapeutic interventions were performed on patients. These interventions included the use of NSAIDs that continued until patients recovered completely.

In a study by Savoia et al (2014), techniques such as cold water compression or topical surgery were used to resolve the complication. People with tumefaction also treated with NSAIDs.6 The results of our assessments show that postoperative complications in this study are lower than other studies, including previous studies by this author. Also, therapeutic interventions for elimination of possible complications in this study were less than other studies.

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CONCLUSION

The results showed that satisfaction in patients and surgeons increased over time (after 6 months). Postoperative (minor) complications were also assessed, and ecchymosis was found to be the most common complication. However, the proportion of postoperative complications was relatively low. These results demonstrated that facial rejuvenation thread lifting with APTOS is effectiveness, safe, and cosmetically more acceptance with minor complications than other face-lifting techniques.