Not one week goes by when I don’t see a new patient who wants “a bit of a lift” to sagging tissue and believes threadlifts (not mono threads) with either barbs or cones that temporarily reposition sagging tissues, are the solution. The vast majority of the time over the last few years on assessment they’ve not been suitable candidates and I’ve encouraged them to consider actual plastic surgery if it is enough of an issue or to consider other non surgical and minimally invasive options to address their concerns as part of a holistic plan to age well.  I briefly offered threadlifts some years ago, buoyed by the hype around it and frequent patient requests as well as posts by influencers about their own results.  Disappoitingly I found that for the spend ($3500-4500 on average for enough threads to do a good job), the results were disappointing - the lift lasted mere weeks; as early as 2-3 months tissue was back to where it belonged due to gravity. Any collagen induced takes weeks to months to form, and there are better options for collagen induction on the market all the time that were far more reliable and less risky.  More importantly, when I scour the database on evidence, I’m hard pressed to find any reliable source for good results beyond 6 months, if even that. Due to marketing trickery, many were having threadlifts, and posting their before and immediately after results but surprisingly silent on results at 3, 6, even 12 months.  If we were honest with people, as we are with anti wrinkle treatments for example, whereby we know results only last 3-4 months at best, they could truly make an informed decision about whether the spend is worth it, but we are often told by companies results last upto 18-24 months, which means in theory, we should have great results to showcase at these timeframes by the companies and providers - there’s none that exists to my knowledge.  It wasn’t until I began my skin cancer work in ernest, including skincancer surgery on the face, that it clicked for me. The material used in threads is similar to that used in suturing to close wounds. These materials hold the wound together for a few weeks, and then gradually lose their holding strength and are gradually absorbed by the body and removed. So the “lift” logically, would only last a few weeks, and the rest would be dependent on the collagen induced to support tissue.  Further, during skin cancer surgery, when we sometimes don’t remove enough of the tissue with cancer in it, I advise patients to wait around 3 months to allow skin to stretch and settle before we go back for another round of excision ie skin stretches (which makes sense- think of how it stretches to accomodate pregnancy, weight gain, and then deflates with weight loss) - so how on earth, with only threads to “lift” tissue to reposition them, would we expect them to last? We would not.  And here’s the clincher - there are easier, safer and more reliable ways to induce collagen that are less involved. Biostimulatory fillers as well as skin therapies such as laser genesis, chemical peels and radiofrequency  microneedling as well as add-ons such as the humble LED light, all work by inducing collagen over a series of treatments. The collagen gradually produced subtly adds volume to the skin, and that shiny, dewy glow but it DOES NOT LIFT.  So where’s the lie?  For these and other reasons - including the fact that in order for threads to even look good and to work, you need decent skin quality that is not too thin and not too heavy/ saggy as the threads only allow around 1-2cm of lift before breaking- I largely stopped offering threadlifts despite having had it twice myself with reasonable results. I simply could not justify the cost for the results for the demographic I was seeing - women in their 40s and 50s with significant volume loss and sagging, often significantly sundamaged skin whereas the only group that can be expected to have possibly decent results, are around a decade younger, when there’s hardly any sag, and it’s more of a preventive treatment.  The closest article I could find that discussed results, admittedly old (2009) in a small sample size  was here “Thirty-three patients underwent a thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Ten patients underwent thread-lifts only, and 23 had thread-lifts with other procedures. Ten additional patients having had non-thread-lift rejuvenation procedures, including lipotransfer, chemical peels, and rhytidectomies, were randomly designated as controls. The mean follow-up period was 21 months (range, 12-31 months). Photodocumentation was obtained at each visit. Although aesthetic improvement was noted in all groups at 1 month, measurable results persisted to the end of the study for all but the group that underwent the thread-lift procedure only. Aesthetic improvement scores of the non-thread-lift control group were better than the group that underwent thread-lift only. Similarly, when the thread-lift was combined with other procedures, scores were better than when thread-lift was used alone. Statistical significance was demonstrated in both of these comparisons (P < .01).” So what are the alternatives?  When I’m consulting with patients my key goal is to understand their concerns, and what they hope to gain from (any) treatment as well as how realistic they are about the degree of their own commitment to the process as these are the factors that will ultimately determine success.  If sagging is their primary concern, then if they are willing and able, I’d suggest plastic surgery as there is no comparable alternative at present. For everything else - sundamage, lines and wrinkles, volume loss, pigmentation, textural issues, collagen induction, excess fatty pockets there are non surgical and minimally invasive options available, but not significant and lasting lifting.  As with all medical aesthetics, my goal and aim in writing this is to inform

Earlier this week there was a post by a journalist Jolene Edgar who writes on all things medical aesthetics, about the effects of non surgical procedures on future face/neck lifts and a forum which has plastic surgeons weighing in on their experience of this.  Here's what she said  "Interesting discussion over the weekend on the topic of nonsurgical treatments (like certain energy based devices, threads and injections) complicating facelift surgery by creating scar tissue, fusing natural tissue planes, obscuring landmarks that guide dissection and so forth. As with nearly every topic in aesthetics, there's debate surrounding these claims - debate over which nonsurgical treatments are the worst offenders, how much damage they actually do, and what the repercussions of said damage may be (increased risk of nerve injury during a facelift, a less-than-ideal cosmetic outcome, longer/tougher recovery).  And as some pointed out, surgery itself is the ultimate scar maker and can therefore compromise the results of any nonsurgical treatments that may follow facial surgery."  As expected, there was a wide variety of opinions, from uber conservative surgeons who actively dissuade everyone from non surgical aesthetics in favour of surgery “at any age” and as young as their 20s, to surgeons who were more balanced in their view that given that face/neck lift and associated plethora of procedures costs upwards of $50,000 and easily much more ($100k and upwards) if we add in fat transfer, eye surgery, brow lifts and more, that this is not something most people will be able to budget for or afford, and as such it behoves  all of us to be more cautious about our recommendations of non surgical and minimally invasive procedures including steering patients away from certain procedures that are notorious for poor results on the table and post surgery, notably, Ulthera, Thermage, HIFU and similar options as well as arguably, threads.  For me, watching and commenting where able, it was an interesting insight into what I see over and over in the field of medical aesthetics, which, without the fence of sound and evidence based medical scaffolding, can often seem very much like the Wild Wild West - since this is a very new field, and fueled by want rather than need and since health care workers are only human, with little to no basic understanding of business (we are not taught that in medical school) it's no surprise that some of us fall into unethical and questionable practices with the lure of big bucks.  It is a big part of why I work the way I do. When I began, like many others, I began in a chain clinic and very quickly learnt how I did NOT want to work. Opening my own practice even pre Covid was a big risk, but it aligned with my ethical and moral values as a doctor who wanted longterm patient centered care that focused on longterm goals and realistic expectations, as opposed to on-demand, quick fixes that ultimately did not fix much at all.  So, as someone who was a trainee in a surgical field between 2002-2011 and is now a Fellow of the College of GPs, and has been doing procedural work for most of my career, what are my thoughts and experiences based on aesthetic work since 2016 since I do non surgical and minimally invasive surgical work in my rooms including FaceTite and skin cancer surgery?  these concerns are not new, but they are newly being discussed which can only be a good thing. It is a big part of why I have never offered, nor seriously ever been tempted to offer, certain energy based devices such as Ulthera, HIFU and Thermage. Aside from scant evidence suggesting they are highly operator dependent for results, and results only lasting around 6 months, I worry about the crude methods used to provide "lift" and what layers are being destroyed in the process. It would seem some of my concerns based on theory and logic, are possibly true.  in my experience, biostimulatory fillers that work by triggering collagen through inflammation, do not have quite the same effects for two main reasons - the filler is usually placed far more superficially, just below the skin, unlike the layers that surgeons usually work for deep plane surgery. Additionally, in my experience, since biostimulatory fillers need an initial course of treatments followed by annual maintenance, I've had the opportunity to revisit skin I've treated over the years and have not found any significant degree of scarring when I've done so. In saying that, anytime the skin is penetrated by sharp objects, there is the potential for scarring.  I love radiofrequency (RF) microneedling as well as its corollary, RF Assisted Lipolysis aka FaceTite and AccuTite for small pockets of fact and collagen induction and to date, have not found it induces any appreciable degree of scarring or access issues for other procedures.  a popular fat dissolving injection on the other hand, does cause significant scarring, and on the rare occasions when I've performed FaceTite following fat dissolving injections, it has been hard going and tough work which has led me to be far more selective about who might be suitable for these injections and where eg bra fat, back fat, fat pad over the neck as opposed to double chin etc especially if they are open to the idea of FaceTite or surgery at some later stage.  Obviously opinions and experiences are like noses in that everyone has one and barring a scientific trial, there's not much to be said except that this is one person's experience.  It does however, inform me in terms of what procedures I am more and less likely to do and to offer my patients, especially if they are likely to be open to the idea of surgery down the track because as always, the first adage ought to be, "First do no harm".  For these and many other reasons I believe it is so important to have a comprehensive consultation when you