Replenishing the volume of the middle third of the face

Thread lifting at a young age is an excellent preventive measure for gravitational ptosis. Correction and tissue replenishment occur using one's own tissues, eliminating the need for additional fillers.

Currently, we can offer an incredibly large number of procedures for both the prevention of tissue ptosis and the correction of existing changes. In this clinical case, my choice is SoftLift threads (PLA-PCL absorbable threads: 80% PLA, 20% PCL).

Thread lifting, like any invasive procedure, is prescribed by a doctor based on clinical manifestations of gravitational ptosis. The indications for thread lifting include the formation of nasolacrimal and nasolabial folds, the sagging of mouth corners, and changes in facial contour.

The task of a cosmetologist in combating gravitational ptosis is lifting, raising soft tissues, returning them to their original position, and fixation. All these points are possible only with the thread lifting technique.

A. E. Belousov classified gravitational signs by facial zones. Cheek ptosis is determined by the clarity of the lower jawline.

1. Initial: no noticeable cheek tissue drooping.
2. Moderate: noticeable relaxation of tissues, double contour of the cheek.
3. Significant: pronounced "jowls" do not extend to the neck.
4. Extreme: pronounced "jowls" extending to the neck.

The patient in my clinical example belongs to the first stage of gravitational ptosis according to this classification. In cosmetic practice, prevention is a top priority, so young and middle-aged patients with the first and second stages of gravitational ptosis are the most appropriate choice for correction and guarantee high satisfaction with the results.

Therefore, the goal is maximum tightening, lifting of sagging tissues, and returning them to their original position. To achieve this, I have chosen threads made of polylactic acid (PLA). They have micro notches that hold the soft tissues, can withstand up to six kg, which demonstrates their fixation, strength, long-lasting effect, and have a lifting-reinforcing effect. They do not cause allergic reactions and provide an effect for up to seven years.

The placement patterns of threads on two guiding needles vary and have been practiced in plastic surgery and cosmetology for a long time. For the patient, a "simple pattern" was chosen, taking into account her young age. A thread will be implanted from one insertion point along two vectors with additional tension, and the fixation point will be the insertion point.

When placing the threads, it is necessary to observe the following points:

• carefully mark the area,
• observe all aseptic rules,
• administer anesthesia to the patient,
• accurately insert the threads based on the previous markings on each side,
• and strictly maintain the depth of insertion along the entire length of the needle - subcutaneously in the subcutaneous fatty tissue, without affecting the dermis or delving into the muscle layer.

Markup should be done sitting down, using a ruler, following the lines clearly, and selecting puncture points. In my practice, I use vectors starting from the hairy part of the head, so the threads are attached to a less mobile area ^[Fig.1].

For safety purposes, the puncture area is carefully shaved. Then, an infiltration anesthesia is performed along the specified vector. The puncture is made on a skin surface that has been treated twice with a skin antiseptic and a larger diameter needle ^{[Fig. 2]}.

The prepared SoftLift threads (PLA-PCL) are carefully extracted from a paper case ^{[Fig. 3]}. First, we introduce one needle along the upper vector ^{[Fig. 4]}, exiting at a specified point (without entering the projection of the circular muscle of the mouth), strictly upward from the depth of insertion. The vector is directed toward the nasolabial fold. We guide the second needle along the lower vector ^{[Fig. 5]}, exiting according to the same principle. The direction of the vector is towards the "sad folds" (marionette lines).

The prepared SoftLift threads (PLA-PCL) are carefully extracted from a paper case ^{[Fig. 3]}. First, we introduce one needle along the upper vector ^{[Fig. 4]}, exiting at a specified point (without entering the projection of the circular muscle of the mouth), strictly upward from the depth of insertion. The vector is directed toward the nasolabial fold. We guide the second needle along the lower vector ^{[Fig. 5]}, exiting according to the same principle. The direction of the vector is towards the "sad folds" (marionette lines).

Anatomical insertion depth:

• Superficial temporal fat pad
• Lateral temporal-cheek fat compartment
• Medial buccal compartment
• Mid-cheek fat compartment
• Nasolabial fat compartment

It is important to consider the vascular channel and nerves. The thread passes through the transverse facial vein, zygomatic vein, wing-nasal part of the superior alveolar artery, zygomaticofacial nerve, infraorbital artery, and nerve (CN V2).

I evenly distribute the thread in each vector, pulling from each needle exit point to the desired length, carefully rotating at the thread bending point of insertion, burying it, and starting to tighten the loose ends. I twist it like a comma. When tightening the loose ends of the thread, I support the point of insertion for control. After tightening, I use sterile scissors to trim the loose ends, burying the blade in the skin and not leaving the thread end at the skin level.

With this simple technique, we corrected the middle and lower thirds of the face. SoftLift threads (PLA-PCL), thanks to the material density, provide tight fixation and satisfactory results even with such a simple technique.