Mid-Face Thread Lift

What is a mid-face thread lift?

A mid-face thread lift repositions soft tissue that has dropped in the cheek and cheekbone area, moving it upwards with barbed threads placed under the skin. In a thread lift, barbed threads are placed along pre-planned lines and lift the face’s superficial layer of muscle and connective tissue, the SMAS (superficial musculoaponeurotic system). A mid-face thread lift is this method applied to the cheek area. Unlike a surgical facelift, it usually needs no surgical incision, and no skin is removed.

In one study of the mid-face, the treatment targeted the deep medial cheek fat and the inner layer of the SMAS; the threads were anchored to the periosteum (the membrane covering the bone) at the outer rim of the eye socket, and the soft tissue was suspended upwards. This was the technique used in a single study; it should not be seen as the only correct approach. According to a review of the anatomy of this area, threads should be placed taking into account the paths of blood vessels and nerves, the fat compartments (fat pads) and the retaining ligaments.

The clinic uses dissolvable threads (PLLA/PDO). At the clinic, ‘thread lift’ is the general name for lifting treatments done with threads; the French Thread Lift is one of the techniques within these methods. A mid-face thread lift is the version of these treatments aimed at the cheek and cheekbone area.

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Where is the mid-face, and what changes over time?

The mid-face is, roughly, the cheekbone and cheek area between the under-eye area and the corners of the mouth. With age, both the position and the amount of tissue in this area change. A thread lift addresses only one of these two changes: the position of the tissue. This is why you need to understand how the area is built before considering a thread lift.

The tissue often referred to as a single cheek fat pad is actually made up of separate compartments. A cadaver study found that the inner, middle and outer (temporal-cheek) compartments are separate units, and that the fat where the nasolabial fold lies is also a separate compartment with its own boundaries. According to this study, the face does not age as a single mass; shifting between neighbouring compartments can contribute to tissue moving out of place.

Imaging studies have measured what changes with age. A study using computed tomography (CT) found that, in the older age group, the mid-face fat compartments sat further from the lower rim of the eye socket and the volume within the compartments had shifted towards their lower part; volume loss in the deep medial cheek fat was also reported separately. Magnetic resonance imaging (MRI) scans of the same people taken years apart also showed a decrease in the volume and thickness of the superficial mid-face fat, with the upper and middle compartments shrinking while the lower compartment expanded.

Nor do all the compartments move to the same extent. An ultrasound study found that, when smiling, the superficial mid-face compartments moved upwards by an average of 3.7 mm, while the deep compartments showed no similar shift. In other words, the mid-face has a superficial layer that shifts and a deep layer that stays more fixed.

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Retaining ligaments: the structures that hold tissue in place

The soft tissue of the mid-face is held in place by retaining ligaments that run from the bone to the skin. The loosening of these ligaments with age is one of the factors that cause sagging. What a thread lift can do, and how long its effect lasts, also depends largely on this structure, because the thread works within this ligament system.

Research shows that age-related loosening of these ligaments contributes to sagging, jowls (sagging along the jawline) and volume moving downwards. In a cadaver study of the ligament in the cheekbone area, tissue examination showed that this ligament is a dense, collagen-rich band running from the periosteum (the membrane covering the bone) to the skin; it was described as a constant anatomical landmark, independent of facial proportions.

A detailed anatomical study showed that the well-known retaining ligaments are in fact reinforced parts of a widespread system of small supporting fibres. These fibres support the tissue against gravity while still allowing a certain amount of movement. The same researchers list the thread lift among the methods that lift tissue without separating it from the surrounding ligaments (without releasing it). In these methods, the way the fibres hold the tissue against gravity changes, and the weight of the lifted tissue rests only on the point where the thread is anchored. According to the researchers, this limits how long the lift lasts.

Reviews of thread lift anatomy consider it important to take the retaining ligaments into account for a lift that can last without distorting the tissue. Where the ligaments lie and where the thread will grip are part of the planning.

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Sagging or volume loss?

Some of what looks like sagging in the mirror may be caused not by mid-face tissue dropping but by tissue being lost. A thread lift moves displaced tissue upwards; it does not replace lost tissue. This is why the two need to be told apart before treatment: a thread lift used for the wrong problem will not give the expected result.

This distinction has a history. Thinking about facial ageing has moved from explaining it by gravity alone to an approach that also takes changes in volume into account. A key step in this shift was showing that facial fat is made up of compartments with defined boundaries. Growing interest in volume treatments planned compartment by compartment is also linked to this change.

A cadaver study that described the deep medial cheek fat gives this a name: pseudoptosis (‘false sagging’). When the volume of this fat compartment decreases, the overlying skin becomes relatively excessive and the nasolabial folds look more pronounced, even though the tissue has not dropped. According to the researchers, supporting this compartment increases the forward projection of the cheek; repositioning the tissue only sideways does not have this effect.

Researchers who measured the movement of the mid-face compartments by ultrasound also recommend giving volume support to the deep compartments in the deep plane, just above the bone. These findings suggest that volume loss calls for volumising methods, not a thread lift. Cheek Filler and the Liquid Facelift with Collagen Stimulators are methods of this kind; you can find details on their own pages. Both conditions can be present in the same face; which one is dominant is determined at a consultation.

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How does a lifting thread work in the mid-face?

A barbed thread grips the tissue under the skin and lifts it upwards along the line of the thread. In the mid-face, this means holding cheek tissue that has dropped in a higher position. The effect is mechanical: which tissue layer the thread passes through, which direction it pulls in and where it is anchored are planned on the basis of an anatomical assessment.

In a study of 143 people that compared photographs taken sitting up and lying down, soft tissue shift between the two positions was significantly smaller in the group that had had a thread lift than in the group that had not. This result suggests that a thread lift may limit tissue sliding downwards under gravity. However, the study did not follow the same people before and after treatment; it compared different groups. Its measurements also covered the face as a whole, not the mid-face specifically. The researchers also stress the importance of assessing laxity in a sitting position.

Studies of dissolvable threads suggest that the threads both give an immediate lift and stimulate production of collagen, a protein that supports the structure of the skin. Evidence is limited on how long this second effect lasts and how far it shows in your appearance. When research on barbed threads is considered as a whole, side effects appear to be fewer with dissolvable threads, but long-term effectiveness is still uncertain.

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How strong is the evidence for a mid-face thread lift?

The short answer: limited. Studies specific to the mid-face have included few people and were mostly done without a comparison group. Results also vary from study to study: in one case series the effect decreased markedly towards the end of the first year, while in another study the improvement lasted up to six months. This does not mean the method does not work; it shows what you can base your expectations on.

In a case series that followed 64 women who had a thread lift in the mid-face, patient satisfaction, scored out of five, averaged 4.7 at one month but fell to 2.8 at one year. The doctors’ score for the vertical position of the top of the cheekbone also fell from 4.5 to 3.1; this scoring was done by blinded assessment so that it would be impartial. The researchers state that results were satisfactory for at least six months; however, the same data also show that the effect decreased markedly towards the end of the first year.

In a prospective study (one in which participants were followed according to a plan made in advance), 30 women had dissolvable barbed threads placed in the mid-face, and their wrinkle severity scores decreased significantly up to six months. This study measured wrinkle severity and overall improvement in appearance, and did not follow participants beyond six months. The researchers themselves note that they could not make comparisons with other types of thread, and that knowledge in this area comes largely from retrospective studies (which review past records) or individual case reports.

In an older study with blinded assessment, the improvement seen at one month in the group that had a thread lift alone was not maintained until the end of the study. The researchers stated that the short-term improvement may have been largely due to post-procedure swelling (oedema) and an inflammatory response. This study dates from the early days of the method and covered several areas of the face together. Since then, permanent (non-absorbable) threads have been replaced by dissolvable threads; however, according to a more recent review, although the method looks promising, no new evidence supporting its use has been added.

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The mid-face and the nasolabial folds

Mid-face sagging is associated with deepening of the nasolabial folds. However, these folds do not have a single cause, and a thread lift addresses only one of those causes. The folds can be deepened by cheek tissue dropping, but also by volume loss in the deep cheek fat.

A study describing the mid-face thread lift lists sagging of the cheek tissue, deepening of the nasolabial folds and reduced light reflection at the top of the cheekbones among the typical features of facial ageing. On the other hand, according to a study of the deep medial cheek fat, volume loss in this compartment can make the folds look more pronounced even without the tissue dropping.

Even in surgery, this area has its own particular difficulty. An anatomical and mechanical testing study showed that, in a composite surgical technique that lifts the mid-cheek, the pulling force is carried by the skin, not by the fat pad over the nasolabial fold, even when the stitch is placed directly in that fat pad. The researchers attribute the early return of the folds after surgery, as the skin loosens, to this. For a longer-lasting correction, they recommend researching methods that target this fat pad, possibly combined with restoring fat and bone volume.

This finding relates to a surgical procedure and cannot be applied directly to a thread lift. But it does show that the nasolabial folds are not a problem solved by lifting alone. Whether sagging, volume loss or both lie behind the folds is determined at a consultation.

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When a thread lift and volume support are considered together

Because sagging and volume loss can occur together in the mid-face, there are also studies in which a thread lift was combined with volumising treatments. However, the evidence on this so far comes only from small pilot studies, and combining the two methods has not been shown to be better than using either one alone.

In a single-centre pilot study, 11 people with mid-face volume loss were treated with hyaluronic acid (HA) filler combined with dissolvable barbed threads and followed for 24 months. Three-dimensional measurements showed a significant reduction in mid-face width, and both participants and researchers reported improvement in their assessments. The researchers state that these results need to be confirmed in different populations and compared with other methods.

With few participants and no comparison group, this study does not show whether the combination is better than a thread lift alone or filler alone. Which methods are considered, and whether they are used in sequence or together, is decided at a consultation based on which condition is dominant in your face. Combining a thread lift with collagen stimulators is a separate topic, covered on the Combined Facial Rejuvenation page.

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What a mid-face thread lift cannot do

A mid-face thread lift does not replace lost volume, does not correct advanced sagging and is not a substitute for a surgical mid-face lift or facelift. Its effect fades over time; studies do not give a definite figure for how long it lasts, and long-term evidence is limited.

The first limit concerns volume. Flattening and pseudoptosis (‘false sagging’) caused by loss of deep medial cheek fat are not corrected by repositioning the tissue. According to the study that described this fat compartment, volume support increases the forward projection of the cheek; repositioning the tissue only sideways does not have this effect. So a thread lift should not be expected to make the cheek project further forward.

The second limit concerns how advanced the sagging is. According to a review comparing surgical facelift techniques, less invasive techniques that preserve the retaining ligaments give more limited correction in advanced laxity, while techniques that release the ligaments can move the mid-face tissue further. This review does not look at thread lifts directly; however, a cadaver study lists this treatment among the methods that lift tissue without releasing it.

The third limit concerns duration. According to this cadaver study, when tissue is lifted without being released, its weight rests on the anchoring point, and this limits how long the result lasts. A case series of mid-face thread lifts also reported that results declined within the first year. Researchers who reviewed the evidence stress that anyone considering this treatment should be given detailed information about side effects, how long the effect lasts and the limits of the evidence on effectiveness. These limits do not mean the treatment should not be done; they show where to set your expectations. Your doctor assesses you; the decision is yours.

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Anatomy of the area and safety

In the mid-face, the depth (plane) at which the thread passes determines its relationship to blood vessels, branches of the facial nerve and glands. Much of the safety of the treatment depends on this anatomy; some of the serious but rare complications reported are linked to these structures being affected.

According to a review of thread lift anatomy, working carefully around blood vessels is important for reducing the risk of complications such as bleeding and bruising. Knowing the course of the facial nerve is important for reducing the risk of nerve damage, which can result in facial weakness or paralysis. A systematic review that brought together studies of face and neck treatments also lists altered sensation and injuries to blood vessels and glands among the serious but rare reports.

There is also no full agreement on which layer the thread should pass through. The authors of a study on eight cadavers state that there is no consensus on this for the side of the face; in their own examination, threads placed in the layer just above the SMAS did not damage blood vessels, nerves or muscles. This is a cadaver finding and does not directly show the results in living tissue.

This information is not meant to put you off the treatment; it explains why this area needs care. The plane and direction in which the thread is passed, and where it is anchored, depend on the doctor’s assessment and technique.

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Known risks

The most commonly reported effects of a thread lift are swelling and bruising. Less often, visible or palpable threads (threads you can see or feel under the skin), skin dimpling, asymmetry, altered sensation and infection are reported. Swelling and bruising have been linked more often with mid-face treatments.

A meta-analysis (an analysis that looks at the results of many studies together) combining data from 2,827 patients in 26 studies reported swelling in 34%, bruising in 26%, visible or palpable threads in 10% and skin dimpling in 7%. Numbness around the ear and a pulling sensation, which were included in fewer studies, were reported in about 5% and 7% respectively. The researchers class swelling, pain and bruising in the first four weeks as early complications, and visible threads, dimpling and thread migration (the thread moving out of place) as late complications that may be more significant. The variation between studies is high.

A systematic review covering 19 studies and 1,406 patients, using dissolvable threads only, reported bruising (19.49%), swelling (16.79%) and tenderness (9.96%) as the most common effects, and a collection of blood (haematoma, 0.64%), sensory disturbance (1.14%) and infection (2.49%) as the least common. Swelling and bruising were more strongly associated with mid-face treatments, barbed threads and polycaprolactone (PCL) threads; threads left unanchored were also associated with more complications than anchored threads.

A systematic review of face and neck treatments covering 14,222 patients found asymmetry to be the most commonly reported finding. Most findings were temporary and resolved on their own; irregularities in the facial contour, injuries to blood vessels and glands, infection and inflammatory reactions were listed as exceptions to this. More serious cases were reported to have resolved with treatment.

Before the procedure, you will be asked about blood thinners, antiplatelet medicines and supplements that can affect bleeding. Antiplatelet medicines stop blood platelets from clumping together. Do not stop any prescribed medicine on your own. If needed, the procedure is planned or postponed after consulting the relevant doctor. The rates above come from studies with different threads, techniques and follow-up periods; they do not show the expected result for any one person, and they are not data from this clinic.

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