|Year : 2022 | Volume
| Issue : 1 | Page : 71-75
Efficiency of barbed polydioxanone threads for neck lifting using the tight neck fontana protocol: Series of cases
Ana Laura Fontana, Gustavo Lessing, Jose Ricardo Albergaria-Barbosa, Celia Marisa Rizzatti-Barbosa
Department of Dentistry, Inga University Center, Orthodontics PostGraduation Course, Maringa, PR, Brazil, Feevale University, Novo Hamburgo, RS, Brazil
|Date of Submission||22-Jul-2021|
|Date of Decision||03-Aug-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||31-Dec-2021|
Celia Marisa Rizzatti-Barbosa
Rua Sousa Reis, 120 - Apto 93A - Butanta, Sao Paulo, SP, ZIP-05586 080
Source of Support: None, Conflict of Interest: None
The aim of these clinical cases descriptions was to describe the clinical results of barbed polydioxanone (PDO) threads in neck lifting using the Tight Neck Fontana Protocol (TNFP). Three-barbed PDO threads (19G or 18G and 150 mm in length) were implanted bilaterally in six female adult patients with an indication for neck lifting. Two threads were inserted in the sub-dermis of the neck through the diagonal vectors from the angle of the mandible toward the midline and fixed with a knot. The third thread was implanted in parallel and just below the first vector. The post-operative results were evaluated by the occurrence of adverse events, scores attributed on a Visual Numerical Scale, questionnaire inquiring the satisfaction patient about the treatment (QSP), and evaluation of photographic records. The results were quite satisfactory on the procedures performed, suggesting the indication of the TNFP using barbed PDO threads for the neck lifting.
Keywords: Aesthetics, neck lifting, polydioxanone threads
|How to cite this article:|
Fontana AL, Lessing G, Albergaria-Barbosa JR, Rizzatti-Barbosa CM. Efficiency of barbed polydioxanone threads for neck lifting using the tight neck fontana protocol: Series of cases. Adv Hum Biol 2022;12:71-5
|How to cite this URL:|
Fontana AL, Lessing G, Albergaria-Barbosa JR, Rizzatti-Barbosa CM. Efficiency of barbed polydioxanone threads for neck lifting using the tight neck fontana protocol: Series of cases. Adv Hum Biol [serial online] 2022 [cited 2022 Jan 25];12:71-5. Available from: https://www.aihbonline.com/text.asp?2022/12/1/71/334592
| Introduction|| |
Face and neck ageing is due to progressive tissue degradation that arises because of intrinsic and extrinsic factors. The demand for aesthetic solutions in these regions has grown in recent years, especially in middle-aged individuals., Some minimally invasive alternatives have been proposed for the correction and control of tissue ptosis and wrinkles in these areas. Barbed, permanent or resorbable threads have been considered important tools for ptosis solution in the neck.,
The advantage of resorbable threads is that they are effective in tissue traction while promoting intense callogenesis around the thread even after its resorption, providing durability to the treatment., The barbed polydioxanone (PDO) threads have been frequently used in a facelift.
Since the demand for lifting on the neck has increased, it becomes necessary to define safe and effective protocols for this purpose. However, there are few studies that mention the use of threads on the neck, and no specific protocol for neck ptosis tissue was found in the investigated literature using resorbable bidirectional barbed PDO threads with 19G and 18G.
Therefore, in this case report, we aimed to describe a simple and effective protocol of 18G and 19G bidirectional-barbed PDO threads implantation for neck tissue ptosis.
| Case Report|| |
The work was carried out on six female patients, aged between 35 and 48 years old, with similar characteristics for muscle mass, skin thickness and biotype, general and local health and indication for neck lifting. All received barbed PDO threads for aesthetic reasons and signed the free and informed consent form to participate in the work.
All procedures were performed by the same professional (A. L. F.) using the tight neck fontana protocol (TNFP), previously defined by the Authors (G. L., J. R. A. B., C. M. R. B.), according to their clinical experience. All patients received a total of three bilateral threads, according to the previous treatment plans.
Briefly, after biosafety care and infiltrative anaesthesia in the regions to be treated, three patients (#1, 2 and 3) were implanted with 18G bidirectional barbed PDO thread neck lifting (Sculpt® FML18100G185, i-Thread®/MedBeauty®, Sao Paulo, Brazil), and three (#4, 5 and 6), were implanted with 19G bidirectional barbed PDO thread for neck lifting (FCL19100E160, i-Thread®/MedBeauty®, Sao Paulo, Brazil).
The implantations were guided by three vectors traced in the region of the upper third of the neck. The first thread started from the angle of the mandible and followed the lower limit of the mandibular body towards the mandibular symphysis, to the line of Ziarah Atkinson, which adopts the second lower premolar with vertical reference line, follows straight to the mandible edge and then continues towards the fibres of the platysma muscle; the second thread started from the same point, with anterior direction and slightly diagonally downwards, crossing the median line; the third thread started from a point 20 millimetres below the angle of the mandible, parallel to the second vector, with direction to the anterior to the hyoid bone [Figure 1].
|Figure 1: The three vectors traced in the region of the upper third of the neck that guided the implantation of the threads.|
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An orifice was performed with a 16G needle at the first implantation point of the threads. The two threads were inserted at this point according to their respective vectors (first and second vectors). Both were implanted in the subdermal layer with the single and constant anterograde movement of the microcannula until its complete implantation. After removal of the microcannulas, the inserted threads were tied with a knot, and after being cut with surgical scissors, they were totally pushed inside the subdermal layer.
In the third vector, the last thread was inserted through the orifice performed with a 16G needle at the starting point of its implantation. Like the previous threads, its implantation was on the subdermal layer, through a single and anterograde movement, until the total implantation of the microcannula. After the microcannula was removed, the thread was cut with surgical scissors and totally pushed into the sub-dermis, without knot fixation. After implantation of all threads, the patients received instructions from home care, and no post-operative medication was prescribed. All procedures were performed by the same professional (A. L. F.)
Patients were evaluated in different post-operative periods through standardised questionnaires and photographic records (PR) analysis.
Both PR and questionnaires application were conducted by the same professional (G. L.). Data analysis was conducted by two other professionals (C. M. R. B. and J. R. A. B.). The following periods were considered for the evaluation of the results: Pre-operative (baseline) and post-operative (immediate, 24 h and 30 days).
Adverse events (AE) were investigated by patients' responses considering the questionnaire applied 24 h after procedures; personal impressions about the treatment were measured on a Numerical Visual Scale (NVS) after 30 days of treatment, and the aesthetic effects in different regions of the face and neck observed by the patients (QSP) were also designated in their own questionnaire after 30 days of the procedures.
PR of pre, 24 h and post-operative 30 days [Figure 2] were organised on the same screen and compared by two authors (C. M. R. B., J. R. A. B.), defining the quality of the protocol on a scale from 0 to 3 (0 = bad, 1 = satisfactory, 2 = good and 3 = excellent). Only one of the patients, who was implanted with 18G thread, did not have 30-day post-operative PR. The results were compiled, grouped in tables and analysed by two professionals (J. R. A. B. and C. M. R. B.). Data regarding AE are explained in [Table 1].
|Figure 2: Assembly of PR for comparison among preoperative, immediately post-operative and 30 days after the treatment. The first three patients were implanted with 18G wire threads. The three subsequent patients were implanted with 19G threads. Scoring of photographic records on a scale from 0 to 3 (0 = bad, 1: Satisfactory, 2: Good, 3: Excellent).|
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|Table 1: List of AE presented by patients after 24 hours of the procedures|
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All patients presented at least one AE, with skin traction being the most prevalent (six patients). Only one patient-related pain. Recovery of all AEs was observed at most at 7 days post-operatively. For personal impressions regarding the treatment measured in the NVS after 1 month of treatment, the three patients that received 18G thread implant assigned scores of 10, and the three patients who received 19G thread implant assigned 9 and 8 scores. QSP regarding aesthetic effects assigned by patients in the different regions of the face and neck defined 1 month after treatment is expressed in [Worksheet 1].
The QSP scores in the regions far from threads implantation (nasolabial fold, marionette line and cheeks) were 4 (without any aesthetic effect). Scores 1 and 2 (excellent aesthetic effect and good aesthetic, respectively) were assigned in the regions with direct correlation to the intervention areas (contour of the face), with excellent aesthetic effect in mental definition (the three patients who received implant with 18G threads, and one patient treated with 19G thread); and with good aesthetic (two patients who received the 19G threads). However, the two patients who received 18G threads and one who received the 19G threads considered that there was no aesthetic effect regarding facial symmetry. All patients considered that there was an excellent (1) or good (2) aesthetic effect in the regions where there was intervention (neck fat, mentual, mandibular definition and neck), except for one patient who received treatment with 19G thread, who considered few aesthetic effects (3) to the neck.
PR comparing the pre-operative with 24 h and 30 days after treatments, a score of 3 was defined for three patients (two who received 18G threads and one who received 19G threads), 2 (good, for patients who received 19G threads) and 1 (satisfactory, for a patient who received 19G threads). In no case was it considered that the immediate result of implantation was bad [Figure 2].
| Discussion|| |
The aim of this cases reports was to describe a simple and effective protocol for the implantation of 18G and 19G PDO bidirectional barbed threads for the correction of ptosis in the neck region.
The corrections of ptosis and neck lifting can be made through orthognathic surgeries, plastic surgeries or minimally invasive treatments. The application of the TNFP is included in this context. This protocol intends to correct ageing alterations that arise in the mandible, mentual and neck, through the implantation of resorbable PDO threads, using simple procedures and under local anaesthesia.
These are completely reversible procedures but require some care to be considered for their execution. One of them is the appropriate anatomical knowledge of the regions through which the threads will pass because some complications and AEs may be inherent to the protocol used. The most common events are vessel rupture and consequent haemorrhagic process with haematoma exaggerated deepening or superficialising of the cannulas, involvement of the platysma muscle, asymmetries, infections, inflammatory processes, among others. These effects can be decreased when the procedures of application of the threads follow standards in the knowledge of local anatomy, coherent diagnosis, appropriate training in the procedures of threads implantation and criterion in the conduction of post-operative home care reinforced about the importance of care in the execution of orofacial harmonisation procedures.
In the clinical cases described, no major or persistent complications resulting from the procedures were observed, probably because all pre-, trans- and post-operative care were adopted. Among the post-operative AEs observed, the skin traction sensation of implanted tissues was common to all patients, and only one reported post-operative pain. There were no haematoma, oedema, infection or important inflammatory processes. Considering that the patients did not receive post-operative medication, the observed events would be expected because they did not persist for more than 7 days. However, analgesic medication or antibiotic coverage may be prescribed if the professional considers it relevant.
For the correction of neck ptosis, the implantation of the threads should be supported for resistant, good quality threads and with high fixation competence in tissues. The TNFP recommends the implantation of six barbed threads, three on each side, with 19G or 18G thickness. The implantation of the threads at the limit of the mandibular body determines a good aesthetic response for the correction of the mandibular contour. The fixation of the two threads inserted in the same orifice through the knot ensures the traction of this critical area, where the fibres of the platysma muscle interlace those of the masseter, the depressor of the oral commissure and the mentual muscle fibres. However, the implantation of the threads in the neck will ensure the quality of the lifting in the submandibular region, maintaining the evidence proposed by the two upper vectors. This aspect is fundamental to obtain a satisfactory aesthetic result. The PR showed excellent and good scores by the professional's evaluations for both threads, especially when the records for the 30-day post-operative period were verified [Figure 2]. This was probably due to the competence of neo collagen formation that PDO threads provide over time. Collagen induces better quality and elasticity to implanted tissues, which is a highly positive factor for the maintenance of treatment; although the threads are resorbable, it is possible to maintain the achieved results for longer depending on this property of the PDO threads.
TNFP demonstrated efficacy for both threads, 19G and 18G, although the two patients who received the 18G threads expressed greater satisfaction with the treatment, as well as the analysis of pre- and post-operative PR, that showed better results in these patients. Sculpt® 18G has manufacturing characteristics that give them a higher quality of fixation through the spicules and more durability during their resorption process. In the description of these cases, longer evaluation periods were not considered, which depending on the technical features, would certainly change the result.
No aesthetic changes have been reported in the areas of the nasolabial fold, marionette line or cheek. Initially, because the muscles and fat compartments involved in the formation of these grooves do not establish a direct correlation with the treated areas, it is necessary to consider that the ultimate goal of a functional aesthetic treatment is to provide the most viable options to the patient through an individualised treatment plan, which, in this case, consisted of neck lifting only.
Any experienced professional in maxillofacial surgery would attest that, often, orthognathic or plastic surgery is not the best options to achieve good results for neck lifting and mandibular contour design. Less invasive and effective therapies may bring interesting results to the proposed objectives, such as what was observed in the description of these clinical cases.
| Conclusion|| |
The observed results allow suggesting the efficacy of the TNFP for neck lifting when 19G and 18G threads are used. The satisfaction demonstrated by the patients, the low prevalence of AEs and the positive evaluations defined by the PR analysis admit to establish that the cases were performed with criteria and that both the protocol and the threads corresponded to the expectations.
However, we consider that blinded and randomised clinical studies comparing the TNFP with other neck lifting protocols, and using other thread templates, should be conducted with an appropriate n sample to prove, through statistical tools, its quality and indication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank the company MedBeauty®, particularly to Pedro Miguel and Daniele Oliveira, for the partial literary support and for providing the material used in these cases reports.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]