My View
Barbed Sutures: Rationale and Technique
The author provides a comprehensive overview of
barbed suture technology, explaining the hypothesized
underlying cellular mechanism. He then describes the
procedure, including patient selection, materials, and
technique. (Aesthetic Surg J 2006;26:223-229.)
T
he enthusiasm for barbed sutures has been largely
patient driven. Although some aesthetic surgeons
have embraced this technique, many more express
doubts about its safety and efcacy. As surgeons, we are
quite justied in being skeptical about new procedures,
especially if they sound too good to be true. We need
assurance that the procedure is safe and effective, and we
need proof of its ultimate efcacy.
Barbed sutures are typically manufactured from a
monolament suture material. Although several different
technologies have been used over the past few years,
they all involve hooking the tissues onto barbed sutures
so that they subsequently become encased in brous tis-
sues, inciting a biologic response. The response achieved
by the diminution of tensile forces on skin is the oppo-
site of the response achieved when tension is applied (tis-
sue expansion). The use of barbed sutures may be the
rst step in understanding and taking advantage of tissue
expansions reciprocal process, which for lack of a better
term may be called tissue contraction (see sidebar
Biological Opposite of Tissue Expansion).
Here, I report primarily on the Contour Thread
(Surgical Specialties Inc., Reading, PA), a suture
designed to be anchored to a fixed structure, such as
the deep temporal fascia. In contrast, the APTOS thread
(Kolster Methods, Inc., Anaheim, CA) is designed to
be used in freely mobile tissues. With APTOS, bidi-
rectional cogs capture tissues and compress them
toward the midpoint of the thread (Figure 1).13 APTOS
devices are designed to bunch up the tissues, relying
on the relative fixation of certain tissue planes for
elevation. However, like Contour Threads, APTOS
threads rely on the cell death or apoptosis noted
in all tissues that have had tensile forces reduced
or removed.
AESTHETIC
Materials
Contour Threads, avail-
able since January 2005, are
FDA approved for use in
the brow, midface, and
neck. Threads previously
used for facial tissue con-
touring, described by
Sulamanidze et al,13 con-
Claudio L. DeLorenzi, MD,
sisted of bidirectional cogs Kitchener, ON, is a board-
on a polypropylene thread certied plastic surgeon and an
ASAPS member.
(Figure 1, A). Sulamanidzes
procedure involved 2 steps: rst, a spinal needle was
passed into the proposed pathway of the bidirectional
thread; second, a bidirectional thread was then placed
into the lumen of the needle. The thread end was held so
that when the needle was removed, the thread remained
in place. Because all the cogs pointed toward the center
of the thread, the device compressed the tissues so that
tissues at the center point were tension free (Figure 1, A
and B). With these bidirectional threads, no knots are
used. It is very important that there are a similar number
of barbs on either end of these devices because other-
wise, as in a tug of war, the stronger side (with more
barbs) will prevail and the thread will be pulled towards
the prevailing side. These devices are slightly easier to
deploy but require greater precision to ensure that they
do not migrate to a distant site. (The change in skin ten-
sion is a signicant recurring theme.)
In contrast to bidirectional barbed sutures, which were
only about 12 to 15 cm in total length, Contour Threads
have a 7-inch straight deployment needle, a 2-inch non-
barbed portion, a 4-inch (10-cm) barbed portion, and a 4-
inch (10-cm) nonbarbed portion attached to a 26-mm half-
circle needle to be used for xation purposes (Figure 2).
Deployment of Contour Threads is fundamentally dif-
ferent in several ways. First, the needle is passed through
soft tissues that are not under tension (Figure 3). Using the
long needle, the suture is passed through the tissues to be
elevated. The curved needle at the opposite end of the
suture is then used to secure the device to brous tissue, or
alternatively, to tie it to another barbed suture, creating
SURGERY JOURNAL ~ MARCH/APRIL 2006 223
 MY VIEW
Biological Opposite of Tissue Expansion
Tissue expansion has historically been practiced
by many cultures, but the cellular processes respon-
sible were clarified in the 1980s. While cells stretch
initially, they soon increase in number and eventu-
ally re-establish their original size and architecture.
Although it is recognized that tension and even
gravity1-3 operate at the cellular level, compression
can slow growth and may lead to apoptosis.4 The
cell survives and thrives while it is under some ten-
sion, but when tension is removed, some cells die in
response. The growth of all noncirculating (blood-
borne) cells is mediated by the attachments of their
cell membrane receptors, integrins, to extracellular
ligands.4-6 Mechanical stimuli (simple tension and
compression) are important in many different sys-
tems. For example, embryonic muscle cells will
grow and become organized into fascicular struc-
tures when subjected to physiologically relevant
load cycles.7-9 Absence of tension prevents develop-
ment, just as absence of light prevents development
of vision (amblyopia). Not only are mechanical
stimuli necessary to the normal development of
muscles, they are also important to maintain func-
tion. For example, astronauts rapidly lose muscle
mass in low-gravity environments. Conversely,
transplanted muscles must be sutured under some
minimal tension along their fibers; otherwise, they
will undergo atrophy and fibrosis.11,12 These find-
ings provide support, although indirectly, for the
premise that tissue elevation with barbed sutures
causes changes that eventually result in attrition of
excess skin.
A B
Figure 1. A, Bidirectional thread. B, Polarized photomicrograph of typical bidirectional thread. The cogs (barbs) are meant to gather tissue towards
the center of the device. C, Example of a failed thread.
224 Aesthetic Surgery Journal ~ March/April
an inverted U (with the knot at the base of the U).
Once the knot is seated into the xation port, tension can
then be applied on the distal barbed threads. Lax tissues
are tightened, and the redundancy is shifted toward the
anchoring point in the scalp. Tension is removed from the
distal tissues as tissue is ratcheted up the cogs toward the
anchored knot. This process is termed contouring.
During this procedure the tissues are lifted toward the
upper part of the thread, causing visible tissue gathering
that may alarm patients. Patients must understand that
gathering will occur and will also dissipate over time,
depending on the volume of the displaced tissue. Skin
wrinkling is a result of tissue displacement and will occur
towards the knot in Contour threads, or towards the
midline of bidirectional threads. In traditional surgery,
we cut out excess skin but with barbed thread techniques,
we do not cut away extra skin, we simply displace it. The
displaced skin will tend to shrink away over a period of
time similar to how wrinkles and folds disappear in verti-
cal breast reduction techniques. It should be noted that
Surgical Specialties Corporation has recently introduced a
device with two opposing unidirectional barbed sections
and a smooth suture gap section, which has been FDA-
approved for the midface and brow.
Patient Selection
The ideal patient will have mild to moderate laxity, as
evidenced by moderately deep nasolabial folds or jowl
formation. The ideal age is (perhaps) 35 to 55, but
chronological age is not as relevant as biological age.
There may be some skin wrinkling, but this procedure
does not improve skin wrinkles to any degree; therefore,
patients without signicant solar elastosis are superior
candidates. Patients who have thin translucent skin and
C
2006 Volume 26, Number 2

A B
Figure 2. A, Contour Thread. B, Close up of barbs cut into thread.
minimal or absent subcutaneous fat are poor candidates,
as are patients who are morbidly obese and have tight
facial skin.
Patients must be given informed consent that skin will
be elevated, causing signicant gathering in the soft tis-
sues because skin will not be excised as would occur with
traditional methods. Typically, for treatment of the mid-
face, gathering occurs in the lateral cheek and temple
regions; for treatment of the neck, gathering occurs in
the retro and infra auricular areas.
The surgeon can predict success by checking with gen-
tle nger pressure to see if soft tissue elevation occurs. If
the skin cannot be lifted with a nger, it will not be lifted
with a barbed suture. Deep-tissue scarring, or any process
that prevents tissue mobility when checked with the exam-
iners nger pressure, will also impede elevation with
barbed sutures and must be considered a contraindication.
Procedure
The patient is marked in the upright position and,
similar to other aesthetic procedures, plays an active role
in determining objectives. While looking into a handheld
mirror and applying skin pressure with the ngertip, the
patient is asked to demonstrate the aesthetic effect that
she or he is seeking. Using the patients feedback, the sur-
geon draws vectors on the skin and notes asymmetry or
other relevant issues.
The barbed suture procedure is typically performed
using a local anesthetic unless it is combined with oth-
er aesthetic surgical procedures that require a general
anesthetic. Local anesthetic with epinephrine is infil-
trated along the proposed suture pathway. Typically, I
use 0.5% lidocaine with 1:200,000 epinephrine, a total
of about 3 mL per thread. The thread is then inserted
and fixed to fascia according to the manufacturers
instructions.
Usually, it is necessary to place 2 threads in each area
to lift the area appropriately (2 threads in each jowl, mid
Barbed Sutures: Rationale and Technique
MY VIEW
cheek, lateral brow area, etc.). Failure of these devices is
most commonly not because of thread breakage but
because of an incorrectly tied knot (a half hitch instead
of a square knot). This is easily prevented by tying the
sutures over the tip of a needle holder, which is held in
place by an assistant, to ensure that the knot is tied
square and tight.
The final step is to contour the face by holding the
thread in the nondominant hand and applying pressure
on the tissues to engage the barbs on the sutures. This
is most easily done with the patient upright so that the
effects of gravity are taken into account; however, I
sometimes perform this contouring step with the
patient recumbent.
If a patient undergoes the procedure under general
anesthesia or is too sedated to cooperate, a small
dressing (antibiotic ointment and a tape bandage) may
be applied to the exit sites of the threads on the skin.
The tissues may then be elevated on the following day,
with the patient fully awake and cooperative. This will
minimize risk of damaging the barbs with excessive
tension followed by excessive stress by external pres-
sure. This is an important detail because excessive ten-
sion on the barbs followed by correction will result in
breaking of the barbs with fewer barbs capable of
holding the tissues in place long enough to achieve the
biologic goals.
For this reason, I no longer signicantly overcorrect
when elevating tissues (Figure 4). Further, the endpoint I
use for tissue elevation has changed over the last several
months. The original procedure involved overcorrection
of all sites. Now, I recommend moderate tension only, so
that tissues are held in a position that appears natural
when the patient is lying down. In fact, if I can maintain
the tissues in the same position when the patient is stand-
ing as is evident when she or he is lying down, then I
have achieved a successful rejuvenation. Results from a
typical procedure are shown in Figure 5.
AESTHETIC SURGERY JOURNAL ~ March/April 2006 225
 MY VIEW

Figure 3. Illustration of typical xation technique. A long needle with attached thread is passed through deployment ports into the tissues to be treat-
ed. The short curved needle is passed through toward xation port after taking a bite of deeper xed tissues. The knot is tied in the proximal xation
port. Thus, a bidirectional device has been created with a xation point in the middle.

Postoperative Management
In fully awake patients who have undergone the pro-
cedure with a local anesthetic, no further steps are neces-
sary, assuming patients are compliant. Ideally, there
should be no pressure or tension applied to the treated
areas for several days until edema resolves and scar col-
lagen builds up around each suture. Although it is
impossible to completely avoid pressure on the face,
immobilizing the skin with a few strips of skin-colored
tape is helpful for several reasons. It splints the tissues
somewhat and reminds the patient not to laugh or cause
sudden tissue stretching while healing.
My goal in the postoperative period is to minimize
risk of patients dislodging the tissues from the barbs.
One of the greatest risks of losing support from the
sutures occurs during sleep. Direct pressure on the face
from a pillow may result in release of tissue support dur-
ing the early phase of healing before collagen has been
deposited around the barbed sutures. The use of skin
tape, a travel pillow, or a recliner for sleeping may be

226 Aesthetic Surgery Journal ~ March/April 2006 Volume 26, Number 2

 MY VIEW

Figure 4. Contouring procedure. Tension is held on the end of the suture exiting the skin. The skin is manipulated to engage the barbs on the sutures.
The weight of the tissues is then maintained and distributed among the barbs, each one holding a small amount of weight.

helpful for a few days, if only to remind the patient not
to lie directly on the areas.
Regardless of these precautions, some patients will lose
a degree of lift by inadvertently pressing or pulling down
on the face before the biologic processes have been com-
pleted. Typically, this will occur on one side or the other,
but eventually both sides tend to become symmetrical,
almost as if these threads auto-adjust to the correct level.
If there is complete loss of support, it may be possible to
reposition the barbed segment, especially in the brow;
you may be able to stabilize the lower end of the thread
with the ngertip while upwardly adjusting the tissues
cephalad. However, this is not always possible, and some
patients will need to undergo further treatment.
Discussion
My longest follow-up for Contour Threads is from
January 2005. In my hands, about 80% of patients have
been satised with results. However, results vary; in
fact, in about 10% to 20% of patients, I could not see
any results when comparing preoperative and postoper-
ative photos. So far, I have not been able to predict who

Barbed Sutures: Rationale and Technique AESTHETIC SURGERY JOURNAL ~ March/Appril 2006 227
 MY VIEW

A B

C D

E F

Figure 5. A, C, E, Preoperative views of a 54-year-old patient. B, D, F, Postoperative view 4 months after Contour Thread treatment to the cheek and
jowls (4 threads per side, 8 threads in total).

228 Aesthetic Surgery Journal ~ March/April 2006 Volume 26, Number 2

 MY VIEW
will be a good responder. It is possible that some
patients may have a genetic predisposition toward this
(purported) mechanism of action.
A review of US statistics presented by the American
Society for Aesthetic Plastic Surgery14 shows huge gains
for minimally invasive procedures. I attribute this trend
to patients who are apprehensive of unnatural-looking
outcomes from surgical procedures, possibly arising from
their impressions of the abnormal appearance of celebri-
ties and others appearing in the popular press.
Unfortunately, poor or operated results are the only
ones that receive public attention, since natural results
are, by denition, less dramatic. Therefore, although aes-
thetic surgeons certainly can and do create a natural out-
come with traditional techniques, many people are reluc-
tant to have surgery.
I believe that the era of the nondetectable result is
upon us. Nondetectable does not mean (as critics of
barbed suture techniques claim) that the results are so
minimal as to be literally undetectable, but rather that
the results are subtle, natural, and do not look operated.
Patients are willing to accept a less dramatic result, as
long as they look natural. In addition, barbed sutures
may be an attractive alternative for patients because they
are perceived as less invasive and inherently safer. My
view is that this procedure does not cannibalize an aes-
thetic surgery practice but, instead, attracts new patients
that may otherwise not surface.
I was trained in conservative methods; the concept of
closing wounds under tension was regarded as ill advised
and ill conceived. Surgery consisted of delamination (sep-
aration of layers) of tissues along natural cleavage
planes, followed by repositioning under no tension, fol-
lowed by careful closure and support until healing
occurred. Recent trends in face lifting have questioned
this approach, at least some of the time. The 10-year
result of the twin facelift study comparing the different
techniques of Sam Hamra with those of Dan Baker (pre-
sented at the annual meeting of the American Society for
Aesthetic Plastic Surgery in New Orleans, 2005) reveals
that taking tissues apart completely may be unnecessary,
adding layers of complexity, tissue trauma, and pro-
longed recovery for little or no permanent benet.
From existing scientific studies, do we have enough
evidence to define a mechanism of action for the
process occurring with barbed sutures? Probably not
completely, but it is interesting to entertain the possibil-
ity that we have uncovered the biological opposite of
tissue expansion. The work that needs to be done now
is to elucidate the parameters that modulate this effect,
Barbed Sutures: Rationale and Technique AESTHETIC
as well as to define it more thoroughly. Of course,
there will be those that doubt the existence of these
phenomena, just as there were those who doubted the
existence of tissue expansion as a legitimate medical
process. I am convinced that there is a real effect here,
and that what we have seen is the first attempt at capi-
talization of that effect.
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Editors Note: The author has been paid by Surgical
Specialties Corporation to conduct research and training
preceptorships.
Reprint requests: Claudio L. DeLorenzi, MD, 11 Agnes Street, Kitchener,
ON N2G 2E7, Canada.
Copyright 2006 by The American Society for Aesthetic Plastic Surgery,
Inc.
1090-820X/$32.00
doi:10.1016/j.asj.2006.01.009
SURGERY JOURNAL ~ March/Appril 2006 229