Dear Editor,

Liposuction, fat grafting, and filler treatments are frequently used alongside thread lifting to achieve a voluminous and three-dimensional facial appearance, countering the sagging caused by aging and gravity. It is recommended that those with low facial volume first undergo volume-enhancing procedures such as fillers or fat grafting.^{1, 2} Conversely, for individuals with excessive volume, methods like liposuction or laser lipolysis may be suggested to reduce it.

Concerns have been raised about liposuction reducing the effectiveness of thread lifting, prompting some practitioners to implement a waiting period for stabilization post-liposuction.³ This, however, necessitates two recovery phases. Research indicates that if threads are placed in layers parallel to the liposuction cannula's movement, a significant reduction in thread tensile strength occurs due to tunnel formation and damage to the fat's septum, undermining the anchoring of the thread's barbs.⁴

Moreover, placing threads at a 90-degree angle to the liposuction direction also decreases their traction due to similar disruptions in tissue integrity. Results suggest that effective thread lifting should target layers deeper than those affected by liposuction, such as the SMAS layer, which remains stable and can securely anchor the threads.⁵

When liposuction and thread lifting are performed concurrently, it's advantageous to insert threads in the unaffected deeper SMAS layer. This ensures that the threads can effectively engage firmer tissues, enhancing the lifting effect as superficial layers reattach to these deeper, uplifted tissues. Care must be taken when considering liposuction after thread lifting, as premature intervention can risk breaking the threads.

For areas with significant volume loss like the lateral cheek hollows, enhancing volume with fillers or fat grafting prior to thread lifting can optimize the lifting outcomes.^{6, 7} Modern fillers with high viscoelasticity and other minimally invasive techniques like laser lipolysis allow for simultaneous treatments without compromising thread integrity.⁸

Additionally, the use of energy-based devices (EBDs) has become popular for skin tightening.^{9, 10} These devices, while primarily targeting the skin and SMAS layer, do not substantially weaken the threads' tensile strength. There is speculation that thermal energy changes might enhance thread lifting effects, though conclusive evidence is lacking. Nevertheless, the added tightening from EBDs may enhance overall satisfaction with the procedures, providing a comprehensive approach to facial rejuvenation.

CONFLICT OF INTEREST STATEMENT

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