Facial aging constitutes multiple changes in the physical composition and function of the skin and its underlying structures. The skin gradually undergoes dermatochalasis and there is a decremental loss of hya-luronic acid, a major component responsible for the youthful appearance of the face. Simultaneously, there can be seen a fat redistribution of the maturing face, whereby the periorbital fat pad may atrophy and/or hypertrophy and protrude from its natural position. A deepening of the melolabial folds secondary to the senescent changes to the buccal fat pad too can be observed. In addition, some patients exhibit deepening of the marionette lines and an increase in the fat along the jawline and jowl area, concomitant with loss of definition to the jawline.1-4Supporting Ptotic Facial TissueIn the last issue, we described a multitude of relatively non-invasive techniques to subtly correct some of these problems. This article addresses some procedures that are more technically involved, while remaining minimally invasive, to correct the variety of changes that occur in the aging face. In contrast to the traditional facelift approach, which addresses the entire face and is extensively invasive, the recent advances in resuspension thread-lifting technology have allowed the dermatologic surgeon to focus on specific areas of the face as an early intervention to support the ptotic facial tissue, while avoiding aggressive facelifting.1 The core discussion of this article will be a summary on the various new types of minimally invasive thread-assisted lifting techniques for the correction of a variety of ptotic facial structures. There will be also a brief overview of the latest technology in tissue resuspension, the Silhouette suture lift.Patient Selection for The Thread-Assisted LiftRealistic expectations. As in any cosmetic procedure, patient selection is the key to a good outcome. It is of utmost importance that the patient fully understand the goals and have realistic expectations from the procedure in question. It must be made clear to the patient that the thread-lifting technique specifically addresses facial subunit ptosis and that additional cosmetic procedures may be be required to to address other aging problems.Indications The thread-assisted lift is indicated for rejuvenating the following cosmetic subunits: the eyebrow, the forehead, the cheek area, nasolabial fold resuspension, mid-face sagging, jowls, and jawline and neck definition.CandidatesPatients who have already had a facelift, but require a touch-up for specific facial units are also good candidates for thread-assisted lifts. Severe tissue laxity and underlying muscular and bony atrophy are relative contraindications to this procedure because the final outcome will be less than ideal. In matching the patient and appropriate procedure, chronological age is less important than the patient’s general skin quality and its supporting structures.5 BackgroundThreads and SuturesIn the late 1980s, Dr. Sulamanidze was one of the first to develop threads to lift facial tissues. In his landmark study, 186 patients were treated with threads and showed recontouring results for as long as 30 months post-operatively.6,7 In 1999, Dr. Sulamanidze obtained a worldwide patent on the Aptos thread, a polypropylene product that is a permanent suture material. Aptos threads are made with slits that are at a diagonal slant and have sharp ends (Figure 1). These slits allow for the anchoring of the tissue in the opposite direction, thereby uplifting the corresponding tissues. No suturing is required in this technique. However, these threads have recently been shown to migrate to far distances from the point of insertion, making them less than ideal.We have also used the Monograms suture, a specialized absorbable suture, with cross-segmented stabilizers at 90 degrees to the main axis of the suture, which was developed by Dr. Eremia for the treatment of sagging facial tissues (Grams Surgical Suture, GramsMed, LLC Grafton, WI) (Figure 2). It can also be used in combination with various other techniques to produce overall face and neck improvement with minimal surgical manipulation.8  LiposuctionNeck, jowl and malar liposuction, if needed, may be performed through a nick incision adjacent to the affected facial subunit, concomitantly with various resuspension procedures.9Silhouette Lift Apparatus and Suture Most recently, we have used the Silhouette lift apparatus and suture to redefine brow, midface, jawline, and neck tissues. This comes with a built-in apparatus that provides for ease of introduction of this specialized polypropylene suture.10 There will be more on this subject in the literature to come.Our TechniqueHere we describe the technique we have employed for jawline redefinition and jowl correction in 10 patients thus far. Other complementary procedures, such as liposuction, fat transfer and other various tissue augmentative techniques can be performed concurrently.AnesthesiaAfter the patient is prepped, the closed technique is performed under local anesthesia, with or without conscious sedation. When done in conjunction with neck and jowl liposuction, the procedure is usually preceded by the introduction of tumescent anesthesia.Surgical MethodAn incision is made in the posterior auricular crease that is approximately 1.5 cm to 2 cm in length. This is taken to the depth of the supra-SMAS layer. Subsequently, Metzenbaum scissors are utilized for minimal blunt undermining at this level. In general, the specialized thread can be inserted to the desired location, while simultaneously taking care to stay in the supra-SMAS layer and parallel to the surface of the skin. The suture then is plicated to the underlying SMAS at the proximal anchoring point, which subsequently achieves the desired resuspension of the tissue in the proper vector and direction. Additional specialized sutures may be utilized in the same plane to achieve the required aesthetically acceptable endpoint.The curved tapered needles on the proximal end of the suture are tied in pairs to the underlying SMAS, thereby achieving the immediate result of tissue repositioning and suspension. The distal suture ends are severed at level with the skin. Finally, the posterior auricular incision is reapproximated with a 5.0 prolene suture, which is removed 5 to 7 days post-operatively. (Figures 3A and 3B). Minimally Invasive and Compatible ProceduresThe aforementioned minimally invasive techniques are ideal for the improvement of the early signs of tissue laxity. The procedure can be tailored to an isolated facial subunit without causing distortion to surrounding facial tissues. This can be done under local anesthesia or with mild intravenous sedation, which is adjusted to maximize patient comfort.These minimally invasive lifting techniques are a great addition to the armamentarium for alleviating the senescent changes of the face. They can be performed in conjunction with neck and jawline liposuction, soft tissue augmentation, botulinum toxin injections, blepharoplasty, and laser resurfacing.