Facial Gold Reinforcement: 28 Years of Experience in the Use of Gold Threads

Abstract

Introduction: Gold threads became widely used in esthetic surgery in the early 1990s. Produced in Spain, these threads consisted of a gold thread (5/0) with a diameter of 0.1 mm, composed of 99.99% pure gold, which was combined with a polyglycolic thread. Since then, discussions about their effectiveness have continued, which is the focus of our study. Patients and Methods: Gold thread implantation was performed on 11,062 patients in four clinics in Moscow over the course of 28 years. This study used a comparative analysis of photo collages created for the visual representation of data and changes before and after the procedure, as well as patient satisfaction assessments using the Patient Satisfaction Scale (PSS). We examined the results of 492 patients who underwent gold thread implantation in the face between 1996 and 2024. Of these patients, 86% were women aged 30 to 60 years, 11% were women aged 20 to 30 years, and 3% were men aged 25 to 60 years. Results: One year after thread implantation, the PSS assessment showed a 91% success rate with minimal complications. Patient satisfaction was high, with an average score of 4.8 out of 5 after one month, 4.7 after six months, and 4.6 after one-year post-procedure. Discussion: Gold thread implantation is a minimally invasive procedure that has demonstrated a high level of safety, making it an effective option for facial rejuvenation. Histological studies have shown that gold threads stimulate the production of collagen and elastin and activate angiogenesis, thereby improving skin nourishment and hydration, as well as enhancing the skin tone, elasticity, and turgor. To improve the qualitative characteristics of the skin, it is necessary to work in the subcutaneous layer. Conclusions: Gold thread implantation strengthens the connective tissue framework at the implantation site, thus improving skin nourishment and hydration. Gold threads provide a long-term rejuvenating effect, slowing the ptosis of the soft tissue of the face and neck. Gold thread implantation does not interfere with tissue dissection during surgical interventions or the performance of any cosmetic procedures, including hardware-based treatments.

1. Introduction

The first implantation of gold threads into the subdermal space for rejuvenation and wrinkle elimination was proposed by F.P. de Caux in 1969. This technique involved implanting threads in the cheek area, running in parallel from the ear towards the nose and chin. After 6–8 weeks, the author noted wrinkle smoothing. In 1975, J. Conley and D. Baker applied a new implantation scheme, placing gold threads strictly under wrinkles in different directions, which resulted in wrinkle smoothing. The authors noted that the effect of gold thread implantation could not be compared to that of lifting procedures [1]. In 1991, P. Orenes proposed an extended version of gold thread implantation, including in the chin and neck areas [2]. An analysis of the results showed a positive effect on the skin structure, elasticity, and firmness [3,4,5]. He also introduced threads consisting of a gold thread (5/0) with a diameter of 0.1 mm and a length of 25 cm, composed of 99.99% pure gold, combined with a polyglycolic thread (3/0) to prevent gold breakage. The threads were crimped into an atraumatic straight needle that was 6 cm long with three-sided sharpening (Figure 1).

Since 2010, a new “generation of gold threads” has been introduced, simplifying the implantation procedure. These new gold threads are available in size M.1 (USP 5/0) and come in three different lengths, and they are assembled with an injectable cannulated needle and a polymer fastener (Figure 2).

The modification of the implantation process reflects the evolution of minimally invasive surgical interventions, shaping the trend for more effective plastic surgery (

Table 1. Size range of modern gold threads.

Size	Description	Needle
M.1 (5/0)	Gold monofilament: 100 mm	Needle: 90 mm 26G
M.1 (5/0)	Gold monofilament: 70 mm	Needle: 60 mm 26G
M.1 (5/0)	Gold monofilament: 45 mm	Needle: 38 mm 27G

).

Gold Threads in Individual Sterile Packaging

Since the beginning of gold thread research up to the present day, the discussion about their effectiveness, safety, and long-term results has continued, which is the focus of our study.

2. Patients and Methods

From 1996 to 2024, gold thread implantation was performed in 11,062 patients. This study analyzed the results of 492 patients. Of these patients, 86% were women aged 30 to 60 years, 11% were women aged 20 to 30 years, and 3% were men aged 25 to 60 years.

The indications for use were the following:

• Prevention of ptosis of soft facial tissue;
• Reduction in skin turgor;
• Treatment of early signs of ptosis of the soft tissue of the face and neck in patients not ready for facelift surgery;
• Stabilization of surgical intervention results.

The contraindications were as follows:

• Acute and chronic inflammatory skin diseases and subcutaneous tissue in the acute stage;
• Autoimmune diseases affecting the connective tissue and skin.

2.1. Technique of Gold Thread Implantation

Gold thread implantation was performed under sterile conditions in the operating room. Marking was performed using a sterile marker. Infiltrative anesthesia was administered. The implantation of the threads was carried out along previously marked directions, forming a continuous framework of gold threads that overlapped each other to create a closed oval shape (Figure 3).

The threads were implanted into the subcutaneous fat layer at a depth of 3–4 mm, avoiding insertion directly into the dermis (Figure 4 and Figure 5).

The patients left the clinic after 30–40 min. A preventive dose of a broad-spectrum antibiotic, Cefixime 400 mg (in the cephalosporin class), was prescribed as a single dose, along with a nonsteroidal anti-inflammatory drug, Ibuprofen 400 mg, to be taken twice a day for 2 days.

After gold thread implantation, the patients adhered to the following recommendations:

• For the first 5 days after the procedure, they slept on their backs;
• They applied a dry cold pack to the skin in the thread implantation area for 15–20 min at 2 h intervals during the first two days;
• They washed their faces with cool water and a facial foam;
• They dried their faces by patting with a towel, without rubbing (for one week);
• They treated the facial skin with lotion;
• They limited sun exposure (for 3 weeks);
• They avoided facial massages (for 3 months) and cosmetic procedures for the face (for 3 weeks);
• They limited sauna visits (for one month);
• They limited their facial expressions (for 2 weeks).

2.2. Photography Methods

Standardized clinical photographs were taken to document the results of gold thread implantation. Photographs were captured at baseline, as well as at 1 month, 3 months, 6 months, and 1 year after the procedure. Images were taken in frontal, oblique (left and right), and lateral views to ensure the comprehensive visualization of the facial contours and soft tissue changes. All photographs were taken under consistent lighting conditions and against a neutral background, using a high-resolution digital camera mounted on a tripod to ensure reproducibility. The patients were instructed to maintain a neutral facial expression and avoid smiling or exaggerated expressions.

2.3. Microcirculation

Microcirculation studies were conducted on 20 female patients aged 28–59 years, considering the coefficient of variation. The sensor location point was positioned above the gold thread implantation area and was photographically fixed with measurements in cm from selected skeletal landmarks (

Table 2. Number of Packages/Thread Length (cm).

Implantation Zone	Number of Packages/Thread Length (cm)
Cheeks (both sides)	2 (70 mm); 4 (100 mm)

).

Microcirculation in the gold thread implantation area was assessed using a Transonic Systems BLF-21 laser Doppler flowmetry device, manufactured by Transonic Systems Inc. in Ithaca, New York, NY, USA.

2.4. Morphological Studies

Morphological studies were conducted prior to the use of gold threads to evaluate the response of the soft tissue and analyze the results in 3 patients [6,7]. A 2 cm gold thread was implanted into the inner surface of the forearm. Written consent for participation in the study was obtained.

The tissue examination was performed on the 10th day (Van Gieson stain, magnification 63×) and on the 180th day (Weigert stain, magnification 250×; Van Gieson stain, magnification 250×) after implantation using a Leica DM750 light microscope (by Leica Microsystems GmbH, headquartered in Wetzlar, Germany). Additionally, an electron microscopic analysis of the connective tissue capsule was performed using a JEOL JEM-1400 microscope at high magnification (400×) on the 180th day.

2.5. Patient Satisfaction Assessment

Patient satisfaction was assessed at 1 month, 3 months, 6 months, and 1 year after gold thread implantation. Data were collected through patient questionnaires and subsequently analyzed using the IBM SPSS Statistics software, version 27.

The Patient Satisfaction Scale (PSS) [8] included the following categories:

• Completely satisfied;
• Mostly satisfied;
• Neutral;
• Mostly dissatisfied;
• Completely dissatisfied.

In this study, to simplify the analysis, the categories “completely satisfied” and “mostly satisfied” were combined into a single group called “satisfied patients”. The significance level was set at p = 0.05.

2.6. Statistical Analysis Methodology

IBM SPSS Statistics (version 27) and Microsoft Excel 2019 were used for data analysis. Descriptive analysis, including means, standard deviations, and satisfaction percentages, was conducted for each time point (1 month, 3 months, 6 months, and 1 year). ANOVA was applied to compare the satisfaction levels across different time periods, while Student’s t-test was used to analyze the differences between two independent groups. The chi-square test was used to analyze categorical data.

The significance level was set at p = 0.05. p-value deviations (±0.05) were taken into account for the reliability assessment.

Regression analysis was performed to evaluate the influence of factors such as the patient age and the number of threads on the outcomes. Correlation analysis was conducted to identify the relationships between variables such as patient satisfaction and skin condition improvement.

3. Study Results

3.1. Results of Gold Thread Implantation in Patients (Figure 6, Figure 7 and Figure 8)

By applying a personalized approach to the indications for gold thread implantation, we studied the properties and clinical outcomes of this implant.

The results demonstrate and confirm the ability to maintain tissue support over periods ranging from 3 months to 15 years.

Gold reinforcement was performed as a course (two implantations with an interval of 1–3 years).

Figure 6. Patient K, 34 years old. Appearance before (A) and three months after gold thread implantation without any additional procedures (B).

Figure 6. Patient K, 34 years old. Appearance before (A) and three months after gold thread implantation without any additional procedures (B).

Figure 7. Patient A, 40 years old. Appearance before (A) and fifteen years after gold thread implantation without any additional procedures (B).

Figure 7. Patient A, 40 years old. Appearance before (A) and fifteen years after gold thread implantation without any additional procedures (B).

Figure 8. Patient N, 42 years old. Appearance before (A) and eight years after gold thread implantation without any additional procedures (B).

Figure 8. Patient N, 42 years old. Appearance before (A) and eight years after gold thread implantation without any additional procedures (B).

The clinical effect of “gold reinforcement” was most significant when the procedure was performed to prevent ptosis. In the above photos, we can see that the facial contours of the patients were well preserved. The facial oval remained stable over time.

3.2. Side Effects and Complications

After the gold thread implantation procedure, the patients experienced side effects such as edema, bruising, tenderness, and tingling during facial expressions, as well as thread contouring on the neck. In other implantation areas, no contouring was noted. These symptoms were temporary, lasting for 1–2 weeks.

Two patients experienced the explantation of the thread end at the puncture site. To resolve this complication, the skin was shifted to the side of the protruding thread, the thread was trimmed at the skin level, and then the skin was shifted in the opposite direction to tuck the thread end under the skin. One patient experienced inflammation associated with the threading of an undiagnosed cheek epidermoid cyst (atheroma) prior to thread implantation. After the excision of the atheroma and removal of the thread, the inflammation subsided. The patients were able to undergo any cosmetic procedures without restrictions, including hardware-based methods, three weeks after gold thread implantation. No allergic reactions to 99.99% gold were noted. Moreover, gold thread implantation was performed in patients with multiple allergies without adverse reactions.

3.3. Microcirculation

An increase in volumetric blood flow indicators during laser Doppler flowmetry indicated an improvement in microcirculation due to neoangiogenesis (

Table 3. Results of microcirculation study in the gold thread implantation area.

Time Period	Average Microcirculation Indicators (Units)	Coefficient of Variation (Units)
Pre-surgery	20.7–32.3	2.1–3.15
10 days	26.8–40.1	2.2–3.14
3 months	34.5–52.3	2.01–3.25
6 months	33.8–52.1	2.12–3.30

). Enhanced vascularization contributed to improved skin nourishment and hydration, as well as the maintenance of skin turgor. The non-resorbability of the gold thread [9] was another important aspect, as it prevented the lysis of newly synthesized connective tissue [10], thereby preserving the rejuvenating effect.

3.4. Morphological Studies

Histological studies showed the formation of a connective tissue capsule around the gold threads and the presence of numerous blood vessels in the capsule, confirming the neocollagenogenesis and neoangiogenesis stimulated by gold thread implantation (Figure 9).

An electron microscopic analysis revealed the structure of the capsule around the implanted gold thread (Figure 10) and allowed it to be divided into three layers.

A minimal aseptic inflammatory reaction observed with the use of gold threads is a key factor leading to the gradual encapsulation of the threads with the formation of a connective tissue capsule. The formation of the capsule around the thread is a dynamic process involving neocollagenogenesis and neoangiogenesis [11]. Our studies showed that such stimulation leads to an increase in collagen and elastin content in the subcutaneous layer, thereby improving the tone, elasticity, and turgor of the soft tissue (Figure 11).

4. Patient Satisfaction Assessment

The results of the patient satisfaction assessment are as follows (

Table 4. Analysis of patient satisfaction data using IBM SPSS Statistics, version 27.

Period	Satisfaction Percentage	Number of Satisfied Patients	Score on a 5-Point Scale	Standard Deviation (σ)	p-Value Deviation (0.5)
1 month	95.93%	472	4.8	0.1	±0.05
3 months	98.35%	484	4.9	0.05	±0.025
6 months	94.09%	463	4.7	0.15	±0.075
1 year	91.02%	448	4.6	0.2	±0.10

).

• 1 month: 95.93% of the patients (472) reported complete satisfaction.
• 3 months: Satisfaction increased to 98.35%, corresponding to 484 patients.
• 6 months: Satisfaction level was 94.09%, or 463 patients.
• 1 year: Satisfaction decreased to 91.02%, corresponding to 448 patients.

5. Discussion

Gold threads, consisting of 99.99% pure gold, hold a unique position in facial rejuvenation due to their inert nature. Gold is an inorganic, monofilament, sterile implant that possesses biocompatibility. In clinical observations, patients exhibited soft tissue reactions after implantation, such as mild edema, and, in 10% of cases, bruising.

However, the medical community has been quite skeptical of both gold threads and subsequent generations of threads. This skepticism is mainly driven by the novelty of the method and concerns regarding tissue reactions to gold and the behavior of the metal in the soft tissue of the face [12,13]. In recent years, new thread technologies have entered the practice of plastic surgeons, with varying degrees of success. Among the widely used threads are the following:

• Silhouette lift—polypropylene threads with rigid cones composed of polylactic acid [14];
• Aptos—polypropylene threads with barbs [15];
• Spring thread—polyester threads coated with silicone with silicone spikes in the shape of a Christmas tree [16].

All of these threads are positioned as lifting threads composed of non-resorbable materials. The use of these threads has shown success in certain patient groups [17].

However, complications such as soft tissue deformities, skin retraction with the formation of “pits” (indentations), and visible “tracks” and skin wrinkling along the threads, which deform facial contours, especially during facial expressions, have been noted. These complications have led to the reevaluation of the use of non-resorbable materials in thread technologies [18].

Manufacturers have shifted to producing threads from resorbable materials, particularly polylactic acid and polydioxanone [19]. The implantation technique has also changed, moving from aggressive tension to a stabilizing approach [20,21].

Among non-resorbable threads, gold remains the only material devoid of all of the disadvantages of both non-resorbable and resorbable mesothreads [22], including polydioxanone and polylactic acid threads. The advantage is evident: none of the synthetic threads implanted in tissue can avoid breaking or reducing their length before resorption, and, during this period, they can deform the facial tissue. In contrast, gold threads break at facial flexion points and do not cause “snags”, tracks, creases, or deformation in soft tissue.

This study allowed us to assess the effectiveness of gold threads for facial rejuvenation and determine their potential for patients and future use in plastic surgery.

According to the results of the electron microscopic analysis, gold threads stimulate neocollagenesis and neoangiogenesis, thereby increasing the collagen and elastin levels in the subcutaneous fat layer and strengthening the connective tissue framework of the facial soft tissue. This is particularly important for patients with reduced turgor caused by weak connective tissue, such as hyperelastosis or dysplastic syndrome.

Given all of the positive aspects of implantation, we consider gold thread implantation as a stabilizing factor for the prevention and slowing of soft tissue ptosis of the face.

Gold reinforcement does not interfere with, and is even compatible with, other cosmetic procedures, including hardware techniques such as fractional photothermolysis, Ulthera, and microneedling RF (Fractora).

Another important factor is that, during surgical interventions, gold threads do not create any issues for the surgeon during tissue dissection.

When used according to medical indications, this technique is an excellent office-based procedure that expands the range of non-surgical facial rejuvenation options.

6. Conclusions

The main philosophy behind the implantation of gold threads lies in creating an additional connective tissue framework under the skin that integrates bone–skin and muscle–skin ligaments into a unified structure, stabilizing the tissue and counteracting skin ptosis. The process of gold thread implantation promotes neoangiogenesis, resulting in improved vascularization, enhanced metabolic processes, and tissue hydration, thereby improving the qualitative properties of the skin.

The advantage of gold threads over other types of non-absorbable threads is that gold breaks at the sites of facial skin folds, thus preventing skin deformation during facial expressions. The advantage over absorbable threads is that there is no lysis of the capsule surrounding the thread over time. The created framework, along with the bone–skin and muscle–skin ligaments, remains stable over time. Thus, the implantation of gold threads can slow down the process of ptosis of the soft tissue of the face and neck. Additionally, the procedure can be performed on an outpatient basis with a short recovery period.