Background: There are intrinsic difference facial aesthetics between Asian and Caucasian, as well as racial differences in beauty standards. Bi-directional cones threads are effective in mid-face lifting but there was yet no study in Asians.Objective: This study aimed to determine the effects on mid-face laxity the effect size of using bidirectional cone suture for facelifting in Asian patients. Methods:In this prospective study, three pairs of bidirectional cone threads were used for mid-face lifting in 10 healthy volunteers with mild-to-moderate facial laxity. Results:The validated assessment parameters used in the study were the facial laxity rating scale (FLRS) to evaluate the severity of mid-face laxity and the wrinkle severity rating scale (WSRS) to assess the severity of the nasolabial fold (NLF). Overall, there was a substantial improvement in mid-face laxity and the NLF after thread lifting, supported by treatment effect size (Kendall W's value: 0.96 and 0.85, respectively). Significant improvements for both mid-face laxity and NLF were observed in all patients by 3 months (p<0.05), with significant differences in FLRS (p=0.000) and WSRS (p=0.001). At each follow-up, all patients would complete a selfadministered questionnaire that included the subjective satisfaction rating scale. The results showed that patient satisfaction was substantially improved; the differences between baseline and the 6-week and 3-month follow-up were significant (p<0.05), and the treatment effect size was W=0.950 (p<0.05). All subjects tolerated the procedure well with transient and minimal side effects. Conclusion:In Asians with mild-to-moderate laxity, absorbable cones sutures produced considerable improvement in mid-face laxity and NLF within three months. The findings were consistent among the three reviewers and were statistically significant (p<0.05). Patient satisfaction was higher at the 6-week and 3-month follow-up compared to the baseline (p<0.05).

Soft tissue ptosis occurs with age, leading to loss of facial volume. The facial retaining ligamentous system is an intricate network of fibrous tissues connecting the whole face, restraining soft tissues from gravitational forces, and opposing facial movements. With proper positioning and anchorage within the ligamentous grid and superficial fat repositioning, lifting the mid-face and adjacent areas (e.g., jowl) is likely to occur. We aimed to determine whether inserting 3 pairs of bidirectional cone sutures can effectively improve the nasolabial fold (mid-face) and jowl (lower face) in Asian patients with mild to moderate mid-face laxity at 6 months and 12 months. Ten healthy volunteers with mild to moderate facial laxity received 3 pairs of bidirectional cone threads, inserted in a straight parallel technique. Based on validated evaluation parameters: facial laxity rating scale (FLRS) and the wrinkle severity rating scale, a total of 7 independent reviewers, among which 3 assessed the change in mid-face laxity (nasolabial fold), and the other 4 reviewers evaluated the change in jowl or lower face contour based on FLRS at 6 months and 12 months. All reviewers were experienced esthetic doctors. According to the reviewers' evaluation based on the validated parameters, there was a linear improvement in the mid-face laxity/nasolabial fold and lower face laxity/jawline contour self-reporting patients' satisfaction at 6 months and 12 months compared to baseline in all 10 patients. There was continuous improvement in mid-face laxity and lower face laxity from baseline, 6 months, and 12 months after treatment. The evaluation results among the reviewers were similar, apart from reviewer 7. All patients gave their best rating at 12 months, and their satisfaction almost doubled compared to that before treatment.