March29, 2023

Abstract Volume: 5 Issue: 3 ISSN:

Ashary pyramidal Technique for permanent face thread lifting

Ibrahim Ashary. MD *

Corresponding Author: Ibrahim Ashary. MD, Consultant plastic surgery and laser specialist, Saudi Arabia.

Copy Right: © 2022 Ibrahim Ashary. MD, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: May 16, 2022

Published Date: June 01, 2022



Because of the surging popularity of cosmetic treatments in social media, people in today’s society are more conscious about staying young and looking young. When there is bone resorption & distortion, soft tissue atrophy and shrinkage, tissue displacement due to deflation and gravity, compensatory over activity & hypertrophy of central muscles, skin changes (Shrinking Process), loss of teeth, laxity of the orbital septum, laxity and descent of the orbicularis muscle, descent of the lid-cheek junction, descent of the cheek fat pad with laxity of the orbitomalar ligament, laxity of the zygomaticus muscles and other elevators of the upper lip, deepening of the nasolabial fold in the face, people tend to seek help from dermatologists and plastic surgeons. Most people who have the means, decide for a surgical facelift however majority of the people opt for an easier, less costly procedure like fillers, ultrasound, radio frequency machines, botox and thread lifting; among these procedures thread lifting stood out because it has a similar effect that of surgical face lifting, stay longer and yet cost less than its surgical counterpart. Ashary pyramidal technique, among others, is one of the most satisfactory techniques in thread lifting. Coupled with Ashary threads, these are two factors that contribute to an adequate outcome among patients. This study aims to differentiate Ashary technique.

Ashary pyramidal Technique for permanent face thread lifting


Thread-lifting are becoming more popular among surgeons and patients as an alternative to traditional surgical rhytidectomy or neck lifting. The reason is, most patients are skeptical about surgical face lifting and thread lifting have lesser cost and down time. Ashary Pyramidal technique in thread lifting was made in the intention of having a long-lasting effect on patients going through a less invasive procedures. This technique has stood out among the other techniques because it uses vertical traction targeting SMAS and uses different types of threads that suits the patients need which differs from most practitioners. The SMAS or the superficial musculoaponeurotic system is the main target of this technique because of its anatomic significance. Anatomically, the SMAS is inferior to the zygomatic arch and superior to the platysma's muscular belly. The SMAS's fibromuscular layer connects to the superficial temporal fascia and frontalis muscle superiorly and the platysma muscle inferiorly. The SMAS is sometimes referred to as a fibrous degeneration of the platysma muscle. However, there are variations not just in its anatomical placement, but also in its overall morphology and basic terminology. Despite disparities, the SMAS unquestionably performs an important function in providing facial flexibility and stability, as well as facilitating coordination of cheek muscle activity. SMAS serves as a linen that when pulled the rest of the structure goes with it (see fig 1). Also, this technique targets not just the laxity of the face but also helps in the improvement of the neck (see Fig 2). In the care of the aging neck, three anatomic and surgical planes are involved: the superficial plane (subcutaneous fat), the intermediate plane (platysma muscles and the fat between the two muscles), and the deep plane (subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands). These planes must be thoroughly reviewed in the preoperative examination and treated with according to the demands of each patient. The neck shape and the cervicomental angle are critical factors of overall facial attractiveness. Almost all facelift operations (including thread lifting but is limited to minor laxity), particularly those involving the superficial muscular aponeurotic system (SMAS), have an effect on the neck, notably the jawline. This may be sufficient for a small number of patients, whilst others will require more intensive treatments to correct the neck contour.


Material and Method

A retrospective review of Ashary technique (See fig 3,3-a,3-b for Ashary concept) was performed from April 2018 to April 2022. In total, 102 patients (all women; age, 35-60 years) underwent a midface thread lift. The procedure was performed with the patient under general or local anesthesia and intravenous sedation. An imaginary assumption of the exterior branches of the facial nerve should be presumed in order to safely insert the threads(see fig 4,4-a,4-b,4-c,4-d,4-e,4-f) . The face was marked (resembles like a pyramid shape) preoperatively to determine the appropriate vector of the thread and its fixation points. The incision is approximately 2cm anterosuperior to the Helix. After a small temporal incision was made, the marked part of the face is then infiltrated with 2% 50ml 2% lidocaine 1:100,000 epinephrine carried all the way down to the deep temporal fascia to create a plane between the superficial and deep temporal fascia. Using blunt 18-G pre-cannulated PDO cog threads were inserted in a posteromedial direction from the temporal incision to the lower face through the sub-submucosal aponeurotic system (sub-SMAS) plane, which was marked preoperatively, targeting the deep medial fat pad and inner layer of the superficial muscular aponeurotic system. The threads were anchored to the periosteum of the temporal area, suspending the soft tissue to a more superior direction. Surgical results were evaluated subjectively (patient satisfaction ratings) and objectively (blinded physician ratings based on changes in the vertical position of the malar highlight and using serial photography). After the pull, the distal sutures were trimmed, and the proximal ends were secured on the deep temporal fascia. Small incision was closed with vicryl 3.0.



After surgery, all but two patients (100/102, 98.1 percent) were pleased with the results. Objective outcomes were rated "excellent," "good," "fair" and “bad” by two independent plastic surgeons, and the postoperative course was uneventful except for one patient (1/102, 1 percent) swelling and another patient (1/102, 1 percent) who experienced infection in the incision site. These two complex situations were resolved naturally, without the need for surgical intervention.



The presented technique has a number of advantages over existing approaches. First, the use of nonabsorbable sutures with enough maintenance potential can result in long-lasting, satisfactory results. Second, by using the authors' Ashary thread, you can have a maximum pull (see fig) which has long staying satisfactory effect. Lastly, using Ashary pyramidal technique and thumb technique for the facial nerves ensures a safer, deeper than typical lift approach, including SMAS and sub-SMAS devoid of essential structures, can avoid any traction line during rest or animation without substantial difficulties.


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