Presentation (CTI)

OBJECTIVES: Aesthetic procedures are driven by patient choice rather than medical necessity, warranting a safety-centered appraisal distinct from conventional efficacy-based recommendation grading. A national HTA agency (NECA) conducted a systematic review of midface thread lifting and piloted a newly developed Safety Recommendation grading framework integrating risk level, evidence strength, and regulatory intensity.
METHODS: A systematic literature search of international and domestic databases (Ovid-MEDLINE, Ovid-EMBASE, Cochrane Library, KoreaMed, RISS, KISS) was conducted through October 2025. Studies reporting overall complication rates after absorbable suture-based midface thread lifting were eligible, and two independent reviewers performed screening and data extraction. Complications were classified as major (requiring active intervention: infection, hematoma, nerve injury, granuloma, tissue damage, or thread removal) or minor (self-resolving or conservatively managed: swelling, bruising, erythema, tenderness, dimpling). A four-tier grading system (S1-S4), integrating invasiveness, evidence quality, and regulatory considerations, was developed and piloted by a four-member plastic surgery advisory panel across four rounds, which assigned the final grade.
RESULTS: Eleven case series (469 patients; PDO predominant) were included. Major complications were absent in 9 of 11 studies (81.8%); where reported, rates were low (extrusion 5%, infection 6.2%, hematoma/bleeding 5%), mild, and resolved spontaneously within one month. Minor events (bruising, swelling, erythema, pain, dimpling, asymmetry) were common but transient and self-limiting. Most procedures were reported by board-certified plastic or dermatologic specialists. Applying the framework, the panel unanimously assigned grade S2 (conditional recommendation): more invasive than lasers/superficial peels (S1) but comparable in risk to fillers and botulinum toxin, permitted under specialist qualification and accredited facility/equipment conditions.
CONCLUSIONS: Midface thread lifting demonstrated a favorable safety profile. This study holds significance as a pilot in which a national HTA agency, together with practicing clinicians, analyzed the safety of an aesthetic procedure and collaboratively assigned a recommendation grade, illustrating a safety-centered appraisal model for cosmetic technologies.