CLINICAL ▼

Polydioxanone thread lifting:

considerations and patient expectations

Thread lifting and facial tissues

Abstract Although dermal fillers can correct facial structure
The thread lift is becoming an increasingly popular treatment within the field and restore lost volume, reducing facial sagging and
of aesthetic medicine. The procedure can be performed using polydioxanone minimising the appearance of wrinkles, they do not
(PDO) threads to lift, tighten and rejuvenate areas of sagging skin, and minimise specifically target issues related to the quality of the
fatty tissue. This allows for the non-surgical redefinition of facial contours overlying skin. Lifting of facial tissues with threads, in
and enhancement of skin integrity. Thread lifting with PDO can also provide specific areas, allows for more targeted treatment of
certain aspects of the much sought after surgical facelift in a clinic setting. PDO the skin and superficial tissues. PDO threads can also
threads aim to promote targeted lipolysis of fatty areas and neocollagenesis in be used to address concerns in other parts of the body,
sagging skin, as well as lift the treated areas. However, it is important to note including the neck, chest and arms.
that the extent of these enhancements varies between individuals, and can The use of threads in aesthetic practice is now in
carry unwanted side effects. The author draws on his experience to discuss its third decade (Paul, 2013). Initial thread treatments
the importance of managing patient expectations pre and post PDO thread involved a minor surgical procedure and the use of
lifting, describe the treatment’s mechanisms of action, and highlight important non-absorbable permanent threads. Aptos (anti-ptosis)
considerations for aesthetic practitioners who wish to pursue these treatments. threads were proposed in 1998 as such a method for
lifting drooping facial tissues, such as the cheeks or
Key words jowls (Sulamanidze et al, 2001). These threads used
► Thread lift ► Polydioxanone ► Monofilament ► Absorbable ► Expectations non-absorbable plastic sutures with small teeth (barbs)
cut into the suture material. This would then be passed
subcutaneously in a caudal direction, starting in the

F
acial ageing remains a multifactorial process temporal area to finish at the problematic region. The
that involves changes to the structure, support, proximal end of the thread would then be fixed to the
volume and quality of tissues. Loss of skin quality fascia of the temporalis muscle, following moderate
is often the most obvious sign of ageing; patients lifting (Sulamanidze and Sulamanidze, 2008).
are distressed by the development of wrinkles and the Techniques have evolved along with thread materials.
appearance of skin laxity. As a result, many people opt PDO threads provide a more superficial, non-surgical
to undergo non-surgical aesthetic procedures to create approach to treating wrinkles and laxity than historical
a more youthful facial structure and restore lost volume. thread treatments. They are colourless or dyed, and
In addition to dermal fillers, thread lifting is are bioabsorbable. PDO threads have a rubbery texture
increasingly being requested by patients to address their at room temperature, a melting point of 110o°C, and a
facial ageing concerns. One of the main benefits of thread bioabsorption period of about 6 months (Tiberiu, 2011).
lifting is the ability to have treatment in a clinical setting During this time, minimal foreign body tissue reaction is
using only local anaesthesia, rather than undergoing noted the vicinity of the implant, allowing for retention
more invasive surgery involving a general anaesthetic. of the thread (Tiberiu, 2011; Collier, 2015).
This paper will focus on facial polydioxanone (PDO) PDO threads come in several different preparations
monofilament thread lifting, and outline its indications and vary by number of filaments, with the simplest
and contraindications. The author will draw on his variant being a monofilament straight unbarbed thread.
experience of managing patient expectations of thread These threads are in keeping with expectations of non-
lifting and recommend appropriate aftercare advice. surgical facial lifting techniques, aiming to provide
support and encourage skin and soft tissue improvement
© 2016 MA Healthcare Ltd

in the treated area. Less trauma and tissue invasion is

VIKRAM SWAMINATHAN required than when undergoing surgical lifting.
Academic Lead, British College of Aesthetic Medicine,
and Associate Editor, Journal of Aesthetic Medicine. Mechanisms of action
e: [email protected] Thread lifting is reliant on two mechanisms: physical
thread strength to lift and hold sagging tissues, and

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 ▼ CLINICAL

the biological processes to improve skin and soft tissue Thread insertion
quality as a reaction to the threads. The use of PDO A comprehensive knowledge of facial anatomy is crucial
in tissues has been studied for over  20  years (Lerwick, before inserting PDO threads. Delivery of the thread
1983). In the 1980s, preclinical animal studies showed is via a sharp needle (18–31 gauge, 30–150 mm length).
that PDO threads have desirable characteristics, with a Using conventional methods for insertion, there is no
reliable absorption profile and retention of strength over ability to aspirate and check for flashback (aspiration
a prolonged period (Lerwick, 1983). The absorption of of blood into an attached syringe, suggesting potential
PDO threads takes up to 6 months, which is longer than insertion of the needle into a blood vessel), as there is
other suture materials (e.g. polyglactin 910, polyglycolic no syringe attached to the ends of the threads. In the
acid) (Suh et al, 2015). As a slowly absorbable polymer, author’s experience, this can result in profound bruising
the use of PDO in facial rejuvenation has been shown and care must be taken to identify the direction, length
to be sufficient in lifting tissues with minimal long-term and depth of the needle when deploying threads.
concerns (Ruff, 2006).
Biological processes are known to occur following the Complications
insertion of PDO threads into tissues, which have been Common complications arising from non-surgical
found to influence a variety of structural and chemical aesthetic procedures include bruising (Figure 1), swelling
units. For example, in vivo rodent models have shown and infection (Figure 2) (Swaminathan, 2016). These are
tissue reaction, including the presence of fibroblasts and also important considerations for thread treatments.
macrophages, occurring within 5 days of implantation Although PDO in monofilament form is less likely
into subcutaneous tissues (Tiberiu, 2011). The presence to contain bacteria, the use of prophylactic antibiotics
of increased fibroblasts and macrophages may remain should be considered given the multiple puncture
until the full absorption of the material (Tiberiu, 2011). wounds performed and tissue tracts created during
Myofibroblasts found around threads have also been thread lifting (Tajirian and Goldberg, 2010). However,
shown to influence fibrous tissue contracture 4 weeks evidence is limited to show the benefit of antibiotic use
after insertion (Jang et al, 2005). following PDO thread treatment, so medication should
Histological studies have demonstrated the presence of only be prescribed to patients on a case-by-case basis
thicker dermal papillae following PDO thread insertion, (Tajirian and Goldberg, 2010).
suggesting interstitial growth of new collagen components Swelling normally subsides within 2–3 days following
(neocollagenesis) (Savoia et al, 2014). All of these processes treatment; however, bruising can be extensive and this
aid in the reduction of tissue laxity and help to rejuvenate should be a key factor for practitioners when selecting an
the structure and appearance of skin, enhancing the lift appropriate treatment.
obtained up to the endpoint of treatment (described by
trainers as about 1 year post treatment). Managing expectations
Perhaps the most important consideration when
Treatment considerations providing non-surgical aesthetic procedures is managing
Contraindications patient expectations. In the author’s experience of using
Suitability should be discussed during the pre-treatment PDO threads, patients significantly misunderstand the
patient consultation (e.g. will the threads work and are purpose and outcomes of the treatment. Patients often
there any expected complications following treatment?). have the impression that thread lifting is similar to a
As explained, the properties of PDO threads include surgical facelift, holding back their ageing features, and
a tissue reaction to synthesise relevant proteins and they expect immediate results following implantation.
molecules in the treated area, including collagen. In addition, patients often have little awareness of the
Relative contraindications to treatment with PDO potential complications associated with the treatment,
threads include patients who are immunosuppressed the time required for the tissue reaction to create
or are on medications that can dampen an immune visually noticeable results, and any alternative treatment
response or prolong clotting time. Any potential blood options. PDO threads provide an alternative method
vessel damage could lead to extensive bleeding in these to address patient concerns, without the need to inject
patients, and reduced immunity will impair their ability volumising agents or medical toxins; however, if these
to counteract infection. latter procedures are more appropriate, this should be
In addition, these patients may not implement the relayed to the patient. It may remain that thread lifting
© 2016 MA Healthcare Ltd

required biological processes to an extent required to is the treatment of choice to address their concerns,
produce a noticeable treatment effect. Based on his but this decision must be made after a comprehensive
experience, the author would suggest it is important discussion with the patient. The use of threads is often
to understand that even suitable patients have been part of a multimodality treatment plan.
seen to not react to threads as expected, resulting in a Patients should also be made aware how PDO threads
minimal treatment effect at the endpoint. work, to the extent that they know the effects will

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 CLINICAL ▼

volume loss may be best treated with soft tissue fillers,

with subsequent threading performed as adjuvant to
improve the overlying soft tissue and skin quality.

Patient education and reassurance

Patients should be educated on the potential severity of
thread lifting complications, and given advice on how
to manage them. Post treatment, practitioners need
to ensure that patients are able to report any concerns
or complications, and that they can see an appropriate
practitioner if required.
As complications can be severe, highlighting worst-
case scenarios to patients during their consultation will
help them to make an informed decision on whether
to undergo treatment. In the author’s experience of
managing complications, bruising can extend to cause
Figure 1. Bruising following polydioxanone thread lifting to the lower face a severely bruised jaw or the appearance of a black eye,
depending on area treated, which can take several weeks
to completely resolve. This can lead to embarrassment
for the patient in social situations, with withdrawal from
activities until the symptoms resolve. Other associated
risks include infection, tenderness, numbness and facial
asymmetry; however, most of these symptoms settle in
the post-treatment period.
Often the patient needs reassurance throughout this
period. They should be reviewed on a regular basis to
make sure their symptoms are resolving. If persistence
or worsening of bruising continues, the patient should
be referred to an experienced PDO practitioner or
appropriate speciality to address and manage the patient.
As with complications following botulinum toxin
and soft tissue filler treatment, prompt recognition
of a problem and appropriate patient management is
often enough to get through the troublesome period.
Figure 2. Infection causing delayed healing at thread insertion site in mid-face It is important for practitioners to acknowledge the
occurrence of a complication beyond their management
progress slowly over 1 year, with the endpoint remaining competence. In this case, there is a need for timely referral
for another year on average. Furthermore, patients must to an appropriate clinician, such as an experienced
be aware that treatment outcomes are variable and PDO practitioner or hospital specialist, to reduce the
dependent on their response to the thread. This will likelihood of residual permanent disability.
help alleviate much anxiety about the progression of the
treatment effects; in the author’s experience, one reason Aftercare
for a repeat consultation following thread treatment is Appropriate aftercare should be given to all patients.
due to patient concerns about the lack of progress seen. Post-treatment advice remains important, including
In all cases, it is important to avoid inappropriate directions for cold compression to areas of bruising and
use of PDO threads, resulting in inadequate clinical swelling, and avoidance of the application of potentially
improvement. Poor results obtained following PDO contaminating facial cosmetics until the thread entry
treatment can be avoided by careful patient selection points have healed.
and effective management of expectations from the Inherent to their synthesis, PDO threads can denature
start. Inappropriate patient selection can result in no at extreme temperatures; however, with a melting
© 2016 MA Healthcare Ltd

noticeable change at the endpoint and, ultimately, point of 110o°C, it remains unlikely that they would
disappointment. One must consider the immediate break down in an accelerated fashion once implanted
needs of the patient, with regards their short-term goals (Tiberiu, 2011). To minimise damaging the threads
for aesthetic treatment. Following the consultation, once implanted, patients are advised to avoid exposure
alternative treatments may provide the results required to extreme temperatures within the first 4 weeks (e.g.
to address their concerns. For example, ageing related to sauna, light-based treatments), as there is ongoing tissue

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 ▼ CLINICAL

reaction and associated fibrous tissue contracture still

occurring 4 weeks after insertion (Jang et al, 2005). The Key points
thread also forms a homogeneous fibrous capsule around ►► Skin ageing is an import component of aesthetic
it during this period, which helps to preserve the traction medicine, which is not directly treated by more
of tissues (Suh et al, 2015). traditional cosmetic interventions, such as botulinum
toxin and dermal fillers
Conclusion ►► Polydioxanone (PDO) thread treatments can
PDO thread lifting is a valid treatment option for facial biologically rejuvenate the quality of skin and lift the
ageing and related patient concerns. This procedure treated area(s), by improving contractility of tissues
improves tissue structure, and induces neocollagenesis and providing mechanical support
and contractility effects within targeted areas. This ►► Clinical effects seen following PDO thread treatment
article has not discussed more complex multifilament, are variable between patients
multidirectional, barbed or cog PDO thread treatments; ►► It is important to educate patients before treatment
however, in the author’s experience, excellent results can with PDO threads to manage their expectations
be reported following PDO monofilament treatment, ►► Treatment with PDO threads can be effective in
providing tightness and lift in the treated areas is appropriately selected and counselled patients
maintained for up to 18–24 months in appropriately
selected patients. The use of PDO threads as an adjuvant
Ruff G (2006) Technique and uses for absorbable barbed sutures.
therapy to other aesthetic procedures works well to Aesthet Surg J 26(5): 620–8. doi: 10.1016/j.asj.2006.08.011
enhance treatment effects already gained, or to improve Savoia A, Accardo C, Vannini F, Di Pasquale B, Baldi A (2014)
inadequate results following alternative treatments. Outcomes in thread lift for facial rejuvenation: a study
performed with happy lift revitalizing. Dermatol Ther (Heidelb)
It is important to discuss the role of threads with
4(1): 103–14. doi: 10.1007/s13555-014-0041-6
potentially suitable patients, ascertain understanding
Sulamanidze M, Shiffman, Paikidze T, Sulamanidze G (2001) Facial
and educate comprehensively. Patients must be aware of lifting with APTOS threads. International Journal of Cosmetic
the potential complications. For all aesthetic procedures, Surgery and Aesthetic Dermatology 3: 275–81
the best patient-reported results are obtained when goals Sulamanidze M, Sulamanidze G (2008) Facial lifting with Aptos
methods. J Cutan Aesthet Surg 1(1): 7–11. doi: 10.4103/0974-
and expectations are discussed from the start.  2077.41149
Swaminathan V (2016) Short term complications following
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