PDO Thread Lifting 101

Facial Thread Lifting is a quick, minimally invasive treatment for people with aging facial features; but who are not ready for a surgical facelift, which removes large areas of excessive skin, fat and tissue. A thread lift can help lift the face – inserting threads through small punctures to the skin which later become invisible - and can be used anywhere on the face where a gentle lifting is desired.

What is PDO?

PDO is a colourless, crystalline, biodegradable synthetic non-animal based polymer. Chemically it is based on a polymeric structure composed of multiple repeat ether-ester subunits. It is obtained by ring-opening polymerisation of the monomer p-dioxanone.

The medical device manufacturer Ethicon first used polydioxanone suture technology worldwide for over a decade as a means of wound closure. In South Korea polydioxanone has seen a revolution with PDO threads being used for the last seven years both for orthopaedic and cosmetic indications.

The History of PDO Threads

Historically, the earliest reports of surgical facial rejuvenation go back as far as 1911 by Koll et al. The use of endoscopic malar and midface suspensions were reported by Anderson and Lo et al. in 1998, which paved the way for the future use of thread lifting suture technology as a means of facilitating facial augmentation non-surgically. It was not until four years later in 2002 when Sasaki and Cohen provided the first definitive report of malar fat pad elevation, using a variety of suture material from polypropylene, polyglactin 910, Gore-Tex and Vicryl. This work was further supported in 2002 when non-barbed suture suspensions were used with temporal fascia fixation in bringing about midface augmentation. The first description of barbed suture suspensions to be commercialised was presented in 186 patients by Sulamanidze et al. when the Aptos [anti-ptosis sub-dermal suspension] was described. In 2004, contour threads permanent non-absorbable sutures were introduced to anchor temporal fascia, derived once again using a polypropylene base. These barbed threads were configured in a helicoidal pattern, but failed to gain momentum owing to their "permanence".

PDO has a long safety record in surgery. In South Korea, Polydioxanone has been used for over seven years in orthopaedics ( to treat frozen shoulders, tennis elbow, golfer's elbow, etc.) and in cosmetics (for skin rejuvenation, skin tightening and face 'lifting' indications).

The popularity of PDO threads can be attributed to the safety of Polydioxanone, ease of insertion of the threads, excellent reproducible and sustainable results, minor side effects and the very low incidence of complications.

More recently, in 2011 the Korean FDA approved the use of non-barbed absorbable suture suspensions using polydioxanone as an indication in lipolysis, collagen regeneration, neo-vascularisation in the subcutis and dermis.

Why use polydioxanone?

The main advantage is that PDO is biodegradable. This synthetic polymer is highly versatile and was originally used as a mono- or multi-filament thread. Biodegradation of PDO occurs through a process of hydrolysis over a time period of between six to eight months. The main method of elimination is via the kidneys.

In contrast, the introduction of a poly-L lactic acid coated fine suture using bidirectional cones, was also introduced as means of addressing issues of facial rejuvenation a number of years ago. Silhouette Soft is inserted in the sub-dermal and adipose tissue. A number of issues using this type of technology have been identified; its underlying weak tensile strength, issues of repositioning of the cones, granuloma formation, an increased risk of skin puckering, cone visibility and a lack of lipolysis are limiting factors.

The principal mode of action of polydioxanone in the dermis was first thought to be wholly reliant on the creation of new collagen by a foreign body reaction, which promoted wound healing through tissue contraction. This traditional view of shortening of collagen failed to fully explain what was happening on a histological level. Howe and co-workers in 2006, identified that subcutaneous tissue fibroblasts exhibited greater pleomorphism than originally postulated being responsible for cytoskeletal remodeling, and this was evidenced by a process defined as mechano-transduction, where fibroblasts are able to self-sense, process and respond to mechanical stimuli in their microenvironment and importantly regulate physiological function nearby. The overall effect of this sees actin polymerisation following matrix deformation by external mechanical stimuli. The polymerised actin facilitates cell contraction and activation of the mitogen activated protein kinases (extracellular signal regulated kinases 1 and 2 – ERK1/2) which in turn regulates gene expression, protein synthesis, extracellular matrix modification, cell differentiation, and potentially promotes tissue growth.

The underlying mechanisms that define the regenerative changes that take place in the dermis and subcutis from polydioxanone threads includes neo-collagenesis (Fig 1C/E) from a foreign body reaction (Fig 1B), microcirculation stimulation, increased metabolism, lipolysis, muscle relaxation and increased tissue adhesion.

In summary, a foreign body reaction is observed together with elastic fibrosis around the area where the thread is inserted. Importantly, studies have shown that increasing the density of threads, that when placed either in multi-layers and or in close apposition, creates a denser structural supporting framework.

Indications

Apart from the way in which threads are placed, the diversity amongst the different types of PDO threads currently available allows the experienced and well-informed clinician to tackle many of the aesthetic issues requiring augmentation.

The indications for PDO threads are as follows:

1. Face Contouring · Cheek enhancement · Jawline lift · Brow lift · Nose augmentation

2. Wrinkle attenuation · Crow's feet and peri-orbital zone · Forehead · Cheeks · Upper lip · Volumisation

3. Skin rejuvenation—general and of atrophic scars

4. Skin tightening

5. Pore size reduction

6. Volume reduction (lipolysis)

7. Hair rejuvenation

8. Neck lift · Double chin reduction · Platysmal relaxation—vertical and horizontal

9. Muscle relaxation · Masseter · Glabella · Soleus · Corrugators · Orbicularis (infero-lateral) · Back

10. Body contouring · Upper arm and chest tightening · Abdominal tightening and reduction · Cellulite · Knee lift · Ankle reduction

11. Tissue healing and pain control · Tendonopathies

What happens during a Thread Lift operation?

The procedure

This procedure is usually performed using a local anaesthetic. Implantation and positioning of the threads is quick and takes approximately 30 minutes to 2 hours depending on the number of areas being treated and the type of threads used. Two kinds of threads are usually used for treatment – free floating barbed threads and/or suspension or smooth threads.

Free floating barbed threads

Using a hollow guiding needle, the barbed threads are inserted into the subcutaneous fat under the skin, through small incision points made by the needle. The needle containing the thread is then positioned to provide the required correction and removed. The microscopic cogs on the threads then attach to the underside of the skin and gently lift the skin and secure it in the desired position. The excess thread is trimmed.

Suspension or smooth threads

Suspension threads are inserted into the skin using a standard needle, but in order for them to sustain a lift they do need to be attached to the so called “anchoring point”. The anchoring points are stable points of the scalp or face, and they are different for the different areas of the face and body.

Results

One treatment per area is usually all that is required to achieve the desired effect, often with immediate visible results, even more so after about 3 - 4 weeks. However, the results continue to improve over a 3 - 6 month period as your own collagen begins to grow around the threads aiding the lifting effect. The effects of a thread lift using barbed threads are said to last up to 3 years.

Who is ideal for this procedure?

This procedure does not produce changes as drastic as the traditional facelift and is not permanent, lasting a few years; therefore, it is best suited to younger patients (generally 30 to 60 years old).

How long will it take to recover from a Thread Lift?

Recovery is generally quick, with most patients returning to work the next day. However, you may find that your facial movement is limited for the first two weeks.

1. You can resume normal activities (light walking, watching television etc.) after the procedure but you should take it easy during the first few days.

2. You should not talk or smile excessively or make exaggerated facial movements for the first few days.

3. You should not sleep on your face for the first week.

4. You should not massage, rub or apply pressure to your face for one month as this could disturb the threads.

What are the risks and potential complications from Thread Lift surgery?

Although not as invasive as other lifting procedures, the area treated will often be sore with some swelling or puffiness for a few days, with possibly bruising which will last about a week.

Side effects and risks are minimal and rare but may include:

1. Patients may develop a pucker; this can again be remedied by your doctor lightly massaging the area.

2. Scarring from the insertion of the needle is minimal but is nonetheless possible, particularly in patients with dark coloured skin.

To learn more about the advanced Korean thread lifting technique, sign up for the Hands-on Korean Thread Lifting Master Course now!