PDO Thread Lift
There is a growing trend nowadays for patients to seek the least invasive treatments possible with less risk of complications and downtime to correct rhytides and ptosis characteristic of aging. Nonsurgical face and neck rejuvenation has been attempted with various types of interventions. Suture suspension of the face, although not a new idea, has gained prominence with the advent of the so called ‘‘lunch-time’’ face-lift. Surgical lifting with excision of excessive skin has been the standard of care for decades providing a radical solution and achieving dramatic improvements in the face and neck.
Recent appreciation and understanding of the essential vectors that need to be applied for proper soft tissues elevation have optimized the results by repositioning ptotic soft tissues in a more logical vertical direction. In many situations patients prefer minimally invasive procedures and are willing to trade a more modest degree of cosmetic improvement in exchange for decreased morbidity.
Nonsurgical rejuvenation by volumetric enhancement with various types of interventions including contour injections with a variety of gels or fat has added the ‘‘third dimension’’ to facial rejuvenation. However, though aesthetically pleasing results have been reported and may be achieved when performed by experts having an artistic ﬂare, rejuvenation with soft tissue ﬁllers in general may result in pufﬁness with unnatural contours, visually shifting the center of gravity of the face downward. Using chemical peels or any other ablative or nonablative resurfacing technique, on the other hand, makes it possible to obtain superﬁcial cutaneous improvement, but certainly will not adequately tighten and lift the underlying ptotic tissues, a critical step needed to achieve a more youthful appearance.
There have been lot of negativity regarding the thread lifts in various forums and claim inneffective. It is to be noted that these reviews are related to surgical thread lift or the suspension of SMAS or subperiosteal suspension to temporal fascia or bone anchoring. The cost involved in these procedures is high and the long term effects not worth the cost involved. The Biorevitalization with thread lifts are a recently picked up and act differently from conventional thread lifts or suspension surgeries. This article we discuss the role of PDO thread lift in asthetic practice.
Mechanism of action
Biostimulation is a treatment that consists of the infiltration into the dermis of a substance that is able to favour the production of new collagen and connective tissue. The objectives of the procedure are to improve the elasticity and turgor of the skin tissue, to increase skin firmness and anti-radical action: thus it is a rejuvenation program that operates full-thickness, on different structures and using different mechanisms. Today there are numerous techniques of biostimulation: Platelet-rich plasma (PRP), hyaluronic acid, nucleic acids, organic silicon, polylactic acid, wires, to name just a few. Even non-injected techniques can have biostimulation as their target: radiofrequency, laser, carboxy therapy and oxygen therapy.
The biostimulation inevitably produces functional variation of the cells in the tissue at which it is aimed, and this can be positive or negative. Some biostimulations produce dermal fibrosis as a result of an increase in type I collagen, with biological damage leading to the alteration of metabolic exchanges in the skin. Despite this, the aesthetic effect may be considered beneficial: the fibrosis causes the dermis to retract, producing a lifting effect in the skin.
This aesthetic improvement is accompanied by a loss of tissue function. The neosynthesis of fibrotic type I collagen, even if it produces an aesthetic improvement, always causes biological aging. To have a positive biological effect the collagen fibres synthesised must be predominantly type III.The biostimulation treatment with PDO wires determines neocollagenogenesis of a primarily fibrotic nature. This results in improved skin appearance due to the retraction effect it produces, but it also determines functional damage with compaction and stiffening of the collagen fibres and biological damage from the alteration of metabolic exchanges. So we are faced with biostimulation whose primary results are aesthetic improvement but which cause functional damage to cellular exchange.
The follow-up performed after 18 months showed by histological examination that when the stimulus is no longer present these modifications are partially reversible, because the fibrous type I collagen component remains elevated. When absorption of the threads is completed, the stimulation effect also stops, and at 18 months we witness a full recovery with a slight increase of fibrous type I collagen. The macroscopic-aesthetic improvement to the skin is associated with a negative biological effect with functional alterations.
Collagen induction around threads
For absorb able threads there are polydiaxone(PDO) , poly-L-lactic acid (PLLA) and Polycaprolactone (PCL). They vary in collagen induction and duration of effect. The Plain thread or Mono are used for collagen induction and applied in a grid pattern or mesh pattern. The Screw type induce higher volume of collagen and are to be used in areas of excessive movement like lips, nasolabial area. The cog thread are barbed with different types of barbs they are used for lifting the tissue and inducing collagen. They come in sharp needle and blunt cannula types.
Ideal patient is between 30-45 years with mild to moderate skin laxity, not excessive fat in skin, has realistic expectations, able to followup with repeat procedures.
Are the same as for most cosmetic treatments like fillers (HA etc.) botulinum toxin type A or any medical aesthetic treatment—one must take care. Patients with auto-immune connective tissue diseases must be excluded. Patients with high expectations are always of concern. Don’t sell the PDO thread treatments as a surgical replacement treatment or a treatment that is better than surgery. Patients who are Hepatitis B+, Hepatitis C+ and HIV+ pose more of a risk to the operator. Pregnancy is a contra-indication and so is breastfeeding if any lidocaine is going to be used. Anti-coagulant therapy (coumarin, etc.), existing infection in the treatment area and a history of keloid formation in the face and neck are contra-indications.
Be careful with patients taking aspirin—don’t terminate the treatment but warn them that they run the risk of bruising. Antibiotic prophylaxis is important in patients with bacterial endocarditis. Prescribe acyclovir to patients who are prone to herpes simplex labialis. Smoking has a detrimental effect on healing and tissue regeneration in general. Patients taking oral steroids or topical steroids on the PDO treatment areas can expect a less favourable end result.
Pre treatment procedure
The medical history is important to identify exclusion criteria and one has to ensure that informed consent is obtained. Barbed threads insertion requires antibiotic prophylaxis such as Azithromycin 500mg one hour before the procedure followed by 500mg 24h and 500mg 48h later. Antibiotic cover is not necessary for superficial plain mono thread insertion. If the treated area becomes infected, especially if barbed threads were inserted, it’s going to be very difficult to treat the infection because there is a foreign body in-situ and the threads may have to be removed. In the presence of infected barbed threads, local anaesthesia may not be effective due to the acidity of the infected tissue and the patient may require general anaesthesia.
The most important part of this whole treatment process is photography in order to establish pre-existing asymmetry. Patients may come back accusing the operator of creating asymmetry by using the threads, so make sure during the consultation to point out for example that one cheek is bigger than the other cheek and have a photograph to prove it.
Clean the treatment area very well with surgical spirits, betadine or chlorhexidine. Cover the patient’s hair with two caps and apply sterile drapes. Apply topical anaesthesia for dermal insertion of plain mono threads.
Mark the treatment area with a marker pencil. Put on sterile gloves.
For PDO barbed threads, inject 1.0ml of lidocaine plus 1:80,000 adrenaline (dental 2.2ml cartridge) into the insertion area. Then take a 1 ml syringe (with luer-lok) and aspirate 1.0ml of 3% lidocaine and connect it up to the thread cannula (Dr Irfan Mian’s technique). During insertion of the cannula, if there’s any discomfort, inject 0.05 ml, wait for 30 seconds and continue to insert the cannula. This way there is no distortion due to a lot of tumescent anaesthetic and one can observe an immediate mechanical lift, and more importantly the patient can see it too!
Very importantly, superficial dermal or subcutaneous threads are inserted with a sharp needle but barbed threads of 19G have to be inserted via a cannula in order to reduce the risk of facial nerve trauma and large blood vessel trauma (such as the facial artery). Extra care has to be taken in the region where the facial nerve is crossing the zygomatic bone because it runs very superficially in this region. Below the zygomatic bone, the facial nerve runs deep underneath the parotid glands so it’s a low risk area.
It is also important during the treatment that once the one half of the face is finished, to sit the patient up and take photographs to demonstrate the difference between the treated side and the non-treated side. It’s very important from the patient’s point of view to be able to see that there is an instant effect visible for we can forget very quickly how we looked like.
A single entry point for barbed threads insertion, where all the barbs come together, is important because it results in a lot of new collagen regeneration and fibrosis in the insertion area that is acting as an anchor and hold up the lift. The entry point is above the zygomatic arch and the cannulas pass through the zygmatic retaining ligament superiorly and through false ligaments and connective tissue bands (septa) distally. These structures provide ample anchoring points for maintaining the mechanical lift.
The first cannula passes through the malar region and importantly must pass through the nasolabial fold. This will achieve an instant nasolabial (N-L) lift—as good as any filler agent. For deep N-L folds, one can add additional fillers. If balancing of cheek volume is required then fillers can be combined with threads in the malar region.
The second end-point is near the corner of the mouth to elevate it.
The third cannula passes through the mandibular ligament and the marionette lines. There’s a special technique to pass the cannula through the ligament.
In the mandible and jowl area, the fourth and fifth barbed threads give an instant mechanical lift. It is important to also insert mono threads in the dermis over the mandibular region in order to create a cross-hatched fibrotic mesh effect—fibrous bridging occurs between the skin, mono threads and the deeper barbed threads.
Compression and icepacks may be necessary if bruising is present due to dermal mono threads. Barbed threads inserted via a cannula do not cause bruising!
Apply an antibiotic cream (Bactroban/Fucidin) to the entry point and cover it with a plaster for 24 hours. Clean the treated area with surgical spirits, betadine or chlorhexidine.
An SPF 30 is advised to avoid post-inflammatory hyperpigmentation (PIH), especially in Fitzpatrick skin types IV-VI. Avoid making long dental appointments for at least four weeks after treatment because mouth opening may be restricted. No facial massaging for two weeks and blood thinning herbs and vitamins like Vitamin E should be terminated seven days before the treatment and for another seven days post treatment. For discomfort, paracetamol should be sufficient and NSAIDs like ibuprofen should be avoided because inflammation is necessary for fibrosis. No alcohol for three days post treatment and no sauna for seven days. Arnica (a herb) may be effective against swelling.
Complications include swelling for a few days. Bruising is more likely when using a needle and may last for 10-14 days. Infection can occur due to the deep barbed threads . A foreign body reaction (granuloma) can occur in the epidermis if the plain mono threads are not inserted deep enough. Due to discomfort and restricted mouth opening the patient mustn’t book dental appointments.
The thread can migrate, especially with uni or bi-directional cogs. One has to be very careful when using bi-directional cogs—make sure that they are sufficiently embedded underneath the skin because they can migrate out of the insertion point. Barbed thread protrusion is possible if the threads are not cut short enough at the entry point. Facial nerve trauma is more likely when using a needle. Beware of asymmetry. If the thread is visible, one can remove it by just using a green needle, and some local anaesthetic around the thread. Stick the needle in and hook it out—it’s easy to remove it but you must do it in the first two weeks.
One can combine threads with platelet-rich plasma, botulinum toxin type A, fillers and dermarollers.
PRP is usually injected during barbed threads insertion and it can also be combined with dermarolleing of the skin after threads insertion.
Don’t combine threads with heat generating devices such as lasers or RF before 12 weeks because the heat will cause distortion of the threads.
Patients treated with liquid PLLA treatment before have not presented with problems related to excess fibrosis. Similarly, no problems have been experienced in treating former facial surgery patients.
- Choose the right patient, with minimal to moderate sagging have good soft tissue volume, less facial fat. Do not try to sell PDO lifts as an alternative to surgical procedure the results are moderate and patient may end up unhappy with results.
- Avoid patient with thin skin in which there is more chances of suture show, rippling effect and more bruising.
- It is postulated that a sinuous passage of the barbed suture is preferable to a straight one and both barbed and conventional sutures hold best when they engage connective tissue at a right angle to the collagen bundles. As the suture is tightened, a wavy path straightens causing alternative vectors of force pushing against the suture. If a suture begins to pull out, new ﬁbers then become pressed against the barbs. In contrast, the barbs in a suture that traverses a straight line will only encounter a loosened column of tissue as it is pulled out. Undulations impart also elasticity, helping to prevent suture breakage, particularly with ballistic movements of the engaged tissue.
- Use PDO threads in the first session if patient is happy with results and opts for a subsequent procedure suggest the use of PLLA threads they are more long lasting upto 2-3 years.
- Use tornedo sutures in areas where greater volume is required like nasolabial folts, lip margin etc, mono threads as a mesh to support the tissue. The cog thread are not enough in effective lift as over time get disintegrated its always better to augment the lift effect of cog threads with grid of mono threads as the over all collagen induction produces better lift over time.
- Always combine thread lifts with other modalities of collagen induction as thread lifts induce only collagen 1 which is not ideal in long run due to functional damage. Do not combine with laser and RF within 12 wks of thread lifts.
- Use micro cannulas liposuction / Injection lipolysis for double chin to reduce fat and use of thread lift for skin tightning.
- Avoid use of larger size cog threads to over come excessive skin sagging as the complications are higher and over long term have poorer results than multiple smaller size cog threads.