Lifting the Lower Face With an Absorbable Polydioxanone (PDO) Thread

Loss of tissue elasticity and volume are part of aging. These changes have been attributed to alterations in the formation of collagen.¹ In the face, such alterations are manifested by brow ptosis, jowl formation, and deepening nasolabial folds.² Traditional rejuvenation techniques include chemical peels, rhytidectomy of the skin, laser resurfacing, injection of dermal fillers and neurotoxins, and invasive surgical procedures. Patients currently seek antiaging procedures with no incisions and minimal downtime such as thread-lifting with barbed sutures.Sulamanidze and colleagues³ developed the first barbed suture, called APTOS (anti-ptosis suture), to correct ptotic soft tissue in patients. Made of nonabsorbable polypropylene, APTOS threads had cogs and bidirectional barbs and could be inserted subcutaneously with a long injection needle.⁴ In their 186-patient study, Sulamanidze and colleagues showed that the ATPOS technique lifted various ptotic areas and improved contours of the face of most patients. Loose threads emerged to the surface in only 4 patients.Two years later Lycka and colleagues⁵ reported success in lifting facial skin and suspending subcutaneous fat in 348 of 350 patients treated with the APTOS threads. Side effects were limited to ecchymosis (the most common), erythema, bleeding, visible threads, swelling, and discomfort. All were minor and correctable. Modifications of the thread-lifting technique and material followed, such as Woffles thread lifting,⁶ Isse’s Endo Progressive Facelift suture with unidirectional barbs,^4,7,8 Contour Threads,^9-11 Silhouette Lift suture,^1,12 Quill,^13,14 Happy Lift,¹⁵ and REEBORN, a mesh suspension thread.¹⁶ The evolution of the earlier techniques and complications associated with thread use have been described in detail.^2,4,14,17,18Most of the aforementioned techniques involve a polypropylene thread which is nonabsorbable. A novel thread-lift that uses an absorbable monofilament polydioxanone (PDO) thread has recently been described.^{14,19, 20,21} PDO is a polymer that can be modified with a laser to have unidirectional and / or bi-directional sharp barbs. PDO sutures are more pliable than polypropylene sutures and have greater strength than other absorbable sutures.²² When used in soft tissue approximation, PDO undergoes hydrolysis, which decreases its strength inversely and increases the strength of a wound during healing.⁹ The present report describes a case in which PDO threads (NovaThreads Inc., Miami, FL) were used in the physician’s office to lift the lower third of a patient’s face in three different vectors with minimal side effects.

A 52-year-old female presented with saggy jowls after she had tried creams and injectable fillers into the perioral areas without improvement. The patient was concerned about her facial appearance and had low self-confidence. The decision was made to use NovaThreads to lift the lower third of her face in three different vectors and to inject fillers into her cheeks and tear troughs as well. Hyaluronic acid with 0.3% lidocaine (Restylane L, Galderma Laboratories, LP, Fort Worth, TX) was injected into tear troughs with a 27-gauge microcannula and hyaluronic acid gel (Restylane Lyft, formerly Perlane-L, Galderma) was injected