Cigdem Gali, MSPA, PA-C, owner of Galiderm Aesthetics & Plastic Surgery (Royal Palm Beach, Fla.) uses threads in her practice to provide nonsurgical facelifts. “Today’s patients want a more natural look that will last and enhance their natural beauty,” she said. “In my opinion, bioregenerative treatments are definitely the new wave in aesthetics, and today’s polydioxanone (PDO) threads provide a biostimulatory treatment to restimulate collagen and reposition the tissues for a natural lift, thanks to molded threads that last longer than previous versions. We are now able to treat the aging process, giving our patients better outcomes and longer lasting results.”
Lauren Voss Mitschrich, PA-C, a dermatology physician assistant at Beauty by Buford (Lone Tree, Colo.) believes the aesthetic market is beginning to see the use of threads expand. “With the rise of biostimulators like poly-l-lactic acid (PLLA) and calcium hydroxylapatite (CaHA), PDO is making a bit of a splash with smooth threads. PDO Max (Liverpool, N.Y.) just launched a micronized version of their smooth PDO threads called PDO AfterGlo™, which is a hydrating skin booster made of powered PDO sutures and hyaluronic acid (HA) in a serum,” said Ms. Mitschrich.
“I use suture lifts and specifically prefer the Silhouette InstaLift (Suneva Medical) procedure,” reported Gregory Buford, MD, the president and CEO of Beauty by Buford. “This procedure uses PLLA/poly lactic-co-glycolic acid (PLGA) sutures which are more robust than your average threads, thus providing a more stable and more substantial long-term lifting solution.
I generally use suture lifts in combination with skin tightening procedures such as Renuvion (Apyx Medical) and may use fillers to restore lost volume. Combination therapy provides a much more robust and comprehensive result that is generally far more impressive than with suture lifts alone.”
Thread Techniques and Combination Treatments
According to Ms. Mitschrich, vectors are the focus in today’s thread treatments. “I love the idea of combining traditional vectors and reverse vectors for a superior outcome. This means that the traditional thread vectors for lower face lifting often start in the temporal area and extend to the jawline,” she reported. “Now, we can add reverse vectors that go from the temporal space into the scalp to further increase the tissue lift. Multiple thread companies offer this as an option now and I believe it will become the gold standard for producing maximum tissue support and lift.”
“I reposition the tissues and fat pads with a PDO thread lift using traditional vectors going from the lateral to medial portion of the face,” Ms. Gali shared. “If they need additional lifting, I will use my reverse vectors going from the medial portion of the face laterally, and that could be the mid-face to temple, or from the temple to the scalp, depending on the amount of laxity. I use PDO threads in combination with other treatments to treat the full aging process including tissue laxity.”
Ms. Gali described a typical procedure she uses for her full facial rejuvenation. “I may begin with Hyperdilute Radiesse (Merz Aestehtics) in the face, which is like a precursor. At that point the face is numb, so I can now treat with radiofrequency (RF) microneedling. After this treatment the tissue is nice and warm, and we will go ahead and place the threads for the PDO lift. Since they are also still numb at that point, I will assess if and how much HA filler is needed to address boney reabsorption in the cheek, jawline, or chin, and add volume. Typically, I may do a syringe of filler in the lips, the piriform fossa, the lateral cheek, or the angle of the jaw or chin. Since we have repositioned all the fat pads, the filler is for structure.” Ms. Gali added that each treatment is customized and dependent on the facial shape that they are trying to achieve, along with the patient’s baseline.
Threads for the Body
With three practice locations, Azza Halim, MD, founder of Azza MD Beauty (Boca Raton, Fla.), is known for her trademarked procedures for cellulite which combines carboxytherapy and PDO threads. She uses her procedure to treat cellulite and loose skin on the abdomen, legs, arms and buttocks, in addition to treating loose skin on the face. “I find threads to be very versatile in their applications due to the large variety we have on the market. I use PDO threads for hair restoration, scars and fine lines, as well as for skin laxity and sagging of the face and body,” she reported. “I always assess my patients’ skin quality, lifestyle and previous treatments. My goal is to strengthen and thicken skin, so I first treat photodamage with laser resurfacing and RF microneedling to address the skin at multiple levels. I re-evaluate results at three to four weeks to decide if the patient is now an ideal candidate for PDO threads to reposition or lift tissue, as well as stimulate collagen.”
Dr. Halim explained that each style of thread has a different function including lifting, smoothing skin and collagen induction, and each style requires a different technique. “For example, if there are areas of volume loss or in need of more definition, I may incorporate dermal fillers along with PDO threads,” she said. “In addition, I use a combination of traditional blunt cannula threads as well as sharpneedle PDO surgical threads for the best lift.”
According to Dr. Halim, the ideal candidate for a thread treatment is one with mild to moderate laxity. “Patient selection is definitely key,” she emphasized. “Also, for those receiving lifting threads there are post-care instructions to follow so that they do not disengage the threads, which may lead to migration of the threads or loss of the lifting effect.”
Ms. Mitschrich added that the right techniques not only provide more comprehensive results, but also protect the patient’s results. “I think the key to success with most of these aesthetic treatments is tissue quality,” she noted. “High quality skincare and aging mitigation with revitalizing skin treatments should be used first to improve the overall skin health. After overall skin health is addressed, tissue volumization and muscle relaxation are the next steps. This is important because if the muscles are constantly pulling against the threads, the improvement from the thread treatment will quickly fade. Adequate muscle relaxation with neurotoxins is necessary to preserve the result. I often recommend neurotoxin treatment two to four weeks prior to the thread treatment.”
Complications Management
Managing expectations in both the patient and provider can help avoid problems with thread treatments. “If the patient is lacking in volume, threads cannot do what we expect,” Ms. Mitschrich explained. “They can cause bunching or an abnormal look. We must first restore any lost volume, and this is the step where most injectors that only use filler go wrong, in my opinion. Restoration and enhancement are different. Cheeks that are too big do not lift the lower face; they just make the patient look weird. Volumizing to something near baseline is the key to success for natural results. Then, and only then, do we consider threads for tissue lifting.”
Dr. Buford also warned that while threads may provide successful results, he would like to see more scrutiny of results posted on social media from both providers and patients, as they may not indicate combined treatments, previous treatments used, and how long results last. “As a plastic surgeon, I can assure you that threads are in no way comparable to the results of surgery and that tissue does not hold in place simply by placing threads,” he elaborated. “When used properly, I really do think we can create nice results, but the issue is that like many things in aesthetic medicine, realistic expectations are essential, which is why I encourage anyone posting their results on social media to actually show long-term results.”
Products and Technologies Watchlist
PDO Max recently launched their newest thread for contouring called Molded Levo Max, which are bi-directional barbed threads with a USP size 2, ensuring one of the strongest tensile strength threads on the market. These threads were created specifically to contour the lower face, jawline and general submentum area as part of a comprehensive facial rejuvenation procedure that can be performed in-office in under an hour. These specialized threads grab submental fat and reposition it along the natural contours created by a patient’s bone structure to address sagging, revise the neck area, elevate the jowls, and restore a chiseled silhouette associated with youth. Key features that deliver these benefits include a stopper at the top to ensure the thread does not disengage too early, making it a “sticky” thread that does not float, but instead remains anchored for great results.
VIOLA Threads (Brea, Calif.) have received FDA 510k clearance (#K190264) for barbed sutures designed for soft tissue approximation, particularly when the use of absorbable sutures is suitable. When strategically placed in the dermis, these threads create a framework for lifting and tightening loose, sagging skin, while stimulating neocollagenesis for long-lasting results. According to the company, all VIOLA Threads products are manufactured, sterilized, and prepared in South Korea, maintaining high-quality standards, then shipped directly to Southern California, ensuring efficiency and reliability. Arthur Yu, MD, a board-certified plastic surgeon and owner of Premier Cosmetic Surgery & Medspa (Arcadia, Calif.) credits VIOLA Threads, for helping him win first place in the 2023 AMWC Monaco PDO thread facelift competition. “VIOLA’s PDO threads are very reliable and the results I obtain are fabulous. In my opinion, the service representatives are the best in the industry; if I had an idea, they were always quick to respond by making custom-designed threads I desire,” he shared.
Bridging the gap between fillers and surgical facial rejuvenation are MIRACU PDO threads by BENEV (Mission Viejo, Calif.). MIRACU threads are molded for improved tensile strength and available in an extensive variety of types, sizes, gauges and cannula tips. Their specialty threads include the Forte PDO thread with bi-directional cogs and the ELASTY Meshfill, the 16-line PDO thread for volumizing and rejuvenation. BENEV is the first company to get FDA 510k clearance for a preloaded PDO thread with a designation for soft tissue approximation and the only company to be in a direct partnership with Dong Bang Medical, the largest manufacturer of cannulas and PDO threads in the world.
Resculpt Threads (West Los Angeles, Calif.) supplies physicians and other aesthetic providers with premium selected threads that enable providers of all skill levels to build confidence in their technique. Founded by Nancy Kim, MD, an aesthetic physician who has performed thousands of thread lift procedures at her office, Adagio Aesthetic Medicine and Thread Lift Center (West Los Angeles, Calif.), the company offers absorbable PDO sutures for tissue approximation for nonsurgical cosmetic procedures. Resculpt Threads are curated through experience by Dr. Kim, some of which are exclusive and unavailable through other thread companies. Resculpt threads are selected for ease of use and versatility with a collection that includes Boost Braided threads, reportedly the thickest threads on the market for collagen production, and Precision Barbed threads, which are pre-loaded on correction enabled cannulas. The company also provides training and education to ensure the best patient outcomes.
V Soft Lift® PDO threads from V Soft Lift USA (Atlanta, Ga.) have a Class II FDA-clearance for both the PDO thread and the insertion cannula. According to the Company, V Soft Lift PDO threads deliver the maximum aesthetic results with the minimum number of threads and offer one of the most extensive and innovative high-end PDO thread portfolios available. Specialty techniques include the LIFT Technique with cogged, patented threads for an immediate lift, the GRID technique with smooth threads that boost collagen, and the VOLUME technique™ using smooth threads that are designed to use with filler for extra volume. V Soft PDO threads are competitively priced, while the company partners with top aesthetic training organizations to offer their providers discounted training.
