The use of support threads in facial and body aesthetic treatments gained momentum in the early 2000s, with the introduction of permanent threads (barbed Russian thread, Bulgarian thread and gold thread). However, short- and long-term problems and unwanted effects with the insertion of permanent wires discouraged professionals, leading them to abandon this clinical practice. In many cases, permanent fillers have become permanent nightmares for both patients and professionals.

In the search for safer procedures that support the flaccid facial tissue and, at the same time, cause limited side effects, the use of absorbable support threads emerged. It is important to emphasize that such threads were not developed to replace or compete with rhytidectomy, they complement plastic surgery or replace it only in cases where surgical intervention is impossible due to the patient’s general health status.

Polydioxanone (PDO) is a synthetic and biodegradable substance, used for more than two decades in the form of suture threads by urologists, gastroenterologists and ophthalmologists, and is currently used as a material for resorbable facial support threads.

The insertion of PDO threads in the dermis or subdermis itself causes localized trauma during the course of the needle that contains the thread, promoting mechanical separation of local tissues and injury to small blood vessels. This localized trauma triggers an immediate inflammatory process, followed by an eventual production of fibrocollagenous repair tissue. The local immediate inflammatory response is proportional to the thickness and length of the wire inserted and also to the tissue reached by this procedure – and this constitutes the first important step in the formation of neocollagenesis.

Localized inflammation causes hydrolysis of the PDO thread, aiming at the disintegration of the foreign body, in a process that is completed after seven to nine months. In place of the foreign body, scar tissue is formed, composed of fibrin, elastin and collagen. The duration of the beneficial effect, after insertion of the wire, is estimated between 18 and 24 months.

Polyfilament, spiculated or barbed PDO thread, in addition to causing the formation of scar tissue, gently immobilizes the fine muscles involved in the appearance of wrinkles, through its own physical traction, especially in the region around the eyes, the popular “crow’s feet”.

However, care must be taken with the correct insertion plan of the PDO wires. The spiculated wire, if inserted in the middle of fatty tissue (SMAS), will not have the effect of tractioning the area of ​​skin to be treated, because the soft adipose tissue itself will not provide any support or support. The inflammatory action generated by the PDO thread will dissolve the adipose tissue around it, further damaging the region and compromising the initial objective of the treatment.

  1. What are the purposes of using PDO yarns
    Insert multiple therapeutic needles with absorbable PDO thread in the face region.
    • Cause a limited tissue inflammatory reaction.
    • Stimulate tissue collagen production.
    • Allow the absorbable material to remain temporarily.
    • Achieve a non-surgical effect of reducing sagging facial skin.
  1. Advantages of using PDO yarns
    It consists of a minimally invasive procedure.
    • Promotes localized inflammatory reaction and programmed.
    • Promotes almost immediate reduction of fine wrinkles (between 10 and 15 days after the insertion of the threads, approximately).
    • Stimulates the production of endogenous collagen from the second week after insertion.
    • The minimum permanence of the wire (from six to eight months) does not cause irreversible effects.
    • Requires minimal recovery time at home.
    • The procedure is considered relatively safe.
    • Does not leave visible scars.
    • No special preparations required.
    • It can be applied in an outpatient setting (office).
    • Can be safely used on all skin phototypes.
    • The thread vehicle (the needle) can also be used for drug delivery (to administer mixtures with hyaluronic acid without crosslinking and/or mineral salts and vitamins, promoting skin hydration from the inside out).
    • The application of absorbable PDO threads can be complemented by procedures that precede it, such as:
    – Botulinum toxin (two weeks in advance).
    • There is an advantage in promoting the application of botulinum toxin before the insertion of the threads: the collagen that forms during the time of muscle relaxation becomes more uniform and more homogeneous. One procedure complements the other. Fillers can be applied between three and five weeks after thread insertion.
  1. Disadvantages of using PDO wires
    Relatively expensive, proportional to the number and types of wires inserted.
    • The spiked/barbed wire should not be used on skin with accentuated flaccidity (scale
    of Glogau 3-4).
    • Obese patients not will feel a lot of difference between pre- and post-therapy.
    • As it is a subtle procedure, it will not solve all problems of sagging or aging skin.
    • Very “bruised” or hard skin does not respond well to the procedure.
  1. Wire Types
    There are some types of wire available for face use, with different presentations:
    A. Smooth wire (“V-bent”);
    B. Wire in “screw” or “spiral” (bent in “V”).
    C. Spiculated/barbed (anchored) wires, which come in two presentations:
    – Temporary uni or bidirectional thread – in which the proper direction of the spikes or barbs immobilizes or anchors the thread between tissues (Lift Line, Miracu, i-Thread, etc.), unidirectional and bidirectional PDO thread.
    – Unidirectional, anchored, temporary thread (polylactic acid), fixed at a starting point or in the middle of its path by the thread insertion itself (Silhouette Soft).
  1. Determining factors in choosing the yarns
    Which region of the face?
    • How thick is the skin to be treated?
    • What is the degree of flaccidity in the area to be treated (Glogau Scale)?
    • What is the degree of “wrinkling” of the skin (Fitszpatrick Scale)?
    • Is the skin to be treated well hydrated?
    • What are the essential neighboring structures?
    • The regions of the face where the skin is thinner require the use of proportionally thinner and shorter hair. The areas of the face where the skin is thicker require thicker and longer hair. On the other hand, smooth PDO strands are very helpful in firming the skin. Inserted separately, in parallel or in crosshatchhashtag or “mesh”, they stimulate the production of dermal collagen, better firming tissue flaccidity, in addition to stimulating the hydration of the treated area .
    • Facial flaccidity, when involving the muscles, justifies the use of spiculated/barbed threads to anchor the tissues. Due to the thickness of the wire, its insertion must be deep, subcutaneous. This involves a good understanding of anatomy to avoid unnecessary unwanted effects, which include:
    – Clamping;
    – Insertion in the wrong plane;
    – Sensory or motor nerve damage;
    – Parotid gland injury;
    – Skin ripples on faces with little lipid lining;
    – Asymmetry;
    – Bleeding/bruising.
  1. Contraindications to the use of PDO wires
    Blood dyscrasias (anemia, coagulopathies etc).
    • Treatments that compromise blood clotting (usual use of ASA, for example).
    • Usual use of anti-inflammatory from the  ibuprofen group (because it accelerates the absorption of the thread).
    • Facial lipoatrophy.
    • Skin hypotonicity.
    • Scleroderma.
    • Dermatomyositis.
    • Cutis laxa (connective tissue disease).
    • Acute or chronic skin diseases/infections.
    • Autoimmune diseases.
    • Scars on the face.
    • Pregnancy.
    • Epilepsy.
    • Predisposition to form keloids or scarring hypertrophy.
    • Patients with hepatitis B and C and HIV.
    • Obese patients (small apparent benefit).
    • The objective choice of the right patient to undergo this procedure (screening) avoids many headaches for both the patient and the professional, since the patient’s expectations do not always coincide with the final result. In well-selected cases, the insertion of barbed/spiculated wires, inserted in a correct plane, helps to subtly lift the skin.
    • The intention of inserting spiculated absorbable strands should not be to stretch the skin, as they only serve to better distribute sagging to other areas of the face. Most ambitious attempts to stretch the skin above its natural limit end in unsuccessful procedures.
  1. The clinical procedure
    Wire insertion methods vary from one professional to another and depend on:
    The professional’s personal preference;
    • The flaccidity of the skin and muscles;
    • The age and general health of the patient;
    • Which areas are most in need;
    • The number of threads available to obtain the desired result;
    • The total cost of the procedure. The number of wires used in a session varies between 4 and 120, and the procedure takes approximately 30 to 60 minutes.
  1. Post-operative instructions to the patient
    Avoid using creams containing acids for at least two to three weeks.
    • Avoid any facial rejuvenation procedures for a period of three to four weeks. • Avoid phototherapeutic procedures for six to eight weeks or more.
  1. Homecare (homecare)
    The patient must avoid:
    Direct contact with sunlight in the first few days;
    • Take ibuprofen (accelerates hair absorption);
    • Take very hot baths in the first few days;
    • Massage the face during the first three weeks after the procedure;
    • Drinking alcoholic beverages during the first seven to ten days;
    • Take vitamins C and E for the first seven to ten days (they reduce blood clotting);
    • Eat garlic or ingest ginkgo biloba for the first seven to ten days;
    • Participate in sports activities during the first seven to ten days;
    • Open your mouth excessively during the first seven to ten days;
    • Dental procedures (intrabucal) in the first week after the procedure;
    • For the first few days after the procedure, the patient should sleep in a semi-sitting position or with the head up to reduce swelling.
    • The patient must apply:
    – Cold compresses regularly, every four hours, on the first day after the procedure;
    – Sunscreen SPF 99, during the day, every three hours;
    – Hirudoid or arnica extract in gel, in case of bruise, every eight hours.

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