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Journal of Dermatological Treatment
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ijdt20
Experiences of barbed polydioxanone (PDO) cog
thread for facial rejuvenation and our technique
to prevent thread migration
Mehmet Unal , Gizem Kaya İslamoğlu , Gülbahar Ürün Unal & Nihal Köylü
To cite this article:
Mehmet Unal , Gizem Kaya İslamoğlu , Gülbahar Ürün Unal & Nihal Köylü
(2021) Experiences of barbed polydioxanone (PDO) cog thread for facial rejuvenation and our
technique to prevent thread migration, Journal of Dermatological Treatment, 32:2, 227-230, DOI:
10.1080/09546634.2019.1640347
To link to this article: https://doi.org/10.1080/09546634.2019.1640347
Published online: 15 Jul 2019.
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ARTICLE
Experiences of barbed polydioxanone (PDO) cog thread for facial rejuvenation
and our technique to prevent thread migration
Mehmet Unal
a, Gizem Kaya _Islamoglu
a, G€ulbahar €Ur€un Unal
band Nihal K
€oyl€u
aa
Department of Dermatology and Venereology, Medical Faculty, Selc¸uk University, Konya, Turkey;bDepartment of Family Medicine, Medical Faculty, Selc¸uk University, Konya, Turkey
ABSTRACT
Background: One of the most common nonsurgical options for facial rejuvenation is lifting using threads. Application of polydioxanone (PDO) threads is generally secure and effective procedure, but complica-tions on the involved regions can occur.
Objective: In this study, we shared our experiences of efficacy and safety of PDO thread lifting for facial rejuvenation and presented our technique to prevent the migration of threads.
Materials and methods: Thirty-eight patients who underwent PDO cog treatment for facial rejuvenation were evaluated. Via 23 G/90 mm sharp needle, bidirectional barbed PDO cog thread was inserted into subcutaneous tissue. The outcomes of procedure were assessed by Global Aesthetic Improvement Scale (GAIS) and patient satisfaction.
Results: Thirty-eight patients were included in this study. Mean age of participants was 39.6 ± 7.5 years. The GAIS score showed satisfactory results (very much improved: 78.9%; much improved: 18.4%; improved: 2.6%). According to patient satisfaction, all patients were satisfied with the clinical outcomes of procedure (excellent: 76.3%; very good: 21.0%; good: 2.6%). No patient reported‘fair’ or ‘poor’ result. Conclusions: Our results revealed barbed PDO cog thread is highly effective in facial rejuvenation. Also, tying the PDO threads in same entry point to each other seems to be an effective technique to prevent thread migration.
ARTICLE HISTORY Received 26 April 2019 Accepted 16 June 2019 KEYWORDS
Polydioxanone; face lift; rejuvenation
Introduction
In recent years, the interest in antiaging procedures has increased considerably. With this growing interest, patients want antiaging procedures to be effective, easy to apply and less invasive. The aging process is an inevitable process and the aging process in the face area, as in the whole body, is manifested by different effects in all layers of the face. Variable procedures for facial rejuvenation have been applied surgically or nonsurgically, according to degree of tissue laxity, surgeon assessment, and patient preference. The most common nonsurgical options for facial rejuvenation include the dermal fillers, botulinum toxin, peeling, laser resurfacing, plate-lets rich plasma (PRP), and lifting using threads (1,2).
The evolution of thread lifting techniques and their application in the esthetic field has grown for last three decades. Since Sulamanidze’s procedures for lifting and rejuvenating facial tissues by Aptos threads in 1998, various techniques and products have been developed, such as Woffles thread lifting, Waptos suture ing, Isse unidirectional barbed threads lifting, and silhouette lift-ing. However, some patients are worried about the insertion of nonabsorbable threads which remain permanently in their facial soft tissue. Therefore, barbed suture which is absorbable and has a temporary effect has been designed. Among these absorbable sutures, the polydioxanone (PDO)-containing threads are the most frequently used forms (3–6). Application of PDO threads is generally a secure and effective procedure, but complications including pain, erythema, swelling, ecchymosis, hematoma, facial asymmetry, feeling of discomfort, thread migration, infections or
granulomas, skin dimpling or irregularities and scar formation on the involved regions can occur (1,2,7).
The aim of this study was to share our experiences on efficacy and safety of PDO thread lifting for facial rejuvenation and pre-sent our technique for preventing the migration of threads.
Materials and methods
Thirty-eight patients who underwent PDO cog treatment for facial rejuvenation, between September 2014 and May 2018, were eval-uated retrospectively. The gender and age of patients, preopera-tive and postoperative photographs, and adverse events were recorded.
For the objective assessment, two physicians who were not involved in the procedures reviewed the outcomes using a five-point Global Aesthetic Improvement Scale (GAIS): 5 – very much improved; 4– much improved; 3 – improved; 2 – no change; and 1– worse. Also, patients were followed up after surgery, and their outcomes were evaluated by asking them immediately after pro-cedure to rate their overall satisfaction using the following scale: 5– excellent; 4 – very good; 3 – good; 2 – fair; and 1 – poor (2). Procedure
All procedure were performed by same dermatologist, with the patient under local anesthesia. Via 23 G/90 mm sharp needle, bidirectional barbed PDO cog thread (DongWon Medical Co. Ltd., Bucheon, Korea) was used for application. Two lines from entry
CONTACTMehmet Unal dr.munal1101@gmail.com Department of Dermatology and Venereology, Medical Faculty, Selc¸uk University, Konya, Turkey
ß 2019 Taylor & Francis Group, LLC
2021, VOL. 32, NO. 2, 227–230
point located near to the temporal hairline to the nasolabial fold (NFL) and three lines from entry point located near to the ear lob-ule to marionette line (ML) were drawn to determine the projec-tion, where the threads were to be placed. After cleaning the operation area with antiseptic solution, 2% lidocaine with epi-nephrine (1:100,000) was injected only at the entry points. Entry points opened with 18 G needle, and then, threads were inserted subcutaneously along the designated lines from entry points to NFLs and MLs. After the threads were inserted, the threads were gently pulled backwards to lift the sagging tissues and massage maneuvers were applied from NFLs and MLs to entry points for a better tissue-thread interaction. Finally, after these maneuvers, to prevent thread migration, the threads in the same entry point were tied to each other, and then, the remaining threads on the skin surface were buried into subcutaneous tissue with the help of a 18 G needle (Figure 1). Topical and oral antibiotic treatment was given to the patient for five days.
Results
Clinical characteristics and outcomes of patients are presented in Table 1. Thirty-eight patients (33 females – 86.9%, and five
males – 13.1%) were included in this study. Mean age of partici-pants was 39.6 ± 7.5 years (females: 35.7, males: 29.4 years). Mean follow-up time was 26 months (min: 11 months; max: 44 months).
Figure 1. (A) After the threads were inserted, the threads were gently pulled backwards to lift the sagging tissues, and massage maneuvers were applied. (B) Threads in the same entry point were tied to each other to prevent thread migration. (C) 18 G needle was inserted to subcutaneous tissue through a point about 1 cm far to entry point. (D) Remainder of threads on the skin surface were buried into subcutaneous tissue with the help of 18 G needle. (E) Post-operation first day image of the entry point.
Table 1. Clinical characteristics and outcomes of patients. Gender Female: 33 patients (86.9 %)
Male: 5 patients (13.1 %)
Mean age 39.6 ± 7.5 years
(female: 35.7 years) (male: 29.4 years) Mean follow-up time (months) 26 (min: 11; max: 44)
Physician assessment (GAIS) Very much improved 30 patients (78.9 %) Much improved 7 patients (18.4%) _Improved 1 patient (2.6%) No change 0 patient
Worse 0 patient
Patients satisfaction Excellent 29 patients (76.3 %) Very good 8 patients (21.0%)
Good 1 patient (2.6%)
Fair 0 patient
Poor 0 patient
Adverse events 4 patients (10.5%) (infection: 2 patients)
(granuloma formation: 2 patients) 228 M. UNAL ET AL.
The GAIS score (physician assessment) showed satisfactory results (very much improved: 78.9%; much improved: 18.4%; improved: 2.6%). None of the two physicians reported‘no change’ or‘worse’ result.
According to patient satisfaction, all patients were satisfied with the clinical outcomes of procedure (excellent: 76.3%; very good: 21.0%; good: 2.6%). No patient reported ‘fair’ or ‘poor’ result (Figure 2).
Four patients developed infection (two patients) and granu-loma formation (two patients) within first month of the proced-ure. An extra antibiotic therapy (ciprofloxacin 500 mg per oral 2 1 – 7 days) for infection and intralesional corticosteroid injec-tion (triamcinolone acetonide 40 mg/ml 1/4 diluinjec-tion) for granulo-mas were applied. No other complications were seen (Table 1).
Discussion
PDO is a product previously used especially in cardiac surgery and hydrolyzed in tissue within 6 months. PDO has also been used in the field of cosmetic surgery for a while. Insertion of PDO thread was declared to not only tighten and lift the face, but also to increase skin texture with brightened complexion and improve skin elasticity. However, it is not fully understood how threads provide this improvement in the skin. When PDO thread is inserted into the body, it does not merely disappear but rather causes some changes in surrounding milieu (1,2). Kim et al. observed tissue changes including fibrous capsules formed around the thread, followed by inflammation and increased colla-gen and increased level of TGF beta after the injection of a mono-directional barbed PDO thread into a guinea pig (8). In another study by Yoon et al., after insertion of 9-cm USP 4-0 non-barbed PDO threads into the skin of the Yucatan pig, the authors observed newly developed fibrous connective tissue, merging with existing fibrous connective tissue, tissue contraction by myo-fibroblast activity, increased capillary vessel size and reduced fat layer thickness by fat cell denaturation. Additionally, they detected that the thread retains its shape for 12 weeks, becomes fragmented by 24 weeks, and is fully dissolved by 48 weeks. Thus, they put forward that if the maintenance of thread shape is important, the effect will last for 12–24 weeks; however, if the thread itself is important regardless of fragmentation, the effect will last for 24–48 weeks (9).
These favorable properties of the PDO threads on the tissue are now commonly practiced in facial rejuvenation. Clinical results of PDO application suggest that this procedure will use more
commonly in future. Suh et al. used bidirectional cog PDO in 31 patients for facial rejuvenation. At the end of the study, according to patient satisfaction evaluation, 19 patients (61%) found their clinical results ‘excellent’ and 21 patients (21%) found ‘good’. On the other hand, outcomes according to physician assessment showed that ‘texture improvement’ was excellent for 13 (41.9%), good for 9 (29.0%), and fair for eight patients (25.8%) (1). Another study by Kang et al. reported similar results (2). In our study, results of both patient satisfaction evaluation and physician assessment by GAIS score were higher than these studies (Table 1). We clinically observed that tying the threads in the same entry point to each other provided a better lifting effect. Maybe, this better lifting effect caused higher patient satisfaction and GAIS score than previous study.
PDO thread lifting is mostly a safe procedure. However, studies evaluating the frequency of complications of PDO threads are quite limited. The complications most commonly reported include thread disruption, thread migration, cutaneous exposure, and skin dimpling, but most of these reports were from APTOS studies (3). Thread migration (displacement of threads) is a thread facelift complication that can be seen in all thread types. In their study, Wu observed thread migration in 8% of patients who were applied thread-lift surgery (4,5). We think that the risk of thread migration is higher in the ‘free-floating’ technique, a technique which the threads are not fixed to a point and float freely in the subcutaneous tissue (10). Therefore, to avoid thread migration, we tie the PDO threads in same entry point to each other. The entry point where the threads tie to each other provides a fixation point, even if relatively weak. The resistance of subcutaneous tis-sue restricts the movement of the tying PDO threads, and thus, prevents thread migration. As a result, in our study, complications like infection (two patients) and granuloma formation (two patients) occurred, but thread migration was not observed in any patient, during the 26-month mean follow-up period. In addition to prevent thread migration, we observed that tying threads to each other also provide a better facial lifting and tension effect, confirmed by higher GAIS score and patients satisfaction com-pared to previous studies.
In this study, we shared our experiences of PDO thread facial rejuvenation and our technique to prevent thread migration. The number of publications related to PDO threads facial rejuvenation and its complications is limited in the literature. Moreover, accord-ing to our knowledge, there is no study suggestaccord-ing a method to prevent PDO thread migration. It is clear that further studies are Figure 2. (A) Pre-op and (B) post-op. The improvement in the areas marked by the arrows is clearly seen.
needed on use, complication and prevention methods for compli-cation of PDO threads.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Mehmet Unal http://orcid.org/0000-0002-8964-3314
Gizem Kaya _Islamoglu http://orcid.org/0000-0002-8141-3186
G€ulbahar €Ur€un Unal http://orcid.org/0000-0001-5433-168X
Nihal K€oyl€u http://orcid.org/0000-0001-6004-6113
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