Journal of Dermatological Treatment

ISSN: 0954-6634 (Print) 1471-1753 (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 (2019): Experiences of barbed polydioxanone (PDO) cog thread for facial rejuvenation
and our technique to prevent thread migration, Journal of Dermatological Treatment, DOI:
10.1080/09546634.2019.1640347

To link to this article: https://doi.org/10.1080/09546634.2019.1640347

Accepted author version posted online: 03

Jul 2019.
Published online: 15 Jul 2019.

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JOURNAL OF DERMATOLOGICAL TREATMENT
https://doi.org/10.1080/09546634.2019.1640347

ARTICLE

Experiences of barbed polydioxanone (PDO) cog thread for facial rejuvenation

and our technique to prevent thread migration
Mehmet Unala , Gizem Kaya _Islamog
lua , Gu € u
€lbahar Ur €n Unalb €ylu
and Nihal Ko €a
a
Department of Dermatology and Venereology, Medical Faculty, Selçuk University, Konya, Turkey; bDepartment of Family Medicine,
Medical Faculty, Selçuk University, Konya, Turkey

ABSTRACT ARTICLE HISTORY

Background: One of the most common nonsurgical options for facial rejuvenation is lifting using threads. Received 26 April 2019
Application of polydioxanone (PDO) threads is generally secure and effective procedure, but complica- Accepted 16 June 2019
tions on the involved regions can occur.
KEYWORDS
Objective: In this study, we shared our experiences of efficacy and safety of PDO thread lifting for facial
Polydioxanone; face lift;
rejuvenation and presented our technique to prevent the migration of threads. rejuvenation
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.

Introduction granulomas, skin dimpling or irregularities and scar formation on

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 lift-
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
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

CONTACT Mehmet Unal dr.munal1101@gmail.com Department of Dermatology and Venereology, Medical Faculty, Selçuk University, Konya, Turkey
ß 2019 Taylor & Francis Group, LLC
2 M. UNAL ET AL.

point located near to the temporal hairline to the nasolabial fold males – 13.1%) were included in this study. Mean age of partici-
(NFL) and three lines from entry point located near to the ear lob- pants was 39.6 ± 7.5 years (females: 35.7, males: 29.4 years). Mean
ule to marionette line (ML) were drawn to determine the projec- follow-up time was 26 months (min: 11 months; max: 44 months).
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 Table 1. Clinical characteristics and outcomes of patients.
points opened with 18 G needle, and then, threads were inserted Gender Female: 33 patients (86.9 %)
subcutaneously along the designated lines from entry points to Male: 5 patients (13.1 %)
NFLs and MLs. After the threads were inserted, the threads were Mean age 39.6 ± 7.5 years
(female: 35.7 years)
gently pulled backwards to lift the sagging tissues and massage (male: 29.4 years)
maneuvers were applied from NFLs and MLs to entry points for a Mean follow-up time (months) 26 (min: 11; max: 44)
better tissue-thread interaction. Finally, after these maneuvers, to Physician assessment (GAIS) Very much improved 30 patients (78.9 %)
prevent thread migration, the threads in the same entry point Much improved 7 patients (18.4%)
_Improved 1 patient (2.6%)
were tied to each other, and then, the remaining threads on the No change 0 patient
skin surface were buried into subcutaneous tissue with the help Worse 0 patient
of a 18 G needle (Figure 1). Topical and oral antibiotic treatment Patients satisfaction Excellent 29 patients (76.3 %)
was given to the patient for five days. Very good 8 patients (21.0%)
Good 1 patient (2.6%)
Fair 0 patient
Poor 0 patient
Results Adverse events 4 patients (10.5%)
Clinical characteristics and outcomes of patients are presented (infection: 2 patients)
(granuloma formation: 2 patients)
in Table 1. Thirty-eight patients (33 females – 86.9%, and five

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.

Figure 2. (A) Pre-op and (B) post-op. The improvement in the areas marked by the arrows is clearly seen.
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 dilution) 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
JOURNAL OF DERMATOLOGICAL TREATMENT 3
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 suggesting a method to
prevent PDO thread migration. It is clear that further studies are
4 M. UNAL ET AL.

needed on use, complication and prevention methods for compli- 3. Sulamanidze M, Sulamanidze G. APTOS suture lifting
cation of PDO threads. methods: 10 years of experience. Clin Plast Surg. 2009;36:
281–306.
4. Isse NG, Fodor PB. Elevating the midface with barbed poly-
Disclosure statement
propylene sutures. Aesthet Surg J. 2005;25:301–303.
No potential conflict of interest was reported by the authors. 5. Wu WT. Barbed sutures in facial rejuvenation. Aesthet Surg
J. 2004;24:582–587.
ORCID 6. Park TH, Seo SW, Whang KW. Facial rejuvenation with fine-
barbed threads: the simple Miz lift. Aesthetic Plast Surg.
Mehmet Unal http://orcid.org/0000-0002-8964-3314 2014;38:69–74.
Gizem Kaya _Islamog lu http://orcid.org/0000-0002-8141-3186 7. Rachel JD, Lack EB, Larson B. Incidence of complications
Gu €u
€lbahar Ur €n Unal http://orcid.org/0000-0001-5433-168X and early recurrence in 29 patients after facial rejuvenation
€ylu
Nihal Ko € http://orcid.org/0000-0001-6004-6113 with barbed suture lifting. Dermatol Surg. 2010;36:348–354.
8. Kim J, Zheng Z, Kim H, et al. Investigation on the cutaneous
change induced by face-lifting monodirectional barbed pol-
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