Polydioxanone threads for skin rejuvenation and facial tissue anti-ptosis

Polydioxanone (PDO) has been in use for over three decades in tissue engineering and surgery. It's safe and used on a daily basis in hospitals for wound closure. There are no problems with allergic reactions or long-term complications. Compared to other absorbable threads, PDO is the longest lasting. It takes about 130 – 180 days to be resorbed and replaced by fibrosis. The Korean FDA approved mono 6-0 PDO threads in 2011 for the following indications: (1) neo vascularisation, (2) collagen type 1 and 3 regeneration and (3) lipolysis. Platelet-rich plasma (PRP) also gives neo-vascularisation and collagen regeneration via growth factor release, so that's why PDO threads combined with PRP gives an enhanced effect.

A large number of fibroblasts infiltration around the pair of threads shows an increase in new collagen fibres and a reduction in the number of fat cells—that's the lipolytic effect. It's not a significant lipolytic effect though, so if lipolysis is desired then insertion of threads combined with a lipolytic agent such as Aqualyx can be used to enhance the effect. However, the patient must be warned to expect gross swelling of the treated area.
Fibrous bridging can be observed between the threads and the perimysium of the muscle and also between the threads and the dermis. So, fibrous bridging occurs in all directions and fibrosis is not confined to the immediate area around the threads. Two to three months later, contraction (tightening) of the fibrous bridging takes place.
In summary, skin remodelling takes place because of more capillaries, more fibroblasts, more collagen and less fat cells.

How PDO threads work
Spiral 3-D multi-direction 2-0 thickness barbed threads (cog threads) give an immediate mechanical lift and the lift will continue to take place via fibrosis and tissue contraction over the next three to four months—an instant lift as well as a delayed lift. Plain mono threads can't give an instant mechanical lift.
The plain mono threads inserted into the dermis or sub-cutaneous tissue result in neo-collagenesis and neo-vascularisation. In the adipose tissue, the threads cause a minor degree of lipolysis, and when inserted into the muscle the effect is muscle relaxation (mechanotransduction—acupuncture effect).
If loss of muscle function is not desired (botulinum toxin type A effect) then plain mono threads can be inserted into the muscle, for example into the masseters or gastrocnemius muscles. In Korea and the Far East it's very popular to decrease the calf muscle (gastrocnemius muscle) for cosmetic reasons. In order to reach the desired effect, too much botulinum toxin type A may be required rendering the patient unable to walk normally, especially when wearing high heeled shoes. By using threads, or a combination of threads and botulinum toxin type A, muscle function is preserved.
Mechanotransduction forms the basis of how acupuncture can lead to new collagen regeneration. It is the ability of the cell to sense, process and respond to mechanical stimuli. If one inserts the needle into subcutaneous tissue and twists it twice, a cellular activation process takes place. After the rotations, the fibroblasts around the needle become activated resulting in neo-collagenesis. In the Far East, there are many clinics that perform facial acupuncture facelifts. However, repeated acupuncture needling sessions are required.

Facial ageing
The ageing process in the face involves a number of components that need to be addressed: loss of skin volume and skin laxity, redistribution of facial fat, connective tissue ptosis and muscle hypertrophy. All of the components require PDO threads. Tissue laxity and redistribution of subcutaneous fat contributes to (1) accentuation of the nasolabial fold and the para nasolabial fold, (2) hollowness under the eyes and tear trough accentuation and (3) jowl formation. However, other factors play a part in jowl formation such as platysmal hypertrophy.
Thus, all of the abovementioned factors in facial ageing have to be addressed: (1) elevation (antiptosis) of the connective tissue and adipose tissue, (2) tightening and rejuvenation of the skin and (3) muscle relaxation (platysma). The insertions of barbed threads alone are not going to have a long lasting effect compared with the combination of barbed threads and plain mono threads. The latter technique creates a crossed-hatched mesh network of threads leading to fibrous bridging between all of the threads.

Using PDO threads, one can contour the face, treat wrinkles, improve skin quality, reduce pores and tighten the skin, and reduce the double chin (submental fat pad). In the Far East, especially Korea and China, ladies don't like the square jaw appearance, and prefer a V-shape. Patients as young as 20 years old have V-shape threads treatment, so threads are not only for people aged 40 years or more with skin laxity and other effects of ageing taking place.
Other indications are tissue healing, tendon trauma (tennis elbow, golf elbow), frozen shoulder, knee collateral ligament repair, fibro-myalgia and muscular relaxation (masseters, orbicularis oculi, gastrocnemius skeletal muscle). Also, one can treat hypotrophic acne scars, but not hypertrophic acne scars.

Similar to most cosmetic treatments like fillers (HA etc.) botulinum toxin type A or any medical aesthetic treatment—one must take care. Patients with auto-immune connective tissue diseases must be excluded. Patients with high expectations are always of concern. Don't sell the PDO thread treatments as a surgical replacement treatment or a treatment that is better than surgery. Patients who are Hepatitis B+, Hepatitis C+ and HIV+ pose more of a risk to the operator. Pregnancy is a contra-indication and so is breastfeeding if any lidocaine is going to be used. Anti-coagulant therapy (coumarin, etc.), existing infection in the treatment area and a history of keloid formation in the face and neck are contra-indications.

Be careful with patients taking aspirin—don't terminate the treatment but warn them that they run the risk of bruising. Antibiotic prophylaxis is important in patients with bacterial endocarditis. Prescribe acyclovir to patients who are prone to herpes simplex labialis. Smoking has a detrimental effect on healing and tissue regeneration in general. Patients taking oral steroids or topical steroids on the PDO treatment areas can expect a less favourable end result.

Pre-treatment procedure
Medical history is important to identify exclusion criteria and one has to ensure that informed consent is obtained. Barbed threads insertion requires antibiotic prophylaxis such as Azithromycin 500mg one hour before the procedure followed by 500mg 24h and 500mg 48h later. Antibiotic cover is not necessary for superficial plain mono thread insertion. If the treated area becomes infected, especially if barbed threads were inserted, it's going to be very difficult to treat the infection because there is a foreign body in-situ and the threads may have to be removed. In the presence of infected barbed threads, local anaesthesia may not be effective due to the acidity of the infected tissue and the patient may require general anaesthesia.
The most important part of this whole treatment process is photography in order to establish pre-existing asymmetry. Patients may come back accusing the operator of creating asymmetry by using the threads, so make sure during the consultation to point out for example that one cheek is bigger than the other cheek and have a photograph to prove it.

Technique: Five Point Face Lift
The rationale behind the Five Point Facelift is that in my experience, Caucasian patients require less barbed threads, due to smaller facial features, than Asian patients.
Clean the treatment area very well with surgical spirits, betadine or chlorhexidine. Cover the patient's hair with two caps and apply sterile drapes. Apply topical anaesthesia for dermal insertion of plain mono threads.
Mark the treatment area with a marker pencil. Put on sterile gloves.
For PDO barbed threads, inject 1.0ml of lidocaine plus 1:80,000 adrenaline (dental 2.2ml cartridge) into the insertion area. Then take a 1 ml syringe (with luer-lok) and aspirate 1.0ml of 3% lidocaine and connect it up to the thread cannula (Dr Irfan Mian's technique). During insertion of the cannula, if there's any discomfort, inject 0.05 ml, wait for 30 seconds and continue to insert the cannula. This way there is no distortion due to a lot of tumescent anaesthetic and one can observe an immediate mechanical lift, and more importantly the patient can see it too!
Very importantly, superficial dermal or subcutaneous threads are inserted with a sharp needle but barbed threads have to be inserted via a cannula in order to reduce the risk of facial nerve trauma and large blood vessel trauma (such as the facial artery). Extra care has to be taken in the region where the facial nerve is crossing the zygomatic bone because it runs very superficially in this region. Below the zygomatic bone, the facial nerve runs deep underneath the parotid glands so it's a low risk area. When inserting deep barbed threads, don't do it with a needle!
It is also important during the treatment that once the one half of the face is finished, to sit the patient up and take photographs to demonstrate the difference between the treated side and the non-treated side. It's very important from the patient's point of view to be able to see that there is an instant effect visible for we can forget very quickly how we looked like.
A single entry point for barbed threads insertion, where all the barbs come together, is important because it results in a lot of new collagen regeneration and fibrosis in the insertion area that is acting as an anchor and hold up the lift. The entry point is above the zygomatic arch and the cannulas pass through the zygmatic retaining ligament superiorly and through false ligaments and connective tissue bands (septa) distally. These structures provide ample anchoring points for maintaining the mechanical lift.
The first cannula passes through the malar region and importantly must pass through the nasolabial fold. This will achieve an instant nasolabial (N-L) lift—as good as any filler agent. For deep N-L folds, one can add additional fillers. If balancing of cheek volume is required then fillers can be combined with threads in the malar region.
The second end-point is near the corner of the mouth to elevate it.
The third cannula passes through the mandibular ligament and the marionette lines. There's a special technique to pass the cannula through the ligament.
In the mandible and jowl area, the fourth and fifth barbed threads give an instant mechanical lift. It is important to also insert mono threads in the dermis over the mandibular region in order to create a cross-hatched fibrotic mesh effect—fibrous bridging occurs between the skin, mono threads and the deeper barbed threads.
Compression and icepacks may be necessary if bruising is present due to dermal mono threads. Barbed threads inserted via a cannula do not cause bruising!
Apply an antibiotic cream (Bactroban/Fucidin) to the entry point and cover it with a plaster for 24 hours. Clean the treated area with surgical spirits, betadine or chlorhexidine.

An SPF 30 is advised to avoid post-inflammatory hyperpigmentation (PIH), especially in Fitzpatrick skin types IV-VI. Avoid making long dental appointments for at least four weeks after treatment because mouth opening may be restricted. No facial massaging for two weeks and blood thinning herbs and vitamins like Vitamin E should be terminated seven days before the treatment and for another seven days post treatment. For discomfort, paracetamol should be sufficient and NSAIDs like ibuprofen should be avoided because inflammation is necessary for fibrosis. No alcohol for three days post treatment and no sauna for seven days. Arnica (a herb) may be effective against swelling.

Complications include swelling for a few days. Bruising is more likely when using a needle and may last for 10-14 days. Infection can occur due to the deep barbed threads. A foreign body reaction (granuloma) can occur in the epidermis if the plain mono threads are not inserted deep enough. Due to discomfort and restricted mouth opening the patient mustn't book dental appointments.
The thread can migrate, especially with uni or bi-directional cogs. One has to be very careful when using bi-directional cogs—make sure that they are sufficiently embedded underneath the skin because they can migrate out of the insertion point. Barbed thread protrusion is possible if the threads are not cut short enough at the entry point. Facial nerve trauma is more likely when using a needle. Beware of asymmetry.

Combination treatments
One can combine threads with platelet-rich plasma, botulinum toxin type A, fillers and dermarollers.
PRP is usually injected during barbed threads insertion and it can also be combined with dermarolleing of the skin after threads insertion.
Don't combine threads with heat generating devices such as lasers or RF before 12 weeks because the heat will cause distortion of the threads.
Patients treated with liquid PLLA treatment before have not presented with problems related to excess fibrosis. Similarly, no problems have been experienced in treating former facial surgery patients.
The threads will dissolve after about six to eight months, with maximum contraction at three to our months. Mechanical lift is only possible with cogs—it's not possible with plain mono threads. In my experience, of over 450 patients, one has to place barbed threads to get a lift. Also, the duration depends on the age of the patient, lifestyle, quality of the tissues, medication and the general health and diet. I emphasise during the consultation that PDO threads treatment is a continuous process and that regular additional threads are required at six to nine month intervals in order to maintain the effect.

Dr Jacques Otto is an Aesthetic Practitioner, highly experienced in the field of aesthetic treatments with a worldwide reputation as an innovator and trainer. His main interests include PRP, IV nutrition therapy (co-founder of IntraVita Ltd) and polydioxanone fine thread contouring (co-founder of Neocosmedix Europe Ltd). He was the first to introduce PDO multi-direction absorbable barbed threads into the UK cosmetic market.

Source: http://www.bodylanguage.net/polydioxanone-threads-for-skin-rejuvenation-and-facial-tissue-anti-ptosis/


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