Polydioxanone Thread Lift Complications

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In the last decade, polydioxanone (PDO) thread lifts have been promulgated as a safe and effective alternative to a surgical facelift or necklift.¹ The widespread commercial availability of PDO threads, the ease of application, shallow learning curve, broad applicability to a range of anti-aging chief complaints, and rapid recovery have all contributed to the popularity of this minimally invasive technique. It remains a widely accepted fact that cosmetic patients desire highly beneficial treatments with minimal downtime and recovery. 

Even though PDO thread lift complication rates are higher than 30% in the published literature, the risks associated with these treatments are underappreciated.² The authors have developed a broad clinical practice in the management of foreign body reaction, including the diagnosis and treatment of complications associated with absorbable smooth PDO thread fillers and barbed PDO thread lift sutures. Our intent is to elucidate clinical strategies to optimize the proper diagnosis and management of complications arising from PDO threads used in minimally invasive facial rejuvenation. 

PDO Thread Subtypes 
In cosmetic surgery, there are 2 different subtypes of absorbable PDO threads used: smooth and barbed. Percutaneously positioned in the subcutaneous plane to enhance volume and stimulate collagen production, smooth PDO threads are available as an alternative to dermal fillers.³ Thick-caliber, barbed PDO threads have unidirectional barbs that allow for percutaneous insertion into the subcutaneous space and elicit upward soft tissue suspension when deployed under the skin. These PDO threads, and newer poly-L-lactic acid and polycaprolactone variants, are not merely static foreign bodies in the skin but stimulate neocollagenesis in-vivo.³

Complications
Complications arising from PDO threads are categorized as either transient, acute, or chronic.^2,4

The most common transient complications include: 

• Mild erythema 

• Bruising 

• Localized swelling 

• Pinpoint bleeding at the site of percutaneous insertion 

• Temporary hypoesthesia 

• Pain 

• Discomfort 

• Asymmetry 

• Undercorrection 

• Overcorrection 

• Skin dimpling 

Acute complications that require intervention include: 

• Infection 

• Vascular compromise 

• Loss of skin perfusion 

• Allergic reaction 

• Skin necrosis 

• Skin extrusion 

• Direct nerve injury 

• Under- or overcorrection leading to asymmetry 

Long-term complications related to PDO threads include: 

• Chronic inflammation, pain, infection, foreign body reaction, or wounds 

• Skin changes 

• Permanent nerve injury 

• Contour irregularities 

• Loss of skin integrity 

• Scarring alopecia 

• Dimpling 

• Dynamic skin and soft tissue tethering 

• Sensory loss 

• Asymmetry 

The list of reported complications associated with PDO threads is ever-expanding in the academic literature. The clinician must use experience-based acumen to properly differentiate between transient complications associated with the procedure and more severe complications requiring intervention. Dermatologists and plastic surgeons must maintain vigilance in identifying and managing acute and chronic complications because many of these minimally invasive procedures are being performed by nonphysician practitioners. 

Infection
The percutaneous insertion of an absorbable foreign body, whether through the skin or hair-bearing scalp, may lead to overt contamination with colonizing skin flora, mycobacterium, atypical bacteria, or fungal processes.⁵ Nonhealing wounds, erosions, chronic erythema, fluctuance, purulence, or abscesses should raise suspicion for acute infection, loss of tissue perfusion, or chronic colonization of the foreign body threads.⁶ Distinguishing between an infectious process and chronic inflammation may alert the clinician to confounding variables. Removal of the PDO threads, directed antimicrobials, and wound care are important interventions.

Fluctuance
A fluctuant mass along the linear course of the deployed PDO threads may be a clinical sign suggestive of either a hematoma, seroma, purulent abscess, epidermal cyst, or emerging salivary sinus tract or cyst. PDO threads may elicit skin erosion, and these fluctuant subcutaneous masses may be linear in presentation and correspond to areas of the thread that may be close to the skin surface. The clinician must note the possibility of parotid or salivary gland injury with the insertion of the loading needle during the procedure. These conditions may be difficult to delineate based on history alone. It is important to properly identify the source of the fluctuant mass, exclude a microbial source, and remove (if indicated) the offending PDO thread.⁷ The presence of a pulsatile mass, whether fluctuant or nonfluctuant, may represent a rare superficial temporal artery (STA) pseudoaneurysm complication caused by traumatic injury to the STA during insertion of a PDO thread that requires emergent treatment.⁸

Thread Migration
PDO threads can become displaced from their anchoring position within the subcutaneous tissue.^2,4,6 Thread displacement may lead to skin erosion, chronic extrusion of the foreign body, skin dimpling, skin necrosis, and asymmetry.^2,4 Treatment begins with identification of the displacement by palpation and physical examination. It is often difficult to radiologically identify the absorbable thread on ultrasound or computed tomography scan, often depending on the perithread inflammation and stage of absorption. PDO thread removal, subcision, and excisional en bloc removal are possible treatment modalities for this complication. 

Foreign Body Reaction
PDO is a common component of absorbable suture material and has a proven track record of safety in surgery. However, the possibility of a chronic foreign body reaction is not uncommon in patients who have undergone PDO thread fillers or lifts.⁹ The rate of PDO absorption may be shorter or longer than manufacturer labeling, likely due to perithread reaction within the skin and soft tissue. Granuloma formation, inflammatory nodules, nongranulomatous nodules, hyperemia, and skin and soft tissue inflammation have been reported as complications arising from PDO threads. Pyogenic granuloma formation may require surgical debridement and chemical cauterization, whereas chronic wounds may necessitate antimicrobial therapy. Although rare, cutaneous pseudolymphoma arising from a retained PDO thread is possible.⁹ These reactions can be treated with intralesional therapy, when appropriate, or surgical removal of the PDO material. 

Nerve Injury
Attempts to percutaneously insert a PDO thread along the subcutaneous plane of the facial and neck superficial musculoaponeurotic system may inadvertently expose the patient to nerve injury. Direct injury to motor or sensory nerves within the face can be attributable to PDO thread insertion. In most cases, hypo- or hyperesthesia may be temporary and self-resolving, but the astute clinician must always remain vigilant regarding permanent loss of sensory or motor function arising from PDO mini-lifts. Chronic pain may be a long-term manifestation of nerve injury (partial or complete), perineural inflammation, or neuralgia. Treatment may include the administration of analgesics, removal of the inciting agent, or nerve repair. Facial reflex sympathetic dystrophy may be a possible diagnosis in patients with intractable and atypical pain symptoms. 

Conclusion
In the authors’ experience, PDO threads must be used judiciously considering the high incidence of complications in the published literature. Although popular in anti-aging facial rejuvenation, PDO threads may elicit the development of short- or long-term complications even though the material used is absorbable and minimally invasive. Smooth and barbed PDO threads may be poorly visualized once deployed under the skin, but may be the incipient factor in transient, acute, and chronic soft tissue changes that warrant intervention. 

References
1. Cobo R. Use of polydioxanone threads as an alternative in nonsurgical procedures in facial rejuvenation. Facial Plast Surg. 2020;36(4):447-452. doi:10.1055/s-0040-1714266 

2. Bertossi D, Botti G, Gualdi A, et al. Effectiveness, longevity, and complications of facelift by barbed suture insertion. Aesthet Surg J. 2019;39(3):241-247. doi:10.1093/asj/sjy042 

3. Cho SW, Shin BH, Heo CY, Shim JH. Efficacy study of the new polycaprolactone thread compared with other commercialized threads in a murine model. J Cosmet Dermatol. 2021;20(9):2743-2749. doi:10.1111/ jocd.13883 

4. Niu Z, Zhang K, Yao W, et al. A meta-analysis and systematic review of the incidences of complications following facial thread-lifting. Aesthetic Plast Surg. 2021;45(5):2148-2158. doi:10.1007/s00266-021-02256-w 

5. Surowiak P. Barbed PDO thread face lift: a case study of bacterial complication. Plast Reconstr Surg Glob Open. 2022;10(3):e4157. doi:10.1097/ GOX.0000000000004157 

6. Kim HJ, Lee SJ, Lee JH, Kim SH, Suh IS, Jeong HS. Clinical features of skin infection after rhinoplasty with only absorbable thread (polydioxanone) in oriental traditional medicine: a case series study. Aesthetic Plast Surg. 2020;44(1):139-147. doi:10.1007/s00266-019-01550-y 

7. Joethy JV, Cheah A, Ang CH. Facial abscess from unlicensed thread lift. Singapore Med J. 2020;61(9):498-499. doi:10.11622/smedj.2020133. 

8. Niimi Y, Hayakawa N, Kamei W, et al. Superficial temporal artery pseudoaneurysm following midface thread-lift. Plast Reconstr Surg Glob Open. 2021;9(4):e3524. doi:10.1097/GOX.0000000000003524 

9. Ahn SK, Choi HJ. Complication after PDO threads lift. J Craniofac Surg. 2019;30(5):e467-e469. doi:10.1097/SCS.0000000000005644