PDO Threads in Combined Treatment Addressing the “3 ‘D’s’ of Aging”


PDO Threads in Combined Treatment

Addressing the “3 ‘D’s’ of Aging”

 by Michael Schreiber, DO


We live a magical age of Aesthetics. We now have at our disposal a seemingly endless assortment of options with which to treat the aging patient. Many of these options have required us to make a significant financial investment, and still it’s hard to know when one of our tools would be a better choice than another. We already have Botox, fillers, volumizers, Lasers, Radiofrequency, Ultherapy, etcetera, etcetera… and now there’s PDO Threads?! Why should I learn to use threads, when I already do these other things?

Good question. I’ll do my best to answer it.

When faced with the aging face and body, we in Aesthetics are really asked to address the “3 ‘D’s’ of Aging”: Deterioration, Deflation and Descent. We have an assortment of tools at our disposal, so let’s see how they might all fit together.

Deterioration, more accurately cellular deterioration, is the breakdown of the surface skin under the relentless ravages of time, hormonal changes, environmental exposures, and bad choices. Essentially, the face we show the world is under constant assault both from within (collagen breakdown, biochemical and hormonal changes, diet, disease, medications), as well as from without (sun/UV exposure, environmental toxins, cosmetic products). And it affects us each differently.

For example, accumulated sun-exposure in Caucasian skin (Fitzpatrick I-II) causes it to wrinkle… often prematurely. So “wrinkle-reduction” is what frequently drives Caucasians to seek our services. However, when the sun hits Asian, Latino, or East Indian skin (Fitzpatrick III-VI), it does not wrinkle… it turns brown. What torment these folks are brown spots: solar lentigines, melasma, and post-inflammatory hyperpigmentation (PIH). This demographic will understandably be more interested in solutions that address these concerns.

While there are numerous options for treating wrinkles, brown spots and sun-damaged skin, I like to break the approaches into 2 basic categories: “Cosmetic” and “Regenerative.” Within the Cosmetic category, are included such things as neuromodulators, dermal fillers, lasers, RF and dermabrasion. These procedures actually stimulate and create, in and of themselves, the desired therapeutic effects. On the other hand, Regenerative options, which include PRP/Stem Cell Microneedling, Growth Factors and PDO “Mono” Threads, work by stimulating the body’s own immune system to affect the desired change. The products themselves act as Bio-Stimulators.

PDO Threads are an absorbable surgical suture embedded within very fine needles. Some of these threads are smooth and monofilament, and are inserted into the subcutaneous layer in the form of a meshwork. As the body hydrolyzes the thread, the foreign body reaction stimulates fibroblastic activity, and the consequent elaboration of natural collagen and elastin. The end-result is overall improvement in the previously weakened collagen base, and a visible smoothing and tightening of the overlying skin. They are very effective in treating crepey areas, especially around the mouth and upper lip.

Regardless of which specific approach you choose, the main advantage associated with the Regenerative options is that they address the underlying problem, which is depletion of the collagen base in the skin. While each of the alternatives listed work somewhat differently, they all stimulate fibroblastic activity in the skin, promoting the elaboration of collagen and elastin. As such, their effect is not purely self-limited, but rather exerts a cumulative effect. Consequently, maintenance visits using regenerative procedures create a net gain in the collagen base over time, ensuring that when the procedure itself wears off, the effects do not. The body itself has produced, and sustains, the end result.

Deflation, or volume loss, is similarly multi-factorial. Seen more prominently in women, since fat deposition is so closely aligned with estrogen levels, it typically presents as hollowing of the cheeks, and thinning at the temples. This is not a surface phenomenon, and as such the tools we used to treat the epidermis are of little value here. However, as was the case with Deterioration, our choices in addressing Deflation can be characterized as either “Cosmetic” or “Regenerative.” Within the Cosmetic options, the most commonly used are the volumizing fillers (e.g., Juvederm Voluma®, Restylane Lyft®). Among the Regenerative options are PLLA (Sculptra®), BioiGel Filler, deep PRP/Stem Cell Injections and Fat Transfer.

Descent, or ptosis. When we are young, our faces are roughly heart-shaped, with higher volume in the upper and mid-face, tapering to a “V” at the chin. Over time, the malar fat pads begin to slip, creating deeper smile lines, and exposing the dark hollows under the eyes. As we enter our 30’s and 40’s, our faces become more rectangular, and the formerly protuberant cheekbones are now replaced with flatter frontal planes. While edge-detectors in the human eye are automatically drawn to sharp lines and shadows (e.g., deep nasolabial folds, glabellar furrows, horizontal forehead rhytids), the loss of prominent anatomic landmarks is one of the key visual cues we humans have inborn in us, for judging the ages of others.

As the 50’s and 60’s roll around, the gravitational forces invert the “V-Shape” of youth, and the face becomes almost gourd-shaped. The weight of the malar fat pads has now created even deeper smile lines, as well as marionette lines descending from the corners of the mouth. The sagging jowls and loose skin of the neck and sub-mental region obliterate the sharp jawline, producing another classic visual cue to advancing age.

The traditional way of addressing Descent has been with fillers. While fillers do fill-in the lines and lighten the shadows that automatically draw our eye, they have a downside: they also add volume. Volume in the lower face compounds the appearance of the gourd-shape, so rather than improving the situation, they actually make it worse. So then what is the solution?

Descent, while previously the exclusive purview of the plastic surgeon, can now be addressed non-surgically, and by any MD, DO, NP, RN, or PA who has been properly trained. While “lifting and tightening” energy systems are certainly available (Radiofrequency, Ultherapy), the consensus is that they seem to do a better job of tightening than they do of lifting. They `certainly have an important role to play in our practices, but it’s not in treating moderate-to-severe ptosis.

At present, the only safe, non-surgical means of addressing Descent and reversing gravity is PDO Thread Lifting. While their mechanism of action was discussed earlier, PDO Threads also come in a “barbed” variety. The edges of these long threads are studded with fishhook-like barbs that grab the subcutaneous tissue as the needle is withdrawn, lifting it and holding it in place. The result is a natural looking face “lift” that will last up to 18 months. The threads themselves are dissolved completely within 6 months; however, during this time, they act as a scaffolding upon which the natural collagen attaches and accumulates. So even though the thread is gone, the effects remain long after its disappearance. And although they will improve even more over the ensuing weeks, the results are immediate, hence satisfying the need for instant gratification that both patient and practitioner so crave. The procedure is performed under local anesthetic, it’s relatively painless, and has little-to-no downtime associated with it.

So in summary, here’s how we can use our clinical tools to address the “3 ‘D’s’ of Aging:

Deterioration Cosmetic Regenerative
Neuromodulators PRP/Stem Cell Microneedling
Dermal Fillers Growth Factors
Lasers/RF PDO “Mono” Threads
Deflation: Volumizing Fillers Sculpra® (PLLA)
PRP/Stem Cell, Deep Injections
BioGel Filler
Fat Transfer
Descent: Plastic Surgery PDO “Barb” Threads*



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