A New Era in Thread Lifting: Achieving Better Results with Fewer RisksA New Era in Thread Lifting: Achieving Better Results with Fewer Risks

The field of aesthetics is constantly evolving to balance patient demands with innovative technologies, sparking a resurgence for thread lifting, a bioregenerative treatment with immediate results. As with other aesthetic procedures, there is a chance for complications, but updated technologies and techniques allow providers to deliver impressive thread lifting results with fewer risks. Most experts believe a solid understanding of possible complications as well as prevention and management methods are keys to successful thread lifting results.

Common Complications

According to Lyris Verdura-Dominic, APRN, MSN, FNP-BC (Boca Raton, Fla.), an internationally recognized trainer, mentor and key opinion leader (KOL) specializing in polydioxanone (PDO) threads the most common complications associated with thread lifting include bruising, swelling and asymmetry. “Less frequently, patients may experience thread extrusion, dimpling or a visible thread under the skin,” she added. “The likelihood of these complications varies depending on the provider’s education, experience, patient selection, artistry and post-procedure care. In experienced hands, complications are relatively rare.”

Sheila Barbarino, MD, oculoplastic and cosmetic surgeon and the founder and medical director of Barbarino Surgical Arts (Austin, Texas, and Redondo Beach, Calif.), acknowledged that aesthetic procedures often carry risks, but today the complications from thread lifts are manageable and preventable. “Dimpling is common and due to too superficial placement. Asymmetry is common, especially for newer practitioners, and thread migration is rare, but often due to the thread not being totally locked into place. Thread breaking is also rare but can happen due to expired threads or poor thread quality.” According to Dr. Barbarino, not only can thread lifts provide excellent results, but they are also not associated with vascular occlusion and blindness like their dermal filler counterparts. “Some practitioners might consider using threads instead of filler, especially in high-risk areas,” she clarified.

Pawnta Abrahimi, RN, MSN, is a full-face rejuvenation specialist at Motykie Med Spa in Beverly Hills, Calif., and often treats patients for thread lift corrections. “The most common complications associated with thread lifting that I have treated (from other providers) include bruising, dimpling and infection,” she reported. “Thread migration can result in a lumpy appearance while allergic reactions to the threading material may also occur. With 20 years of practice in aesthetic medicine, I have encountered only one case requiring actual thread removal due to recurrent infection. This situation arose because the previous provider had placed the thread in the incorrect plane of the skin. I was brought in to assist in resolving this issue.

“While nerve damage from thread lifts is rare, it can occur,” Ms. Abrahimi continued. “I have treated several patients referred to me. One had issues with their eyelid due to nerve involvement, while another faced more widespread nerve impact. However, both saw significant recovery after receiving treatment like dexamethasone or methylprednisolone, with full healing typically occurring within a few months. It is vital to understand that while complications such as infection are possible, careful technique and experienced professionals can minimize risks.”

Plastic surgeon Jeffrey Rosenthal, MD (Fairfield, Conn.), explained that threads used in the past were non-absorbable, which led to more complications. “The body sometimes reacted to earlier threads as a foreign material and would reject them,” he reported. “Threads today have evolved and are now absorbable over six months to a year. A column of collagen is produced around the threads, so the threads reposition tissues and the collagen column supports the tissues, an effect which lasts up to two years. The complications of today’s threads are mainly due to technical issues from new or inexperienced practitioners.”

Tips for Avoiding Complications

The general consensus among experts is that the best way to prevent complications from threads is to avoid them. “Education and training are vital to avoid complications, discomfort and potential emotional distress in your patients,” Ms. Verdura-Dominic advised. “New providers should seek hands-on training with experienced mentors in a controlled environment. One-on-one training is best, while attending advanced workshops and specialized courses in thread lifting that focus on both theoretical knowledge and practical experience is [also] important. Additionally, technologies such as ultrasound for assessing facial anatomy can enhance precision.”

Dr. Barbarino added that most thread companies offer training on their threads at a discounted cost or in exchange for a thread purchase order. “Use these offerings to your advantage to learn, grow and get better at thread lifting procedures. Additionally, seek hands on training and watch as many different providers as possible performing thread lifts.”

Dr. Rosenthal is a firm believer that patient selection and communication are keys to success. “Threads are very effective for the right patient. If a patient has a heavy face, significant jowling or heavy lower neck or bands, then threads will not provide the desired outcome. For these patients, a facelift will provide optimal results,” he reported. “Also, be clear about pre- and post-care instructions to minimize the risk of complications.” Dr. Rosenthal provides his patients with printed instructions such as avoiding products that increase bleeding like aspirin, ibuprofen, vitamin E or fish oil for two weeks before the treatment to limit some complications later such as bleeding and bruising. He also suggests avoiding other medical treatments like dental work immediately after treatment and elaborates on the importance of healthy lifestyle habits.

Methods for Managing Complications

While it is generally agreed that avoiding complications is the ideal scenario, aesthetic treatments do carry associated risks. Some complications may have standard management protocols, such as addressing asymmetries with thread repositioning or dermal fillers, while migration may be avoided with appropriate placement techniques. Dr. Barbarino summarized the best way to prepare for managing complications: “Practice, practice, practice. Take your time and know your anatomy. Shadow practitioners experienced in thread lifting and find a thread mentor that lives near you who can help with complications if and when they arise.”

Ms. Abrahimi agreed and added that networking at local aesthetic conferences or joining professional associations can help new providers establish these connections. “A mentor can provide guidance on technique, share insights on complications and offer support in real-time during your initial procedures,” she commented.

In Dr. Rosenthal’s experience, using updated technology is also important. “If a thread is not properly secured, it can release and migrate," he reported. “Also, the mobile portion of the face may get significant puckering or dimpling, which should be addressed immediately before the patient leaves. One method is to release some of the barbs that are holding the tissue up.” He emphasized that mitigating complications may be different between providers, which is why continuing education from a variety of sources is crucial to increase provider confidence.

Achieving Natural-Looking Results

According to Ms. Verdura-Dominic, new providers should focus on understanding facial anatomy and tension vectors, while placing threads in the right plane and orientation are essential for natural-looking results. Additionally, thread lifting is not a cookie-cutter treatment. Ideal results come from a synergistic relationship between threads and other treatments. “Avoid overcorrecting because less is more, and combining thread lifts with skin quality improvement treatments and volume correction can further enhance outcomes,” she remarked. “Precision and subtlety are key.”

Dr. Barbarino also combines treatments and reported that those compatible with threads include fillers, neuromodulators, lasers and radiofrequency microneedling (RFMN). None of these treatments weaken threads, she confirmed. “Best results are achieved by using a combination of lifting vectors and reverse vectors, and long-lasting results are achieved by the number of threads used.”

“Possessing a strong understanding of anatomy and the nuances of skin depth, as well as an artistic eye will help providers achieve natural-looking results,” Ms. Abrahimi noted. “Aesthetic medicine requires more than technical skills; it demands an artistic eye for symmetry and beauty. Practice observing and analyzing facial proportions and how they relate to aesthetic outcomes. Educate yourself about the cultural significance of beauty across different ethnicities and age groups. Understanding these perspectives helps tailor your approach to meet varied patient needs. Engage in discussions with patients about their beauty ideals to ensure their goals align with the techniques you offer.

“Assess skin quality and thickness for each patient before deciding on the type and number of threads to use,” Ms. Abrahimi continued. “This assessment will guide you in selecting the right thread material and placement strategy. Ensure you use enough threads to achieve the desired lifting effect without overloading the area. It is better to use multiple threads distributed evenly than to rely on a few. This not only enhances results but also reduces the risk of complications like dimpling or migration. Pay attention to the angle and depth of thread insertion. Proper technique is vital to prevent complications such as thread extrusion or migration. Practice the vectoring technique to lift the skin naturally while maintaining harmony with the patient’s facial structure.”

In Ms. Abrahimi’s experience, molded, cog hook cone-shaped threads offer superior tensile strength and a more secure grip on tissue, enabling effective lifting with fewer placements. “The placement of these molded threads can be precisely controlled to create specific vectors that reshape the face. As providers familiarize themselves with various thread types and their specific benefits, they can confidently select the best options for their patients. The ability to manipulate vectors effectively contributes to a more aesthetically pleasing result.”

While some plastic surgeons remain opposed to the use of threads in aesthetics, Dr. Rosenthal believes that plastic surgeons are ideally suited to perform thread lifts and can provide optimal outcomes with combination treatments that are best suited for each patient. “The benefit of being a plastic surgeon is that I can stage procedures that will gradually rejuvenate my patients’ skin in a very natural, refreshed way,” he reported. “For example, I may use a nonsurgical laser device to stimulate collagen and remove or soften areas of localized fat along the nasolabial folds or the jowls in conjunction with PDO threads. This laser may be applied on the face, eyebrow area or jawline and then I place threads to lift and support the structures and hold them in place. This combination stimulates collagen and contours the face, while the threads reposition and hold the tissue in place. I also use dermal fillers placed along the mandibular region as a structural support and to stimulate collagen, as well as resilient hyaluronic acid (RHA), which moves with the face. Additionally, neuromodulators help weaken certain muscles in the platysma bands to lift the neck up, so when I put my threads in, the structure will move easier and look more natural.

“Aging is an ongoing process, and we can address the different aging factors in the face with fillers and threads to continually improve the patient for every age,” Dr. Rosenthal added. “If my patients are planning a facelift within a few months then I suggest they do not do threads. But if they are considering a facelift in a year or so, then I recommend getting threads and waiting a year to see if they like them. If so, they can repeat the procedure, and if they are not satisfied and want something more permanent, then they can have a facelift.”

While thread lifts work well in combination with many other aesthetic treatments, providers should also understand which treatments are not compatible, Ms. Verdura-Dominic cautioned. "Avoid treatments that induce significant inflammation like laser, laser resurfacing or deep chemical peels immediately after a thread lift. They may interfere with healing or lead to thread displacement or internal burns or accelerate metabolization of the actual threads,” she concluded.

Product Watchlist

For providers looking to add a diverse line of threads to their armamentarium, PDO Max FDA-cleared in-cannula threads include a complete lineup of thread products with the versatility and strength needed to deliver superior nonsurgical results. Their lineup includes molded threads for advanced procedures and specific placements that elevate patient results, and laser-cut threads for traditional procedures. The Levo threads are considered their workhorse threads for traditional three-vector mid-face / jaw procedures with a maximum tensile strength USP size 2. PDO Max threads are differentiated by their specific omni-directional design with barbs placed all around the thread for better grip. The configuration of barbs creates a broader area of coverage in addition to being flexible and easier to place, causing less tissue trauma.