Dr Victoria Manning and Dr Charlotte Woodward discuss the use of PDO threads for breast lifting and provide their best practice guidance
Over the past few years polydioxanone (PDO) threadlifting has become one of the latest evidence-based aesthetic trends for facial skin tightening, lifting and rejuvenation. As well as facial ageing, breasts also age, which can be an aesthetic concern for some women. They may choose PDO thread treatment because it is a less invasive way to address breast sagging than surgery and PDO thread breast lifting has been indicated as effective and safe with less pain and minimal downtime than surgical interventions.1 Although, this technique is not suitable for all patients.
In this article we shall explore an innovative new use for PDO threads to lift the breasts, discussing the anatomy, techniques used and possible complications.
The threads are made of PDO, which is most commonly used for surgical stitches. PDO threads are used over other types of threads because they are strong and the most cost effective for this procedure. PDO continuously stimulates collagen synthesis under the skin, which means the results should improve over time.1 Spiral 3D barbed cogs, which are similar to a surgical sutures but have been modified to have barbs spiralling around the thread in order to anchor the tissue, give an immediate mechanical lift to the breast. The lift will continue to take place via fibrosis and tissue contraction over the next three to four months, offering the patient an immediate result as well as a delayed lift.1
When inserted into the skin, the threads act as a ‘scaffold’ that helps to ‘hold’ the skin against the effects of gravity. The threads are absorbable and from our experience, the body will reabsorb them in about six months, leaving nothing behind but the collagen structure created, which will continue to hold the breast for another 18-24 months. From our clinical experience, treatment can be repeated after two years as long as no contraindications are present.
As with all aesthetic procedures, patient selection is key. It is important, prior to any treatment, that certain criteria are assessed to determine the patient’s suitability for PDO threads. A thorough medical history should be taken and a full examination of the breasts needs to be conducted to assess suitability. The breast examination is paramount to check for any lumps, skin changes, tethering of the breast tissue or any underlying pathology. If any pathology is found these patients need onward referral and are unsuitable for treatment. Ideally all patients should have a mammogram prior to the procedure, however in practice this may be difficult. Be mindful of patients who appear to be suffering from body dysmorphia or have unrealistic expectations. These patients frequently demand results that a non-surgical procedure like PDO threads cannot achieve. Common sense must also prevail; smaller breasts (A-C cups) will produce better results purely because of the weight of the tissues. Patients with larger, pendulous breasts are more suitable to surgical procedures.
It is vital that the limitations of what can be achieved are fully explained to the patient prior to the procedure. Ptosis is a sagging condition where the breast both falls on the chest, and the nipple points downward. In practice we use a common grading system to categorise the degree of breast sagging, or ptosis, (Figure 1). If the nipple falls below the infra-mammary fold, the outcomes will not be as good as those whose nipples lie above the fold. As shown in Figure 1, good results can be achieved with up to Grade II ptosis.
Understanding the anatomy of the breast is critical, not only to reduce complications but also to understand the mechanism of the lift (Figure 2).
The breast is an organ and its structure reflects its primary function: the production of milk for lactation. The epithelial component of the tissue consists of lobules, where milk is made, which connect to ducts that lead out to the nipple. These lobules and ducts are located throughout the background fibrous and adipose tissue that make up the main mass of the breast.2,3,4
Anatomically, the adult breast sits above the pectoralis muscle, overlying the ribcage. The breast tissue extends horizontally from the edge of the sternum out to the mid-axillary line. A thin layer of connective tissue, or fascia, encircles the breast tissue. The deep layer of this fascia sits immediately on top of the pectoralis muscle, and the superficial layer sits just under the skin. The fascial relationships of the breast are of practical importance; the gland lies in a pocket of superficial fascia, in both deep and superficial layers. The superficial layer lies immediately beneath the dermis and enables injections and implantations of threads, avoiding the glandular mass and in a relatively avascular plane.3 The deeper fascia is thicker and covers the deep aspect of the breastplate. Fibrous processes of this fascia extend up to the skin and to the nipple. They are more developed over the upper part of the breast, where they form suspensory ligaments of Cooper.3 It is the contraction of the ligaments of Cooper that will give the lift. The supporting ligaments of Cooper maintain the tone and shape of the breasts and when healthy, keep the breasts firm and tight on the body.3
The blood supply to the breast comes primarily from the internal mammary artery, which is a branch of the subclavian artery that runs underneath the main breast tissue. The internal mammary artery sends branches along the first, second, third and fourth intercostal spaces, over the pectoralis major and supplying the inner half of the breast, including the nipple.5
Venous drainage of the breast is divided into two systems: superficial and deep. The superficial veins run along the anterior surface of the fascia, following the path of the areola under the nipple.5
The lymphatic vessels of the breast flow in the opposite direction of the blood supply and drain into lymph nodes. Most lymphatic vessels flow to the axillary lymph nodes, while a smaller number of lymphatic vessels flow to internal mammary lymph nodes located deep to the breast.5 The nerve supply to the breast is from the fourth, fifth and sixth intercostal nerves via the anterior and lateral cutaneous branches.5
The technique for thread insertion is relatively straightforward, provided the practitioner is fully competent in facial PDOs, breast anatomy and in taking a full breast and obstetric history, in addition to making a full breast examination. The procedure does involve mild discomfort, some bleeding and post-procedural bruising for up to 10 days after; further side effects are discussed in more detail below.
The initial consultation is carried out discussing risks, benefits and alternatives to the procedure. A two-week cooling-off period is then given, respecting the latest GMC guidance.6
When the patient returns, detailed measurements are taken, as indicated in Figure 3. This allows the practitioner to fully assess the amount of lift achieved at follow-up consultations.
The distance between the sternal notch and the nipple must be measured, which is usually eight to nine inches. This distance should reduce after the threadlift. A pinch test of the upper breast must also be conducted with callipers to measure thickness of tissue – this thickness should increase after the threadlift due to collagen stimulation.
Photographs are also taken, as with any aesthetic procedure, and the position of the threads marked on the breast for future consults. Pre-operative and post-operative photographs are taken, not only to show the patient what has been achieved following treatment, but also to point out any asymmetry that may have been initially present. This can be corrected by varying the After appropriate sterilisation – concentrating around the nipple due to sebaceous (Montgomery) glands on the areola, which can be a source of infection7 – the breasts are taped together and the patient is treated lying down. Depending on the degree of tissue laxity, the amount of threads will vary, however, a standard breast would take 20-25 90mm cogs inserted with a 21G blunt cannula.
Each entry point is anaesthetised with local anaesthetic. The correct tissue plane for the insertion of PDO threads is within the ligaments of Cooper, not into the deeper breast tissue. It is important to note that if the threads are placed too superficially in the dermal plane then they could be felt and may even be visible in the skin, while if they are placed deeper the threads can affect the breast tissue and potentially damage the ducts. Also, if placed too deeply, they will not achieve the correct degree of lifting of the tissues or stimulate collagen production.
We use the technique that was originally developed by aesthetic practitioner Dr Jacques Otto, to ensure the PDO threads are correctly placed. The PDO thread is inserted into a 1ml syringe that can twist to lock for security, which has been prefilled with local anaesthetic. In practice we find mepivacaine hydrochloride 3% without adrenaline useful because, from our experience, it works quickly. The benefit of this technique is that at any time during the thread placement, you can deliver a small amount of anaesthetic when it is needed. This is important as the breast tissue is much more fibrous than the face so much more pressure is required to insert the threads.
It is the contraction of the ligaments of Cooper that will give the lift. The supporting ligaments of Cooper maintain the tone and shape of the breasts and when healthy, keep the breasts firm and tight on the body
An entry point is made and the cannula is inserted into the opening, and two threads are placed per opening. Five entry points are made above and around the nipple in an arc for the inferior threads, then a further five entry points above pointing down to the nipple. A further five to 10 threads are inserted as anchors from just below the clavicle pointed inferiorly.
The cannula is advanced to its end-point. Be aware that this can be quite tender around the nipple region. Once the thread is placed, a 360-degree rotation of the syringe is made to anchor the thread; the free hand is used to ‘massage’ the cannula off the tissues leaving the PDO thread in place. The technique is repeated as required for the placement of other threads. Minimal compression is applied to the threads, unlike when treating the face.
After the treatment, the first effects are visible instantly, but considerable improvement appears after two to three months, when induction of new collagen begins.1
After the procedure the breasts are taped vertically with the tape finishing on the shoulders. The patient is advised to leave this tape in place for the next 48-72 hours to support the breasts. They are also advised to wear a supportive bra, such as a sport’s bra, after the procedure for the next two weeks and a soft bra at night for two weeks.
Post-procedural bruising and discomfort are common side effects. In our experience, due to having up to 25 threads per side, sometimes if threads are placed too superficially they may need hydrodissection to lift the skin from them to avoid puckering. This can be achieved by using a 21G needle and local anaesthetic around the thread to infiltrate and lift the skin above the thread. Barbed thread protrusion is possible if the threads are not cut shortly enough at the entry point.
Autoimmune diseases, hepatitis B and C, HIV infection, pregnancy and breastfeeding, anticoagulation therapy, body dysmorphic disorder, existing infection, history of keloid formation and patients with unrealistic expectations are all contraindications for treatment, as well as breast implants and previous breast carcinoma.1
Breast lifting with PDO threads is a procedure that requires considerable expertise, knowledge and training. In our experience, PDO threads offer a safe and effective method of achieving tissue lifting in the breasts of patients with a grade 1-2 breast ptosis. They should be placed in the correct tissue plane, within the ligaments of Cooper. Due to the number of threads used, the procedure is not cheap, so patient selection is key in order to obtain satisfactory results and happy patients. However, for the right patient this procedure offers a breast lift without many of the complications and risks associated with surgery and general anaesthetic.