Lower Facial Rejuvenation Using Absorbable Casting Barbed Thread
- Admin
- May 16
- 7 min read
Based on Davis & Bennett | Dermatologic Surgery, 2017
Introduction: A New Standard in Thread-Based Lower Face Rejuvenation
Thread lifting has emerged as a minimally invasive alternative to surgical facelifts, particularly for patients with mild to moderate facial laxity. While upper facial lifting techniques are well-established, rejuvenating the lower face, specifically the jowls, oral commissures, and nasolabial folds remains a technical challenge. In their prospective, open-label study, Dr. Jeremy C. Davis and Dr. Richard G. Bennett (2017) evaluated the use of absorbable casting barbed PDO threads as a safe, effective, and precise method for lifting the lower face, while avoiding surgical downtime.
Their research offers evidence that using casting-formed threads with structured barbs, strategically inserted through a defined vector-based mapping system, results in predictable lifting, patient satisfaction, and minimal complications over a 24-week follow-up.
What Makes Casting Barbed Threads Structurally Superior?
A key innovation in this study is the use of casting barbed threads, a departure from conventional threads that use mechanical cutting techniques to form barbs. Traditional cut-barbed threads are manufactured by slicing barbs into the monofilament core. While this design is effective at gripping tissue, it inherently weakens the structural integrity of the suture, reduces tensile strength, and may trigger inflammatory responses due to sharp edges that irritate surrounding tissue.
In contrast, casting barbed threads are created using a molding process that integrates barbs directly into the PDO filament without compromising its core strength. These bidirectional barbs are smoothly formed and geometrically consistent, offering:
Stronger tensile durability, especially under multidirectional pull
Deeper tissue engagement without causing microtrauma
More stable anchoring, reducing the risk of migration or extrusion
Figure A illustrates a cut-barb suture with visible slits weakening the thread’s surface. Figure B shows a casting PDO thread with molded, integrated barbs that extend radially and evenly from the core. The barbs on casting threads also vary in orientation and depth, which helps anchor the tissue more symmetrically and allows for dual-vector traction, making them especially suitable for lower face rejuvenation, where soft tissue descent occurs in multiple planes.
Method: Thread Insertion Design and Mapping
A cornerstone of this study is the precise preoperative marking and thread vectoring system, designed to deliver predictable and symmetric lift along the lower third of the face. The insertion strategy is based on well-defined facial reference lines and anatomical landmarks.
Patient Selection
The study enrolled 61 subjects, aged 40 to 60, all with a Wrinkle Severity Rating Scale (WSRS) score of 3 or 4, indicating moderate nasolabial folds and early jowl formation. All procedures were performed under local anesthesia with tumescent infiltration to minimize discomfort and ensure tissue pliability.
Vector Design and Marking Protocol
The face was mapped using a multi-point vector system, with reference lines drawn as follows:
Line I: A straight line from the alar base of the nose to the mandibular angle, serving as the primary lift axis.
Line II: A horizontal line passing through the alar base, intersecting Line I to guide midface elevation.
Line III: A second horizontal line drawn from the oral commissure, intersecting Line I for lower face and jowl repositioning.
Points A to D: Key anatomical points along these lines used to anchor thread insertion and determine lift direction. For example:
Point A: Entry site near the sideburn/zygoma
Point B: Elevation target for the nasolabial fold
Point C: Lift target for the marionette line
Point D: Anchor point near the mandibular angle or jowl region
This figure visually maps out Lines I–III and Points A–D across the lower face, serving as a clear guide for thread insertion and lift vectors. Using these markings, threads were inserted in a fan-like, multi-vector pattern, typically from a high lateral entry point (Point A) down toward each target (Points B, C, and D), ensuring both vertical and lateral lift across the lower third of the face.
Technique Overview:
A long blunt cannula was used to tunnel subdermally along each vector
Barbed threads were inserted using preloaded needles
Threads were gently pulled until optimal tension was observed along the vector line
No anchoring or knotting was required, relying solely on the strength of the bidirectional barbs
This technique allowed for precise lifting of the nasolabial folds, marionette lines, and jowls, areas traditionally resistant to correction through nonsurgical means.
Results: Objective Lifting and Patient Satisfaction
The results of this 24-week open-label clinical study demonstrated clinically measurable and visually appreciable lifting of the lower face, combined with high levels of patient satisfaction and evaluator agreement. This was assessed using three primary outcome metrics: objective distance measurements, WSRS scores, and Global Aesthetic Improvement Scale (GAIS) ratings.
Objective Lifting: Quantified Improvement in Facial Elevation
To evaluate the mechanical effectiveness of the absorbable casting barbed threads, investigators measured the vertical shift of soft tissue landmarks immediately post-procedure and over time. Using standardized digital photography and anatomical reference points, the team documented consistent elevation across all treatment areas.
On average, Points B and C (nasolabial fold and oral commissure regions) demonstrated the greatest degree of vertical lift, ranging from 0.41 to 0.83 cm on the right side and 0.42 to 0.81 cm on the left.
The lifting effect was bilaterally symmetrical, highlighting the precision of the thread vector planning and the reliability of the barbed thread grip.
Most subjects experienced visible midface elevation, improved nasolabial fold contour, and a notable reduction in early jowl formation.
Figure A shows the immediate right-side lift before the left side was treated, illustrating unilateral correction in real-time. Figure B reveals the final result with both sides elevated, restoring facial harmony and symmetry. These findings underscore that absorbable casting barbed threads not only provide a visually perceptible lift but also achieve measurable anatomical repositioning, making them a reliable tool for nonsurgical rejuvenation in the lower face.
Wrinkle Severity Rating Scale (WSRS): Statistical Reduction in Laxity
Improvement in static wrinkle severity was evaluated using the WSRS, a 5-point validated grading system ranging from 1 (no wrinkles) to 5 (severe folds). Both operator and blinded evaluator scores were recorded at baseline and compared across multiple time points, immediate, 2, 8, and 24 weeks post-procedure.
The mean operator-assessed WSRS score decreased by 1.2 points over 24 weeks.
Independent evaluators reported a mean reduction of 1.3–1.5 points, reinforcing consistency across subjective and objective assessments.
The reduction in wrinkle depth was statistically significant (p < 0.05) at every evaluation point.
This improvement was most evident in the nasolabial fold and marionette line areas, where thread vectoring was most concentrated. It also reflected the dual effect of mechanical repositioning and collagen remodeling stimulated by the barbed thread’s presence over time.
GAIS (Global Aesthetic Improvement Scale): Real Patient Satisfaction
Patient satisfaction was measured using the GAIS, a subjective scale ranging from 0 (no improvement) to 3 (very much improved). Both physicians and patients scored outcomes at various intervals, with the final evaluation at week 24 offering insights into perceived long-term efficacy.
The mean operator GAIS score was 1.85, corresponding to "much improved."
The mean patient GAIS score was 1.84, closely aligning with the physicians’ assessments and reflecting strong satisfaction among recipients.
These photos highlight two case studies showing marked improvement in lower facial laxity, reduced nasolabial folds, and smoother jawline contours, confirming both aesthetic benefit and patient-reported satisfaction. The close correlation between operator and patient ratings underscores that this technique delivers not only clinical efficacy but also aligns with patient expectations, an essential metric in cosmetic dermatology and aesthetic surgery.
Safety and Complication Profile: A Low-Risk Rejuvenation Strategy
The study reported a strong safety profile across all 61 participants, reinforcing the clinical viability of absorbable casting barbed threads for outpatient procedures. No serious or long-term adverse events were recorded, and all complications were minor and self-limiting.
Common observations included:
Mild swelling and tenderness, particularly near entry and exit points, typically resolving within 3–5 days.
Post-procedural tightness, which is an expected outcome from tissue traction and usually subsides as inflammation reduces and tissue adaptation occurs.
Transient dimpling occurred in a small subset of patients, especially when the thread path was close to the dermis. This was managed conservatively and resolved without intervention.
Rare pustule formation was reported in isolated cases, likely due to follicular irritation or minor skin breach. All resolved with topical antibiotics without requiring thread removal.
Importantly, no incidents of thread migration, extrusion, hematoma, or nerve injury were observed. This reflects the benefit of using smooth, cast-molded barbs, which minimize tissue trauma and reduce the risk of irregular healing or delayed fibrosis. These findings demonstrate that when performed with proper anatomical planning and technique, this method is safe, predictable, and well-tolerated, even in regions as delicate as the lower face.
Why This Technique Stands Out
What sets this technique apart is its fusion of thread innovation with structured anatomical planning. The use of casting barbed threads introduces a level of mechanical control not seen with older cut-barb designs. Because the barbs are molded and not incised, they retain the full strength of the PDO filament while providing uniform traction in multiple directions. This allows threads to engage more deeply with the soft tissue matrix and deliver a consistent, smooth lift without risk of cutting through fragile tissue.
Moreover, the multi-vector insertion strategy ensures that correction isn’t one-dimensional. Unlike single-vector lifts, which can result in lateral pull or volume bunching, this approach uses targeted entry-exit geometry to selectively elevate the nasolabial fold, oral commissures, and jawline. This leads to a more balanced aesthetic outcome, with natural movement preserved across smile lines, speech, and jaw articulation. From a clinical workflow perspective, the technique is efficient, typically completed in under an hour with minimal anesthesia and downtime. This makes it an ideal procedure for today’s aesthetic patients who seek visible results without the extended recovery of traditional facelifts.
Conclusion
Thread lifting using absorbable casting barbed threads is a clinically effective, minimally invasive option for patients with facial laxity in the mid and lower face. With quantifiable lift, statistically significant wrinkle reduction, minimal complications, and durable satisfaction rates, this method offers a viable alternative to traditional facelift surgery, especially for patients who prioritize quick recovery and subtle, natural-looking enhancement. Surgeons and dermatologists aiming to expand their non-surgical facial contouring portfolio may find this approach particularly suitable for midlife patients with moderate jowling and deep nasolabial folds.
Reference:
Davis, J. C., & Bennett, R. G. (2017). Lower facial rejuvenation using absorbable casting barbed thread. Dermatologic Surgery, 43(S1), S45–S51.
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