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. 2025 Aug 11;12(1):2546528. doi: 10.1080/23320885.2025.2546528

Synergistic facial rejuvenation with PDO threads and Botulinum Toxin A for aging skin

Aynur Aliyeva a,b,✉
PMCID: PMC12340935  PMID: 40800026

Abstract

Facial aging causes skin laxity, volume loss, and wrinkles. This study examines the effects of combining Polydioxanone (PDO) thread lifts and Botulinum Toxin A for non-surgical facial rejuvenation in 10 patients. After four months, 90% reported improved skin texture and brightness. Mild, transient swelling occurred, with no major complications.

Keywords: Aging, facial rejuvenation, minimally invasive procedures, patient satisfaction, Botulinum Toxin, PDO threads

1. Introduction

Facial rejuvenation necessitates a comprehensive approach to mitigate the effects of aging, such as sun damage, volume loss, skin thinning, and wrinkles induced by the frequent activity of facial muscles. With advancing age, the collagen fibrils that maintain skin strength degrade, and fibroblast connections weaken, leading to skin laxity and a loss of youthful appearance. Wrinkles formed through repeated facial expressions gradually deepen and become permanent [1,2]. Botulinum toxin plays a key role by blocking acetylcholine release at presynaptic neuromuscular junctions, causing chemical denervation that prevents dynamic wrinkles from forming due to muscle contractions [3]. Additionally, PDO demonstrates bio-stimulating effects, ranging from minor enhancements in fibroblast activity to prolonged stimulation of dermal thickness and vascularity [4]. Minimally invasive procedures are favored over traditional surgery due to their brief treatment duration, minimal disruption to daily life, and reduced downtime [5].

Botulinum toxin is widely utilized in aesthetic procedures to temporarily diminish facial wrinkles by relaxing specific muscle groups. By inhibiting the release of acetylcholine, a neurotransmitter responsible for muscle contraction, it leads to smoother skin in areas susceptible to dynamic wrinkles, such as the forehead and periocular regions. The effects typically emerge within a few days, peak between one and four weeks, and last for three to four months, making it a popular choice for those seeking non-surgical anti-aging solutions [6,7].

PDO thread lifting has also gained popularity as a minimally invasive method for facial rejuvenation, providing a non-surgical alternative to address skin sagging with minimal downtime. Unlike traditional facelifts, this technique employs absorbable sutures that lift the skin and stimulate collagen production, thus enhancing skin texture and elasticity over time. First introduced in the 1990s, PDO threads have since become a preferred option for patients who desire quick recovery and natural-looking results, making them an effective treatment that can be easily performed by general practitioners and specialists in clinical settings [8–11].

While the combination of PDO thread lifts and Botulinum Toxin A provides an effective and minimally invasive approach to facial rejuvenation, it is not without potential risks. Transient side effects such as mild swelling, bruising, and localized discomfort are common, while more complex complications, including improper thread placement, infection, or unintended muscle weakness from toxin diffusion, can occur if not performed with precision. Variability in patient response, skin elasticity, and anatomical differences further underscore the need for meticulous technique and individualized treatment planning to ensure optimal safety and efficacy [12].

This dual technique assesses the effectiveness and benefits of combining two minimally invasive approaches: Botulinum Toxin A and Polydioxanone (PDO) thread lifting, specifically for rejuvenating the upper midface in aging skin. The goal is to evaluate patient satisfaction and treatment outcomes to demonstrate the advantages of this synergistic approach.

1.1. Research aim

This study evaluated the synergistic effects of combining Botulinum Toxin A and Polydioxanone (PDO) threads for upper facial rejuvenation in aging skin. The hypothesis was that the combination would produce superior improvements in skin texture, wrinkle reduction, and overall facial aesthetics compared to traditional single-method treatments, offering a minimally invasive alternative for elderly patients.

1.2. Clinical considerations

Integrating PDO threads and Botulinum toxin for facial rejuvenation demands meticulous planning and precise application to optimize aesthetic outcomes and minimize risks. Effective patient selection requires a comprehensive assessment of contraindications, including hypersensitivity, active infections, or previous adverse reactions to cosmetic treatments. Profound knowledge of facial anatomy, particularly in the periorbital and zygomatic regions, is essential to avoid complications such as nerve damage or vascular compromise. Accurate dosing and strategic administration of Botulinum toxin, along with the careful and controlled insertion of PDO threads, are critical to achieving a harmonious and natural appearance, avoiding overcorrection, and ensuring safety and efficacy.

Polydioxanone (PDO) monofilament threads (Ultra V Lift Mono threads) are synthetic (Figure 1), absorbable sutures that dissolve within 4 to 6 months through hydrolysis, stimulating collagen production in the targeted areas. These threads represent a novel, non-surgical technique for facial rejuvenation by providing subtle lifting of sagging tissues while promoting collagen synthesis. As the threads naturally dissolve, they enhance skin firmness and texture, imparting a refreshed and youthful appearance. This method is particularly effective in addressing sagging skin and fine wrinkles without requiring invasive surgery. The study by Fukaya et al. highlights that many patients experienced visible wrinkle improvement following thread-lifting, with approximately 90% of participants perceiving themselves as looking younger one-year post-procedure [10].

Figure 1.

Figure 1.

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Monofilament polydioxanone thread.

Botulinum toxin, a well-established neuromodulator, is employed to reduce muscle activity and thereby diminish the appearance of facial lines and wrinkles. This treatment offers a minimally invasive solution, effectively relaxing facial muscles, reducing fine lines, enhancing skin texture, and even addressing certain blemishes. The procedure is swift, with minimal recovery time, making it a preferred option for those seeking non-surgical facial rejuvenation. Research by Small has demonstrated that botulinum toxin treatments result in noticeable skin-brightening effects and significant improvements in the appearance of fine wrinkles [7]. Patients receiving this treatment reported high satisfaction levels, attributed to enhanced skin luminosity and a smoother, more refined complexion.

The complementary effect is based on the distinct but synergistic mechanisms of action: PDO threads provide a mechanical scaffold and stimulate neocollagenesis, improving skin firmness and contour, while Botulinum Toxin A relaxes hyperactive muscles that cause dynamic wrinkles. By targeting both structural support and muscle activity, the dual approach addresses different facets of facial aging at appropriate tissue depths and anatomical layers, enhancing overall aesthetic outcomes [11].

2. Material and method

This study involved 10 female patients (mean age 66.25 ± 1.25 years) who underwent the dual procedure of PDO thread lifting and Botulinum Toxin A application. The small sample size was selected due to the study’s exploratory nature, aiming to assess preliminary outcomes and patient satisfaction before expanding to a larger cohort. While a control group was not included, all patients served as their own baseline, with pre-and post-treatment assessments conducted using the Visual Analog Scale (VAS). To minimize bias, postoperative outcome evaluations using VAS scores were conducted by independent clinicians who were blinded to the treatment phases. Future studies will also incorporate validated objective scales and inter-rater reliability assessments to strengthen outcome evaluations further.

Patients were selected based on strict inclusion criteria to ensure homogeneity. All participants were over 65, had no prior facial rejuvenation procedures within the past year, and presented with moderate to severe upper facial wrinkles. Exclusion criteria included active dermatologic conditions, coagulopathy, neuromuscular disorders, and hypersensitivity to any treatment component.

To standardize procedures across participants, all interventions were performed by a single experienced ENT surgeon (AA) under identical clinical conditions. PDO threads were placed in a consistent pattern according to predetermined anatomical landmarks, and Botulinum Toxin A was administered following a fixed dosage protocol. Postoperative care instructions were uniform for all patients to minimize variability in healing and outcomes.

All procedures followed the ethical standards outlined in the Declaration of Helsinki. Written consent was obtained for patient data and images for clinical and educational purposes.

2.1. Preoperative planning

Patients’ perceptions of their appearance were assessed using a visual analog scale (VAS) before and four months after the procedure, with results carefully documented. Pre- and post-treatment photographs were taken to track the improvements visually. The technique aimed to evaluate the effectiveness of Botulinum Toxin A in reducing dynamic and static wrinkles by weakening muscle contractions, while PDO threads were assessed for their lifting effect, fine wrinkle reduction, and skin texture enhancement, thereby providing a holistic approach to facial rejuvenation. Four months after the procedure, satisfaction was measured using a rating system of ‘satisfied’ or ‘unsatisfied,’ along with a 10-point VAS score.

2.2. Relevant upper face anatomy

2.2.1. Anatomical considerations for PDO thread lifting in the periorbicular area (lower orbicular region)

In the periarticular area, especially the lower orbital region, PDO threads are placed within the subdermal layer to achieve a lifting effect. Surgeons must be aware of the proximity to the orbicularis oculi muscle, which encircles the eye and plays a role in eyelid closure and facial expression. Proper placement in this region helps to address sagging and fine lines without interfering with muscle function. Critical anatomical structures in this area include the infraorbital nerve, which emerges from the infraorbital foramen, and the infraorbital artery. Careful planning is required to avoid these structures during thread placement, as inadvertent damage could lead to complications like numbness, bruising, or even hematoma formation. The loose areolar tissue and the thinner skin in the lower periorbital area make it more prone to swelling and bruising. Surgeons must use precise, gentle techniques when inserting PDO threads to minimize trauma and avoid complications such as dimpling or thread migration, which can cause visible irregularities in the delicate under-eye area [13].

2.2.2. Anatomical considerations for Botulinum Toxin injection in the periorbicular area

Botulinum toxin injections in the periorbicular area target the lateral part of the orbicularis oculi muscle to reduce crow’s feet and smooth dynamic wrinkles. Surgeons should inject superficially to avoid deeper muscles, as this could lead to unintended muscle relaxation and eyelid drooping. The key structures to be cautious of include the zygomaticus minor and major muscles, which run adjacent to the orbicularis oculi. Incorrect injection placement may result in asymmetric smiling or an unnatural appearance, making accurate muscle mapping essential for optimal results. Due to the proximity of the injection sites to the orbital rim, surgeons need to be aware of the potential risk of diffusion into the levator palpebrae superioris muscle, which could cause temporary ptosis (drooping of the upper eyelid). Low doses and precise injection points help in achieving safe and effective results without complications [14,15].

2.3. Operative technique

Operative technique

  1. Patient Preparation

    The procedure begins by ensuring the patient is seated comfortably upright to promote a relaxed posture throughout the treatment. This position allows for optimal access to the treatment areas and helps accurately assess the natural alignment of facial features. A local anesthetic cream (Emla) is applied generously to the targeted regions, including under the eyes, the forehead, and the nasal bridge (glabellar region). The anesthetic cream is left on the skin for approximately 30 minutes to ensure sufficient numbing, which minimizes discomfort during the procedure.

  2. Skin Sterilization and PDO Thread Placement

    Once the numbing is complete, the anesthetic cream is carefully removed using sterile gauze, and the skin is thoroughly sterilized to reduce the risk of infection. The PDO thread procedure begins with the insertion of smooth, monofilament threads into the subdermal layer. These threads are introduced using a free-floating technique, utilizing 29-gauge needles of varying lengths. After removing the needle (cannula), the threads remain in position, providing support within the skin. While smooth PDO threads primarily focus on enhancing tissue regeneration and improving skin texture, they do not offer significant lifting directly. Instead, they add subtle volume and improve skin elasticity by stimulating collagen production (Figure 2).

  3. Under the Eyes: Threads are inserted in a fan-like pattern, starting from the lateral side and moving towards the medial side. This configuration allows even distribution across the under-eye area, ensuring comprehensive coverage. Typically, at least 7–8 threads are placed to achieve a balanced and natural look, enhancing firmness and addressing fine lines.

  4. Zygomatic Region: One or two PDO threads are strategically placed along the zygomatic arch for the cheekbone area. This placement aids in providing subtle volumetric enhancement and support, improving the contour of the midface without adding bulk.

  5. Botulinum Toxin Application

    Following the placement of PDO threads, Botulinum Toxin A is prepared for administration. The preparation process involves reconstituting BOTOX® with sterile saline to form a consistent solution [16]. The targeted areas are once again sterilized to maintain a clean working environment. Botulinum toxin is then injected into specific areas using a 30-gauge needle, with precision being key to achieving the desired effect.

  6. Targeted Injection Areas: Key treatment areas include the glabellar lines (between the eyebrows and around the nasal bridge), the forehead, and crow’s feet (lateral to the eyes). The focus is on relaxing the muscles, contributing to dynamic wrinkles, and creating a smoother appearance without restricting natural expressions.

  7. Dosage and Injection Protocol: Dosages are adjusted based on the treatment area and the patient’s needs. For example, forehead lines typically receive around 20 units of Botulinum toxin, distributed across five injection points to ensure even and adequate coverage. Each injection is administered with care to avoid unnecessary diffusion of the toxin to surrounding muscles, which could lead to complications such as ptosis or asymmetry [15,16].

  8. Timing Considerations: Botulinum toxin is administered one hour after the PDO thread placement. This timing helps ensure the threads are securely positioned and allows the skin to settle. By spacing the procedures, any minor tissue displacement caused by the thread placement does not interfere with accurately targeting muscles during the Botulinum toxin application.

  9. Post-Procedure Monitoring

    After both treatments, the patient is observed briefly to monitor any immediate reactions and to ensure no signs of complications. Instructions are provided regarding post-treatment care, including avoiding strenuous activity, excessive facial movements, and direct pressure on the treated areas for the next 24–48 hours. This helps to ensure that the PDO threads and Botulinum toxin remain effective and secure in their placement.

  10. Follow-Up Care

    Patients are scheduled for follow-up appointments to assess the outcomes of the treatment, evaluate skin improvements, and address any concerns. The effects of PDO threads typically become more pronounced over the weeks following the procedure as collagen synthesis is stimulated, while the results of Botulinum toxin are usually evident within a few days and peak at around two weeks. Regular follow-ups help determine if additional sessions are needed to maintain or enhance the results, ensuring sustained patient satisfaction (Figure 3).

Figure 2.

Figure 2.

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PDO application.

Figure 3.

Figure 3.

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Before and three months after the view of the upper face. (up photos before, down photos after; left side forehead, right side periorbital area).

2.4. Postoperative consideration

Following the procedure, patients should be advised to avoid strenuous activities, excessive facial movements, and direct pressure on the treated areas for at least 24–48 h to ensure proper thread and toxin positioning. Mild swelling, bruising, or redness can occur, typically resolving within a few days, and cold compresses can be applied to minimize these effects. Regular follow-up appointments are recommended to monitor the healing process, evaluate treatment outcomes, and promptly address any concerns or complications.

Patients were routinely monitored postoperatively for signs of infection, asymmetry, thread migration, or unwanted toxin diffusion. Although no adverse events were recorded, continuous monitoring and structured adverse event reporting protocols will be emphasized in future expanded studies.

2.4.1. Clinical outcomes and complications

Statistical analysis was performed to quantify the effectiveness of the dual procedure using mean ± standard deviation (SD), 95% confidence intervals (CI), effect size (Cohen’s d), and the Wilcoxon signed-rank test. Despite the small sample size, these methods were chosen to assess the magnitude of improvement in VAS scores and determine statistical significance.

The combination of PDO threads and Botulinum Toxin A for facial rejuvenation in this dual technique demonstrated excellent clinical outcomes, particularly among ten patients with a mean age of 66.25 ± 1.25 years. Patients were evaluated four months post-procedure using VAS scores and self-satisfaction surveys, focusing on improved skin brightness and reduced fine wrinkles for Botox and reported high satisfaction levels, with Visual Analog Scale (VAS) indicating 1–3 (very satisfied) in 9 out of 10 patients. Additionally, self-assessment surveys showed that 100% of the patients were satisfied with the results, noting improved skin texture and brightness and reduced fine wrinkles.

The results showed a significant reduction in VAS scores from 5.92 ± 2.70 pre-treatment to 2.37 ± 1.74 post-treatment, with a large effect size (Cohen’s d = 1.56), indicating a strong clinical impact. Additionally, the 95% CI values (pre: 3.08–8.75, post: 0.55–4.19) further support the reliability of these findings, confirming a meaningful improvement in patient-reported outcomes.

Importantly, no complications were observed in our patient cohort, reflecting the technique’s safety and effectiveness when performed with precise anatomical knowledge and careful execution.

Potential risks of the dual approach include thread migration, localized infection, bruising, and unintended muscle weakness from Botulinum Toxin diffusion, which can lead to temporary asymmetry [17–19]. To mitigate these complications, PDO threads were placed following standardized anatomical landmarks, and Botulinum Toxin A was injected at precise depths and dosages to avoid diffusion into unintended muscles. Compared to single-method approaches, PDO threads provide mechanical lifting but cannot relax dynamic wrinkles, while Botulinum Toxin A reduces muscle contraction but does not address skin laxity [20]. Combining both techniques offers a more comprehensive and longer-lasting aesthetic improvement than either method alone [21–23].

2.5. Summary with key points

  1. The study examines a dual approach using PDO thread lifts and Botulinum Toxin A for non-surgical upper facial rejuvenation.

  2. This method is ideal for aging individuals seeking minimally invasive ways to reduce wrinkles and enhance skin texture without surgical downtime.

  3. PDO threads boost collagen production for subtle lifting, while Botulinum Toxin A relaxes muscles to smooth dynamic wrinkles.

  4. Four-month follow-ups showed high patient satisfaction, with clear skin tone, firmness, and aesthetic improvements.

  5. Combining PDO threads and Botulinum Toxin A targets different aspects of aging, enhancing skin structure and reducing wrinkles.

  6. Proper anatomical knowledge is essential, especially around the eyes and forehead, to avoid complications and achieve natural results.

  7. PDO threads are inserted subdermally to improve skin texture, which is particularly effective under the eyes and on the zygoma.

  8. Botulinum Toxin A was applied one hour after threading to treat glabellar lines, forehead, and crow’s feet, enhancing brightness and reducing fine lines.

  9. This technique offers minimal recovery time and a low risk of side effects, with mild swelling, bruising, or redness being manageable through cold compresses, limited activity for 24–48 hours, and proper post-procedure care to prevent Botulinum toxin migration or PDO thread displacement.

  10. No complications were reported, and patient self-assessments confirmed high satisfaction, supporting the safety and effectiveness of this combined approach.

2.6. Study limitations

This study has several limitations. First, it focused exclusively on elderly patients aged 65 years and above, which, while deliberate in evaluating outcomes in aging skin, may limit generalizability to younger populations seeking facial rejuvenation. Second, the absence of a control group prevents direct comparison between the combination therapy and single-modality treatments (Botulinum Toxin A or PDO threads alone). Therefore, the synergistic advantage of the dual approach, although suggested by clinical outcomes, requires further confirmation in larger, controlled studies. Third, the small sample size and case series design restrict the statistical power of the findings. Future investigations involving broader age groups, larger cohorts, and comparative analysis with single therapies are necessary to strengthen the clinical evidence and establish the comprehensive benefits of the combined technique.

3. Conclusion

The dual approach of combining PDO thread lifts with Botulinum Toxin A provides a minimally invasive, effective solution for facial rejuvenation, particularly in the upper face. This technique synergistically addresses skin laxity and dynamic wrinkles, leading to a natural and youthful appearance without surgery. Its minimal downtime and lasting results make it an ideal choice for aging individuals seeking subtle yet significant improvements in their facial aesthetics.

Ethical approval and consent to participate

Not applicable. All procedures followed the ethical standards outlined in the Declaration of Helsinki.

Consent for publication

Written informed consent was obtained to publish images of preoperative and postoperative results.

Authors contributions

Conceptualization, made substantial contributions in collecting, searching, scanning literature, and writing the manuscript, and performed a supervisory role in the manuscript: AA.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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