Predictors of Dissatisfaction After Polydioxanone Thread Lift: A Multicenter Retrospective Analysis

Abstract

Background:

Polydioxanone (PDO) thread lift is a widely used technique for minimally invasive facial rejuvenation. Although the technical outcomes and complications are well-documented, postoperative dissatisfaction remains underexplored, particularly among large multicenter cohorts. This study aimed to identify the predictors of dissatisfaction after PDO thread lift.

Methods:

We performed a multicenter retrospective analysis of 1500 patients who underwent PDO thread lifts at cosmetic surgery clinics in Japan. Postoperative dissatisfaction was defined as a return visit due to insufficient results. Univariate and multivariate logistic regression analyses evaluated the associations between age, thread count, sex, and dissatisfaction. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff values using the Youden index.

Results:

Postoperative dissatisfaction was reported in 51 (3.4%) patients, with age (odds ratio = 1.06; 95% confidence interval = 1.03–1.08; P < 0.001) and thread count (odds ratio = 1.09; 95% confidence interval = 1.03–1.16; P = 0.001) as significant predictors. Receiver operating characteristic analysis identified an optimal cutoff of 43 years (area under the curve [AUC] = 0.701; sensitivity = 0.725; specificity = 0.615) and 10 threads (AUC = 0.674; sensitivity = 0.784; specificity = 0.566). The AUC of the combined multivariate model was 0.754.

Conclusions:

Increased age and higher thread count were independent predictors of dissatisfaction after PDO thread lifts. These findings underscore the need for individualized risk stratification, age- and volume-adapted thread strategies, and preoperative counseling to align expectations with realistic procedural outcomes.

Takeaways

Question: What factors are independent predictors of patient dissatisfaction after polydioxanone (PDO) thread lift?

Findings: Among 1500 patients who underwent PDO thread lifts at cosmetic surgery clinics in Japan, 51 expressed dissatisfaction with their results. Univariate and multivariate analyses of age, thread count, and sex revealed that age and thread count, with cutoffs of 43 years and 10 threads, respectively, were significant independent predictors of patient dissatisfaction after PDO thread lift.

Meaning: Patient satisfaction may benefit from individualized treatment plans, age- and volume-specific treatment strategies, and preoperative counseling meant to align procedural efficacy with patient expectations.

INTRODUCTION

Polydioxanone (PDO) thread lifts have emerged as a popular procedure for minimally invasive facial rejuvenation.^1,2 Owing to immediate lifting effects with minimal downtime, this procedure is appealing to a wide range of patients who desire nonsurgical aesthetic enhancements. However, patient satisfaction is not uniformly high. Dissatisfaction with outcomes, although not formally classified as a medical complication, can negatively impact patients’ trust, the clinic’s reputation, and the overall success of the procedure.³

Although previous studies have focused on the safety, procedural techniques, and objective outcomes of PDO thread lifts,⁴ few have addressed predictors of patient dissatisfaction, a subjective metric. Given that outcomes of PDO thread lift are influenced by both technical factors and patient characteristics and expectations, identifying key predictors of dissatisfaction is critical for improving patient selection, surgical planning, and counseling strategies. This study aimed to identify independent predictors of postoperative dissatisfaction, particularly age and thread count, and support risk-stratified planning for improving satisfaction with thread-based procedures.

MATERIALS AND METHODS

Ethical Considerations

The study protocol was approved by our institutional ethics committee (approval number: UMEDAERB-2025Apr007). Owing to the retrospective design of the study, the requirement for informed consent was waived. All data were anonymized and managed according to institutional policies. The study was performed in accordance with the ethical principles outlined in the Declaration of Helsinki, as revised in Fortaleza in October 2013.

Study Design and Population

This multicenter, retrospective, observational study was conducted across 105 cosmetic surgery clinics affiliated with the Tokyo Chuo Beauty Clinic. It included a total of 1500 patients who underwent PDO thread lift procedures between November 2020 and December 2023. Patients were eligible for inclusion if they had undergone a facial PDO thread lift during the study period and had complete data, including age, sex, and the number of threads used. Patients were excluded if records were incomplete, if treatment involved nonfacial areas, or if energy-based devices (eg, radiofrequency or ultrasound) were concurrently used. In addition, patients who returned for postoperative follow-up solely due to physical complications, without expressing aesthetic dissatisfaction, were excluded. All procedures in this study used absorbable PDO threads, specifically barbed cog-type threads with a standardized length of 17 mm. Thread insertion was standardized across all participating clinics, with entry points consistently located at the temporal hairline and preauricular hairline. Threads were inserted into the superficial subcutaneous plane using blunt cannulas, and the number of threads per patient ranged from 1 to 20, depending on clinical indication. All participating surgeons underwent standardized in-house training on PDO thread lift techniques, ensuring consistency in the procedural approach across institutions.

Outcomes

The primary outcome of this study was postoperative dissatisfaction. In the absence of direct satisfaction scores, dissatisfaction was operationally defined as a patient returning to the clinic after the procedure with any complaints related to insufficient results or aesthetic concerns. It was presumed that patients who did not return were satisfied with their results. Patients who returned for other reasons—such as pain, swelling, dimpling, or asymmetry—without expressing aesthetic dissatisfaction were excluded from the analysis.

Variables and Measurements

The following variables were collected from the patients’ electronic medical records: age at the time of treatment, sex, and number of threads used. The number of threads was obtained from the procedural records and standardized across clinics. Sex, as recorded in the clinical documentation, was treated as a binary variable (man/woman).

Statistical Analysis

Descriptive statistics were performed to summarize the baseline characteristics. Univariate logistic regression analysis was performed to assess the association between each variable and postoperative patient dissatisfaction. Multivariate logistic regression analysis was then conducted using age and number of threads as predictors. Odds ratios (ORs) and 95% confidence intervals (CIs) were determined, and receiver operating characteristic (ROC) curves were constructed for both age and thread count, from which the optimal cutoff points were determined using the Youden index. Area under the curve (AUC) values were used to evaluate the discriminatory performance of the models. Statistical analyses were performed using R software (version 4.4; R Foundation for Statistical Computing, Vienna, Austria), and statistical significance was set at a P value of less than 0.05.

RESULTS

Patient Characteristics

A total of 1500 patients (mean age, 38.3 ± 12.2 y; 98.7% woman) who underwent PDO thread lift procedures were included in our analysis. Among them, 51 (3.4%) returned after the procedure due to dissatisfaction with the outcomes. Table 1 summarizes the baseline characteristics of the patients, stratified by the presence or absence of postoperative dissatisfaction.

Table 1.

Baseline Demographic and Procedural Characteristics Stratified by Postoperative Dissatisfaction Status

Patient Characteristic	Total	Satisfied	Dissatisfied
No. patients	N = 1500	N = 1449	N = 51
Age (mean ± SD), y	38.6 ± 12.3	38.3 ± 12.1	47.5 ± 12.6
Sex
Male	93	90	3
Female	1407	1359	48
Thread count (mean ± SD)	10.2 ± 5.3	10.1 ± 5.3	13.0 ± 4.2
Thread count range	1–20

Univariate Analysis

Univariate logistic regression revealed that age (OR = 1.06; 95% CI = 1.04–1.09; P < 0.001) and the number of threads (OR = 1.10; 95% CI = 1.05–1.16; P < 0.001) were significantly associated with postoperative dissatisfaction. Sex, however, was not significantly associated with postoperative dissatisfaction (OR = 0.94; 95% CI = 0.29–3.09; P = 0.924) (Table 2).

Table 2.

Logistic Regression Results

Model	Variable	OR	95% CI	P
Univariate	Age	1.06	1.04–1.09	<0.001
Univariate	Sex	0.94	0.29–3.09	0.924
Univariate	Thread count	1.10	1.05–1.16	<0.001
Multivariate	Age	1.06	1.03–1.08	<0.001
Multivariate	Sex	0.97	0.29–3.24	0.963
Multivariate	Thread count	1.09	1.03–1.16	<0.001

Multivariate Analysis

In the multivariate logistic regression model including age, thread count, and sex, age (OR = 1.06; 95% CI = 1.03–1.08; P < 0.001) and thread count (OR = 1.09; 95% CI = 1.03–1.16; P = 0.001) remained significant independent predictors of postoperative dissatisfaction, whereas sex remained nonsignificant (OR = 0.97; 95% CI = 0.29–3.24; P = 0.963) (Table 2).

ROC Analysis

ROC analysis was performed for age and thread count. The AUC for age was 0.701, with an optimal cutoff of 43 years (sensitivity, 72.5%; specificity, 61.5%). The AUC for thread count was 0.674, with a cutoff of 10 threads (sensitivity, 78.4%; specificity, 56.6%). The combined multivariate model, incorporating age, thread count, and sex, showed a superior AUC of 0.754, indicating good discriminatory performance (Figs. 1–3).

Fig. 1.

ROC curve for age as a predictor of patient dissatisfaction after PDO thread lift.

Fig. 3.

ROC curve for the multivariate model (age, thread count, sex) as a predictor of patient dissatisfaction after PDO thread lift.

Fig. 2.

ROC curve for thread count as a predictor of patient dissatisfaction after PDO thread lift.

Descriptive Analysis by Thread Count

To further explore the relationship between thread count and dissatisfaction, a supplementary descriptive analysis was conducted. Patients who received more than 10 threads demonstrated a higher incidence of dissatisfaction than did those who received 10 threads or fewer. This trend is visualized in Figure 4 and complements the logistic and ROC analyses by suggesting a possible dose–response effect between thread quantity and dissatisfaction risk.

Fig. 4.

Association between the number of threads used and the incidence of postoperative dissatisfaction.

DISCUSSION

Principal Findings

The analyses mentioned earlier identified increasing age and a higher thread count as significant independent predictors of patient dissatisfaction after PDO thread lift. Patients aged 43 years or older and those who received more than 10 threads were more likely to return for follow-up due to perceived insufficient aesthetic improvement.

Comparison With Previous Literature

PDO thread lifts have gained traction as an option for minimally invasive facial rejuvenation, with numerous studies focusing on the efficacy, complication rates, and technique optimization of the procedure.^5–16 However, dissatisfaction, a subjective yet clinically impactful outcome, remains underexplored in the relevant literature. Although some studies have acknowledged patient dissatisfaction as a secondary observation, few have treated it as a primary outcome based on rigorous statistical evaluations. To our knowledge, no previous study has analyzed patient dissatisfaction after PDO thread lift in a large-scale cohort (>1000 patients). With 1500 patients, our study represents one of the largest and most statistically robust investigations of this clinically relevant yet underexplored outcome.

Notably, the association between age and dissatisfaction aligns with previous findings from both surgical and nonsurgical aesthetic interventions, where age-related tissue laxity, delayed collagen remodeling, and increased asymmetry in older individuals can compromise aesthetic outcomes.^17,18 In the context of thread lifts, which depend heavily on tissue anchoring and skin recoil, age is a background variable and a decisive clinical factor.

Clinical Implications

The findings of our analyses have strong implications for clinical decision-making. Patients aged 43 years or older and those who received more than 10 threads should be considered to have a higher risk of postoperative dissatisfaction, even in the absence of major complications. Notably, the patient dissatisfaction in our study was not driven by infection, nerve injury, or exposure-related complications, suggesting that expectations, tissue response, and aesthetic thresholds may play a more significant role in postoperative dissatisfaction. Therefore, combination strategies involving volume restoration, skin resurfacing, and surgical lift may be more appropriate for these patients.

Interestingly, although a higher thread count is often presumed to result in a greater lifting effect and, in turn, increased satisfaction, our findings suggest an inverse relationship between the 2, as patients who received more than 10 threads demonstrated a significantly higher rate of dissatisfaction. This paradox can be attributed to several factors. First, an increased thread count is often used in patients with more advanced aging or greater tissue laxity, who inherently have a higher risk of suboptimal outcomes. Second, patients undergoing higher thread count procedures may have elevated expectations, believing that more threads translate to superior results. When the actual improvement falls short of these inflated expectations, patients may be dissatisfied despite the procedure being technically successful. Third, excessive thread insertion may lead to unnatural tension vectors, asymmetry, or delayed soft tissue adaptation, contributing to dissatisfaction. These findings collectively suggest that increased thread insertion may paradoxically increase dissatisfaction, particularly in older patients or those with unrealistic expectations. A tailored, conservative approach may be preferable in high-risk populations (Fig. 4). Although the ORs for age (1.06) and thread count (1.09) were significant, the effect sizes were modest. Therefore, although these variables can contribute to preoperative risk stratification and counseling, their clinical relevance should be interpreted with caution, particularly when considered in isolation.

Theoretical and Sociopsychological Context

From a psychological standpoint, dissatisfaction is not simply a function of physical outcomes but of expectation misalignment, self-image, and sociocultural ideals.^19,20 This is particularly relevant for patients who opt for minimally invasive procedures with surgical-level expectations, a mismatch that may predispose them to dissatisfaction. Aging may further complicate this dynamic, as it can influence thread lift outcomes via multiple mechanisms, including reduced skin elasticity, delayed collagen remodeling, and increased facial asymmetry. It is possible that older patients, many of whom opt for less-invasive procedures, approach these procedures with surgical-level result expectations, setting the stage for disappointment. Such mismatches between expectations and reality may be exacerbated by age-related physiological limitations that reduce the maximum achievable effect of thread-based treatments. Future research integrating preoperative psychological profiling and shared decision-making could further evaluate this subjective risk landscape and support the development of individualized expectation-sensitive treatment strategies in aesthetic medicine.

Limitations and Future Directions

This study had certain limitations. First, dissatisfaction was defined through follow-up visits rather than standardized patient-reported outcome measures, which may have resulted in the underestimation of its true prevalence. Notably, patients who were dissatisfied but chose not to return for follow-up were not captured in our dataset. The observed dissatisfaction rate of 3.4% may seem low for an aesthetic procedure; however, it is still a notable concern. This likely reflects an underestimation, as our definition was based solely on return visits for aesthetic concerns. Additionally, sociocultural factors in Japan, where patients may be less inclined to return or express dissatisfaction in the absence of complications, may have further contributed to this low rate. Future studies should include validated patient-reported outcome measures, such as the facial aesthetic clinician-reported outcome and patient-reported outcome instrument, to more accurately assess subjective dissatisfaction.

Second, data on variables such as skin laxity grade, facial volume loss, and psychological traits were unavailable. Additionally, other clinically relevant factors, such as skin thickness, body mass index, hormonal status, and patient expectations, were not recorded in our dataset. Although standardized procedural protocols were followed, detailed documentation of preprocedural counseling was not available. Variability in the depth or content of patient education may have influenced patient expectations and subsequent satisfaction. These unmeasured confounders may have influenced both the likelihood of postoperative dissatisfaction and its interpretation. For instance, patients with more advanced skin laxity or greater volume loss may require different thread lift strategies, and psychological predispositions such as body dysmorphic tendencies could amplify dissatisfaction despite objectively acceptable results. Future studies should collect and adjust for these multidimensional factors to enhance the precision and clinical relevance of the model. Given the relatively low number of dissatisfied cases, small-sample bias may have influenced the estimates. Penalized logistic regression methods, such as Firth correction, should be considered in future studies. We also recognize that categorizing continuous predictors based on ROC cutoffs (eg, age >43 y and threads >10) may result in information loss; therefore, future modeling should consider retaining continuous forms.

Third, the results of our analyses may not be generalizable to non-Asian populations, owing to differences in facial anatomy and cultural expectations among various ethnicities. An international consensus highlighted structural differences between Asian and White individuals—such as ligament density, fat distribution, and superficial musculoaponeurotic system characteristics—that may affect both thread placement and perceived outcomes.²¹ Given the multifactorial nature of postoperative dissatisfaction—including anatomical, procedural, and psychological dimensions—future research should incorporate validated patient-reported outcome measures, standardized satisfaction scales, and artificial intelligence–based predictive modeling to support individualized patient selection, optimize expectation management, and improve outcome predictions.

Fourth, although all participating physicians underwent a standardized in-house training program and followed a unified protocol, we did not stratify data by surgeon experience. Therefore, the potential influence of individual learning curves or technique refinements over time cannot be entirely excluded. Future studies should consider adjusting for experience level of the operator to further isolate patient-related predictors of dissatisfaction.

CONCLUSIONS

In this multicenter retrospective analysis of 1500 patients, both increasing age and a higher thread count were found to be significant independent predictors of dissatisfaction after PDO thread lift. Patients aged 43 years or older and those receiving more than 10 threads demonstrated markedly elevated rates of postoperative dissatisfaction. These findings highlight the importance of individualized treatment planning, age- and volume-adapted treatment strategies, and preoperative counseling that aligns procedural efficacy with realistic patient expectations.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENTS

The authors would like to express their sincere gratitude to all the staff at Tokyo Chuo Beauty Clinic for their invaluable assistance and support in conducting this study. They are especially grateful to Mr. Shinya Fujita for his significant contribution to the data extraction and management process. They also thank Mr. Masayuki Ishikawa for his valuable support in promoting and communicating their academic activities.