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Case Report

Efficiency of Barbed Polydioxanone Threads for Neck Lifting

using the Tight Neck Fontana Protocol: Series of Cases
Ana Laura Fontana, Gustavo Lessing, Jose Ricardo Albergaria‑Barbosa, Celia Marisa Rizzatti‑Barbosa
Department of Dentistry, Inga University Center, Orthodontics PostGraduation Course, Maringa, PR, Brazil, Feevale University, Novo Hamburgo, RS, Brazil

Abstract
The aim of these clinical cases descriptions was to describe the clinical results of barbed polydioxanone (PDO) threads in neck lifting using the
Tight Neck Fontana Protocol (TNFP). Three‑barbed PDO threads (19G or 18G and 150 mm in length) were implanted bilaterally in six female
adult patients with an indication for neck lifting. Two threads were inserted in the sub‑dermis of the neck through the diagonal vectors from
the angle of the mandible toward the midline and fixed with a knot. The third thread was implanted in parallel and just below the first vector.
The post‑operative results were evaluated by the occurrence of adverse events, scores attributed on a Visual Numerical Scale, questionnaire
inquiring the satisfaction patient about the treatment (QSP), and evaluation of photographic records. The results were quite satisfactory on the
procedures performed, suggesting the indication of the TNFP using barbed PDO threads for the neck lifting.

Keywords: Aesthetics, neck lifting, polydioxanone threads

Introduction Therefore, in this case report, we aimed to describe a simple

Face and neck ageing is due to progressive tissue degradation
that arises because of intrinsic and extrinsic factors. The
demand for aesthetic solutions in these regions has grown
in recent years, especially in middle‑aged individuals.[1,2]
Some minimally invasive alternatives have been proposed
for the correction and control of tissue ptosis and wrinkles
in these areas. Barbed, permanent or resorbable threads
have been considered important tools for ptosis solution
in the neck.[3,4]
The advantage of resorbable threads is that they are
effective in tissue traction while promoting intense
callogenesis around the thread even after its resorption,
providing durability to the treatment. [5,6] The barbed
polydioxanone (PDO) threads have been frequently used
in a facelift.[7]
Since the demand for lifting on the neck has increased, it
becomes necessary to define safe and effective protocols for
this purpose. However, there are few studies that mention the
use of threads on the neck, and no specific protocol for neck
ptosis tissue was found in the investigated literature using
resorbable bidirectional barbed PDO threads with 19G and
18G.
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and effective protocol of 18G and 19G bidirectional‑barbed
PDO threads implantation for neck tissue ptosis.
Case Report
The work was carried out on six female patients, aged between
35 and 48 years old, with similar characteristics for muscle
mass, skin thickness and biotype, general and local health and
indication for neck lifting. All received barbed PDO threads
for aesthetic reasons and signed the free and informed consent
form to participate in the work.
All procedures were performed by the same professional (A. L. F.)
using the tight neck fontana protocol (TNFP), previously
defined by the Authors  (G. L., J. R. A. B., C. M. R. B.),
Address for correspondence: Prof. Celia Marisa Rizzatti‑Barbosa,
Rua Sousa Reis, 120 ‑ Apto 93A ‑ Butanta, Sao Paulo,
SP, ZIP‑05586 080, Brazil.
E‑mail: rizzatti@unicamp.br
Submitted: 22‑Jul‑2021 Revised: 03-Aug-2021
Accepted: 23‑Sep‑2021 Published: 31-Dec-2021
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Fontana AL, Lessing G, Albergaria‑Barbosa JR,

DOI: Rizzatti‑Barbosa CM. Efficiency of barbed polydioxanone threads for neck
10.4103/aihb.aihb_110_21 lifting using the Tight Neck Fontana Protocol: Series of cases. Adv Hum
Biol 2022;12:71-5.

© 2022 Advances in Human Biology | Published by Wolters Kluwer - Medknow 71

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Fontana, et al.: Polydioxanone threads for neck lifting
according to their clinical experience. All patients received
a total of three bilateral threads, according to the previous
treatment plans.
Briefly, after biosafety care and infiltrative anaesthesia in
the regions to be treated, three patients (#1, 2 and 3) were
implanted with 18G bidirectional barbed PDO thread neck
lifting (Sculpt® FML18100G185, i‑Thread®/MedBeauty®,
Sao Paulo, Brazil), and three (#4, 5 and 6), were implanted
with 19G bidirectional barbed PDO thread for neck
lifting (FCL19100E160, i‑Thread®/MedBeauty®, Sao Paulo,
Brazil).
The implantations were guided by three vectors traced in the
region of the upper third of the neck. The first thread started
from the angle of the mandible and followed the lower limit
of the mandibular body towards the mandibular symphysis,
to the line of Ziarah Atkinson,[8] which adopts the second
lower premolar with vertical reference line, follows straight
to the mandible edge and then continues towards the fibres
of the platysma muscle; the second thread started from the
same point, with anterior direction and slightly diagonally
downwards, crossing the median line; the third thread started
from a point 20 millimetres below the angle of the mandible,
parallel to the second vector, with direction to the anterior to
the hyoid bone [Figure 1].
An orifice was performed with a 16G needle at the first
implantation point of the threads. The two threads were inserted
at this point according to their respective vectors  (first and
second vectors). Both were implanted in the subdermal layer
with the single and constant anterograde movement of the
microcannula until its complete implantation. After removal of
the microcannulas, the inserted threads were tied with a knot,
and after being cut with surgical scissors, they were totally
pushed inside the subdermal layer.
In the third vector, the last thread was inserted through the
orifice performed with a 16G needle at the starting point of
its implantation. Like the previous threads, its implantation
Figure 1: The three vectors traced in the region of the upper third of the
neck that guided the implantation of the threads.
72
was on the subdermal layer, through a single and anterograde
movement, until the total implantation of the microcannula.
After the microcannula was removed, the thread was cut
with surgical scissors and totally pushed into the sub‑dermis,
without knot fixation. After implantation of all threads,
the patients received instructions from home care, and no
post‑operative medication was prescribed. All procedures were
performed by the same professional (A. L. F.)
Patients were evaluated in different post‑operative periods
through standardised questionnaires and photographic
records (PR) analysis.
Both PR and questionnaires application were conducted by the
same professional (G. L.). Data analysis was conducted by two
other professionals (C. M. R. B. and J. R. A. B.). The following
periods were considered for the evaluation of the results:
Pre‑operative (baseline) and post‑operative (immediate, 24 h
and 30 days).
Adverse events (AE) were investigated by patients’ responses
considering the questionnaire applied 24 h after procedures;
personal impressions about the treatment were measured on a
Numerical Visual Scale (NVS) after 30 days of treatment, and
the aesthetic effects in different regions of the face and neck
observed by the patients (QSP) were also designated in their
own questionnaire after 30 days of the procedures.
PR of pre, 24 h and post‑operative 30 days [Figure 2] were
organised on the same screen and compared by two authors (C.
M. R. B., J. R. A. B.), defining the quality of the protocol on
a scale from 0 to 3 (0 = bad, 1 = satisfactory, 2 = good and
3 = excellent). Only one of the patients, who was implanted
with 18G thread, did not have 30‑day post‑operative PR. The
results were compiled, grouped in tables and analysed by two
professionals (J. R. A. B. and C. M. R. B.). Data regarding AE
are explained in Table 1.
All patients presented at least one AE, with skin traction being
the most prevalent (six patients). Only one patient‑related
pain. Recovery of all AEs was observed at most at 7  days
post‑operatively. For personal impressions regarding the
treatment measured in the NVS after 1 month of treatment,
the three patients that received 18G thread implant assigned
scores of 10, and the three patients who received 19G thread
implant assigned 9 and 8 scores. QSP regarding aesthetic
effects assigned by patients in the different regions of the
face and neck defined 1 month after treatment is expressed
in Worksheet 1.
The QSP scores in the regions far from threads
implantation (nasolabial fold, marionette line and cheeks)
were 4 (without any aesthetic effect). Scores 1 and 2 (excellent
aesthetic effect and good aesthetic, respectively) were assigned
in the regions with direct correlation to the intervention
areas (contour of the face), with excellent aesthetic effect in
mental definition  (the three patients who received implant
with 18G threads, and one patient treated with 19G thread);
and with good aesthetic (two patients who received the 19G
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Fontana, et al.: Polydioxanone threads for neck lifting

Figure 2: Assembly of PR for comparison among preoperative, immediately post‑operative and 30 days after the treatment. The first three patients
were implanted with 18G wire threads. The three subsequent patients were implanted with 19G threads. Scoring of photographic records on a scale
from 0 to 3 (0 = bad, 1: Satisfactory, 2: Good, 3: Excellent).

Worksheet 1: Perception of aesthetic effects (QSP) by patients regarding the treatment performed after 30 days post-operatory. Patients 1, 2 and 3
were implanted with 18G threads. Patients 4, 5 and 6 were implanted with 19G threads. Determination of scores: 1: Excellent aesthetic effect, 2: Good
aesthetic, 3: Few aesthetic effect, 4: Without any aesthetic effect.

Table 1: List of AE presented by patients after 24 hours of the procedures

Pacient None Pain Swelling Purplish skin Skin redness Skin traction Other
1 X
2 X
3 X
4 X
5 X X
6 X

threads). However, the two patients who received 18G threads Discussion
and one who received the 19G threads considered that there
The aim of this cases reports was to describe a simple and
was no aesthetic effect regarding facial symmetry. All patients
effective protocol for the implantation of 18G and 19G PDO
considered that there was an excellent (1) or good (2) aesthetic
bidirectional barbed threads for the correction of ptosis in the
effect in the regions where there was intervention (neck
neck region.
fat, mentual, mandibular definition and neck), except for
one patient who received treatment with 19G thread, who The corrections of ptosis and neck lifting can be made through
considered few aesthetic effects (3) to the neck. orthognathic surgeries, plastic surgeries or minimally invasive
treatments. The application of the TNFP is included in this
PR comparing the pre‑operative with 24 h and 30 days after
context. This protocol intends to correct ageing alterations
treatments, a score of 3 was defined for three patients (two
that arise in the mandible, mentual and neck, through the
who received 18G threads and one who received 19G
implantation of resorbable PDO threads, using simple
threads), 2 (good, for patients who received 19G threads) and
procedures and under local anaesthesia.
1 (satisfactory, for a patient who received 19G threads). In no
case was it considered that the immediate result of implantation These are completely reversible procedures but require some
was bad [Figure 2]. care to be considered for their execution. One of them is the

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Fontana, et al.: Polydioxanone threads for neck lifting
appropriate anatomical knowledge of the regions through
which the threads will pass because some complications and
AEs may be inherent to the protocol used. The most common
events are vessel rupture and consequent haemorrhagic process
with haematoma exaggerated deepening or superficialising
of the cannulas, involvement of the platysma muscle,
asymmetries, infections, inflammatory processes, among
others. These effects can be decreased when the procedures of
application of the threads follow standards in the knowledge
of local anatomy, coherent diagnosis, appropriate training in
the procedures of threads implantation and criterion in the
conduction of post‑operative home care reinforced about the
importance of care in the execution of orofacial harmonisation
procedures.
In the clinical cases described, no major or persistent
complications resulting from the procedures were observed,
probably because all pre‑, trans‑ and post‑operative care
were adopted. Among the post‑operative AEs observed, the
skin traction sensation of implanted tissues was common
to all patients, and only one reported post‑operative pain.
There were no haematoma, oedema, infection or important
inflammatory processes. Considering that the patients did not
receive post‑operative medication, the observed events would
be expected because they did not persist for more than 7 days.
However, analgesic medication or antibiotic coverage may be
prescribed if the professional considers it relevant.
For the correction of neck ptosis, the implantation of the
threads should be supported for resistant, good quality threads
and with high fixation competence in tissues.[9] The TNFP
recommends the implantation of six barbed threads, three on
each side, with 19G or 18G thickness. The implantation of
the threads at the limit of the mandibular body determines a
good aesthetic response for the correction of the mandibular
contour. The fixation of the two threads inserted in the same
orifice through the knot ensures the traction of this critical area,
where the fibres of the platysma muscle interlace those of the
masseter, the depressor of the oral commissure and the mentual
muscle fibres. However, the implantation of the threads in the
neck will ensure the quality of the lifting in the submandibular
region, maintaining the evidence proposed by the two upper
vectors. This aspect is fundamental to obtain a satisfactory
aesthetic result. The PR showed excellent and good scores
by the professional’s evaluations for both threads, especially
when the records for the 30‑day post‑operative period were
verified [Figure 2]. This was probably due to the competence of
neo collagen formation that PDO threads provide over time.[9]
Collagen induces better quality and elasticity to implanted
tissues, which is a highly positive factor for the maintenance
of treatment; although the threads are resorbable, it is possible
to maintain the achieved results for longer depending on this
property of the PDO threads.
TNFP demonstrated efficacy for both threads, 19G and 18G,
although the two patients who received the 18G threads
expressed greater satisfaction with the treatment, as well as
the analysis of pre‑ and post‑operative PR, that showed better
74
results in these patients. Sculpt® 18G has manufacturing
characteristics that give them a higher quality of fixation
through the spicules and more durability during their resorption
process. In the description of these cases, longer evaluation
periods were not considered, which depending on the technical
features, would certainly change the result.
No aesthetic changes have been reported in the areas of the
nasolabial fold, marionette line or cheek. Initially, because
the muscles and fat compartments involved in the formation
of these grooves do not establish a direct correlation with the
treated areas, it is necessary to consider that the ultimate goal
of a functional aesthetic treatment is to provide the most viable
options to the patient through an individualised treatment plan,
which, in this case, consisted of neck lifting only.
Any experienced professional in maxillofacial surgery
would attest that, often, orthognathic or plastic surgery is
not the best options to achieve good results for neck lifting
and mandibular contour design. Less invasive and effective
therapies may bring interesting results to the proposed
objectives, such as what was observed in the description of
these clinical cases.
Conclusion
The observed results allow suggesting the efficacy of the TNFP
for neck lifting when 19G and 18G threads are used. The
satisfaction demonstrated by the patients, the low prevalence
of AEs and the positive evaluations defined by the PR analysis
admit to establish that the cases were performed with criteria
and that both the protocol and the threads corresponded to the
expectations.
However, we consider that blinded and randomised clinical
studies comparing the TNFP with other neck lifting protocols,
and using other thread templates, should be conducted with
an appropriate n sample to prove, through statistical tools, its
quality and indication.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient (s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initial s will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Acknowledgement
The authors would like to thank the company MedBeauty®,
particularly to Pedro Miguel and Daniele Oliveira, for the
partial literary support and for providing the material used in
these cases reports.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Fontana, et al.: Polydioxanone threads for neck lifting

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