Patients rarely point to the nasolabial fold on its own. They lift the cheek with two fingers, tilt their head under the clinic light, and say, If I could just keep it like this. That little move captures the central question with PDO thread treatment for smile lines: do we lift the cheek back where it belongs, or do we fill the etched crease itself so it looks softer? Both approaches use the same material, polydioxanone, but they work through different mechanics and suit different faces.
I have used PDO threads for face contouring and skin tightening since they entered mainstream practice in the US more than a decade ago. In the nasolabial area, the smallest technical decision can be the difference between a crisp rejuvenation and a puckered smile. The goal of this guide is to help you understand the trade-offs, set realistic expectations, and choose a plan that makes sense for your anatomy and your timeline.
What builds a nasolabial fold in the first place
The fold is not only skin. It is a topographic line where a mobile cheek meets a tethered perinasal area. Three things create that line over time:
- Descent of the midface fat pads. The deep medial cheek fat and medial suborbicularis oculi fat thin and drop a little, then the superficial medial cheek fat shifts over a relatively fixed nasolabial ligament. That creates excess volume just above the fold and a trough just below it. Bone and dental changes. The pyriform aperture widens and the maxilla resorbs a few millimeters over midlife. If you have missing upper premolars or long-standing periodontal issues, soft tissue support near the alar base can weaken, which deepens the crease. Skin quality and repetitive motion. Collagen loss, sun damage, and decades of smiling make the skin less elastic. The crease becomes etched even when the cheek is lifted.
A strong fold in a 32-year-old runner is a different problem than a strong fold in a 62-year-old with laxity and volume loss. PDO threading treatment needs to match that difference: reposition where descent dominates, and remodel where the skin and crease itself are the issue.
Two philosophies: lift versus fill
Both strategies use dissolvable threads placed through a blunt cannula. Both aim for facial balancing, not a frozen midface. But the intent and result differ.
- Lift with barbed threads: We place cogs or molded-barb PDO threads to catch and elevate the cheek pad toward a stronger lateral anchor. This PDO thread lift indirectly softens the nasolabial fold by reducing the bulge above it. Think of it as re-suspending the drape rather than ironing the wrinkle. It is a minimally invasive lift, not a replacement for surgery, and it pairs well with PDO threads for jawline or cheek vectors when jowls also bother you. Fill with smooth or screw threads: We place multiple fine PDO threads directly into and around the crease to stimulate collagen and slightly thicken the dermis. These threads do not pull. They induce a controlled wound-healing response that improves elasticity over several months. The result is subtle smoothing, especially for early lines or etched skin that folds easily when you smile.
Neither is always right or wrong. I often combine a light lift to reduce heaviness with a few smooth threads at the deepest segment of the fold to improve texture.
Reading the fold: who benefits from each approach
The quick chairside test is the two-finger lift. If pulling the cheek laterally and slightly upward makes the fold almost disappear, a lift will do the heavy lifting. If the fold remains a carved-in line even after that maneuver, collagen remodeling within the fold matters.
Here is how I think through typical scenarios I see each week:
- The early fold in a firm face. Late 20s to late 30s, good skin, athletic, no significant jowling. The fold is mostly dynamic and tightens when they lift the cheek. A conservative PDO thread lift with two vectors per side along the lateral cheek usually softens the line and sharpens the cheek without bulk. If the cutaneous part of the fold is thin at the alar base, I might add two to three smooth threads right in the crease for extra dermal support. The midlife fold with mild descent. Early to mid 40s, a hint of heaviness along the nasolabial segment and a small jowl. This is the sweet spot for a PDO thread face lift approach. Two to three barbed threads per side, anchored near the zygomatic arch or lateral cheek, redistribute tissue, improve the jawline, and reduce the fold. If skin is sun damaged, I map tiny smooth PDO threads like a picket fence inside the fold to stimulate collagen where the skin crinkles. The etched fold with dental or bone changes. Late 40s to 60s, good cheek lift with the fingers but a deep, fixed groove near the alar base that does not fully soften. A combined plan works best. Lift with barbed threads to reduce the cheek roll, then address the crease. Here, HA filler in conservative micro-aliquots often beats threads alone for the deepest notch at the pyriform aperture. Smooth PDO threads can complement that by improving texture along the mid-portion of the fold. The heavy fold from significant laxity. Late 50s and beyond, thick skin, larger jowl, soft tissue deflation in the midface. PDO threads can refresh and tighten, but they will not replace the vector change that a surgical facelift provides. I am direct here: threads may buy 6 to 12 months of modest improvement, but expecting a facelift effect sets you up for disappointment. Sometimes we stage care with energy-based skin tightening, a modest filler plan for midface support, and a careful PDO threading treatment to improve contour.
Two real patient notes help illustrate the judgment calls. A 41-year-old teacher with a deep crease but good cheek projection improved most when I used two 19G molded-barb PDO threads per side from the lateral zygoma toward the nasolabial bulge, then added a single 29G screw thread into the most etched centimeter near the midfold. She looked fresher at three weeks without the overfilled look she feared. A 57-year-old runner with sun-thinned skin and dental loss near the premolars hardly changed from a lift alone. We gained ground only when we paired a soft HA filler bolus at the pyriform aperture with a grid of 29G mono PDO threads in the crease to build dermal quality.
Thread types and what they actually do
PDO threads come in families. The barbed ones do the lifting. Smooth and twisted ones do most of the collagen stimulation.
- Barbed or cogs, including molded barbs. These are the workhorses of a PDO thread lift procedure. They engage within the subcutaneous plane over SMAS, catch the mobile cheek fat, and allow you to shift tissue along a vector. They are absorbable threads, usually lasting 6 to 9 months in the body, with collagen and fibrous septa providing a longer tail of benefit. The immediate effect you see in clinic is a combination of mechanical repositioning and mild edema. The maintained result depends on tissue ingrowth and scarring along the thread path. Smooth or mono threads. Hair-thin, placed more superficially in the deep dermis or very superficial subcutis. They do not pull, but they do trigger collagen types I and III over several months. In the fold, they work like micro scaffolds that firm crepey skin. Twisted or screw configurations add slightly more bulk. Gauge and count. For a proper lift of the midface and jowl that softens the nasolabial fold indirectly, I often use two to three 18G to 19G barbed threads per side. For in-crease collagen work, that might be 6 to 12 smooth 29G threads along the fold, spaced 5 to 8 mm apart in a shallow grid. Your provider’s plan will vary based on skin thickness, fat distribution, and vector choice.
There is no universal best PDO thread. Technique, vector planning, and depth matter far more than brand.
Vector planning for a natural smile
You can soften a fold and ruin a smile if you pull the wrong way. The safest and most natural vectors do three things:
- Elevate the medial cheek gently toward a stronger lateral anchor, often the zygomatic arch region, which gives a subtle cheek lift and offloads the fold. Avoid crossing the alar base directly with a pulling vector, which can distort the nose shape or bunch the upper lip during animation. Complement adjacent work. If you plan PDO threads for jawline contouring or a PDO threads lift for jowls, set your cheek vectors so they meet at a soft angle, not in a tug-of-war.
Depth is just as critical. Barbed threads live best in a shallow subcutaneous plane over the SMAS where there is glide. Too superficial and you will see ripples when the patient smiles. Too deep and you lose the bite that provides a lift. For smooth threads placed within the fold, I stay in the deep dermis to upper subcutis. Angling shallow here reduces the risk of visible lines or palpable cords.
Cannulas reduce bruising and protect vessels, but they do not eliminate risk. The angular artery runs near the alar base, and the infraorbital nerve emerges about 6 to 10 mm below the orbital rim. A slow, controlled pass with small movements of the cannula tip, plus deliberate avoidance of hot zones, prevents most problems. Ultrasound mapping is an option in vascularly complex or previously treated faces.
PDO threads versus fillers in the fold
Why not just use filler? In many faces, we do. HA filler remains excellent for the deepest segment of the fold near the pyriform aperture and for cheek support when bone and deep fat have receded. But filler pushes out. If the issue is heavy tissue above the fold, pushing on the crease alone can look puffy or hamster-like when the person smiles. Think of filler as sculpting clay and PDO threads as suspension lines. The smartest plans use both where each excels.
One reliable sequence is to lift first, reassess at 2 to 4 weeks when edema resolves, then add tiny filler aliquots only where the fold still shadows. Another is to provide deep medial cheek filler support months before you plan a PDO thread lift, which stabilizes the lift and often reduces the number of threads needed.
What PDO threads can and cannot do for nasolabial folds
This is where expectations make or break satisfaction. A PDO thread face lift is a minimally invasive treatment with real, but bounded, power.
- You should expect a softening of the fold, not erasure. The most consistent improvement comes from reducing the cheek bulge and increasing skin firmness. The result is position-dependent and animation-dependent. The fold will look better at rest and during a gentle smile. A wide laugh will still fold the skin. That is natural. Longevity typically ranges from 6 to 12 months for the lifting effect, sometimes up to 15 months in thicker skin with strong collagen response. The skin quality gains from smooth threads can persist 12 to 18 months because of new collagen. Maintenance is part of the plan. Many patients schedule a re-tensioning at 9 to 12 months. Smooth thread micro-sessions can be peppered every 6 to 9 months for ongoing skin firming.
If you want a permanent change or you have large-volume descent, you will eventually do better with a surgical facelift and fat grafting, possibly preceded or followed by skin therapies. Threads are a bridge, a tune-up, or a strategic boost, not a full rebuild.
The procedure day, recovery, and how it feels
A typical PDO thread lift treatment for the nasolabial area starts with photos and vector mapping, then antisepsis and local anesthesia. I almost always use 1% lidocaine with epinephrine as a field block along entry points and the planned vectors. The placement of barbed threads is not painful once numb, but pressure and a tugging sensation are common. You will feel odd for 10 to 15 minutes, then it fades.
Smooth threads within the fold require only pinpoint numbing along the crease. Those passes feel like firm threading beneath the skin. Plan on 30 to 60 minutes in the chair for a combined lift and in-fold collagen plan.
Downtime is low by surgical standards, but it is not zero:
- Expect swelling for 48 to 72 hours, usually mild to moderate. Bruising can appear along cannula paths or at entry points and last 5 to 10 days. Smile stiffness and chewing tenderness last a few days. Avoid exaggerated mouth opening, dental visits, and heavy chewing for 1 week. Sleep with your head elevated for 2 nights. Avoid face-down sleep for a week. Skip high-intensity workouts and saunas for 3 to 5 days to reduce swelling and thread migration risk.
Makeup can cover most marks after 24 hours if there is no oozing. Tiny entry point tapes come off in 24 to 48 hours. I ask patients to send check-in photos at 1 week and return for a quick touch if a suture tail needs trimming or a small rippling area needs massage.
Risks, side effects, and how we reduce them
PDO threads are generally safe, but they are not risk-free. The most common side effects include bruising, swelling, dimpling, thread visibility or palpability in thin skin, and asymmetry that settles as tissues relax over 2 to 3 weeks. Infection is uncommon when sterile technique is solid. A short course of antibiotics is reserved for signs of cellulitis, which I have seen only a handful of times in many years.
Nerve injury is rare with blunt cannulas and careful planes, but temporary numbness can occur along the cheek. Salivary duct issues are unlikely in a nasolabial-focused plan because the parotid duct runs laterally, but aggressive lateral cheek work can irritate it briefly. Vascular occlusion, the fear with fillers, is not part of thread risk in the same way since threads do not inject volume. Compression or vessel irritation can still bruise you, which is why slow cannula work matters.
The one nuisance that bothers people most is puckering or dimpling when they smile. This usually results from a barbed thread sitting a bit too superficial or from over-tension in a small, tight face. Most dimples soften on their own in 1 to 3 weeks. Gentle massage at the 1-week visit often helps. In rare cases, I release a barb or trim an exposed tail. Early communication with your provider avoids small problems turning into long frustrations.
Cost and how to think about value
Prices vary by city and by the complexity of your plan. For isolated nasolabial fold work using a couple of vectors per side, expect a PDO thread lift price in the range of 900 to 2,000 USD. A more comprehensive midface and jawline plan that indirectly improves the fold typically runs 1,800 to 3,500 USD. Smooth thread collagen work within the fold alone may cost 400 to 900 USD, often as part of a broader skin rejuvenation plan.
Compare that to HA filler, which might be 650 to 900 USD per syringe, with one to two syringes needed if you treat both the pyriform notch and cheek support. Neither option is universally cheaper. The right choice is the one that matches your anatomy and gives a natural look without serial over-correction.
If you are searching for a PDO thread lift near me, look beyond price. Look for a clinic that shows thread-specific before and after photos of faces like yours, not just general filler galleries. Ask how many thread cases they perform monthly, what thread families they prefer and why, and how they handle touch-ups if a barb tail peeks through.
Sequencing with other treatments
Synergy beats stacking everything in one day. A few practical sequences I use:
- Energy devices for skin tightening first, threads second. Radiofrequency microneedling or monopolar RF a month or more before a PDO threads lifting treatment can firm the dermis so the lift holds longer. Doing RF too soon after thread placement can theoretically soften the polydioxanone faster, so I separate them by at least 4 weeks. Filler support before or after, depending on need. If the cheek is flat, small deep boluses in the deep medial cheek fat or along the zygoma can precede a lift by 2 to 6 weeks. If the cheek is full but the fold is etched, I prefer to lift first, reassess, then add tiny HA aliquots to the pyriform aperture last. Skin quality work always. Smooth PDO threads, topical retinoids, conscientious sunscreen, and occasional low-energy lasers or peels maintain the surface so the structural changes read as youthful, not just tightened.
Setting up the consult
A good consult feels like a map session, not a sales pitch. Expect facial analysis from brow to chin, not just the fold. Your provider should check smile dynamics, assess fat pad position, feel skin thickness, and note dental support and occlusion. They should also review medical issues that affect collagen or healing.
Here is a brief checklist I cover before recommending threads:
- Is the fold primarily from descent, skin etching, or both? Does a manual lift almost erase the fold, or does it persist? What is the plan if dimpling or asymmetry occurs at week one? How will we combine or sequence PDO threads with filler or energy-based treatments? What does maintenance look like at 9 to 12 months?
Photos under consistent lighting help with expectations. I like to show early swelling examples next to 2-week and 3-month results so the short-term look does not surprise you.
A few technical pearls that patients appreciate
Small technique decisions shape comfort and outcome. I mark smile lines while the patient is actively smiling because animation changes the vector. I choose entry points that avoid the alar base tug and keep the pull lateral to the midpupil line to preserve a natural nasolabial curvature. I prefer one gentle, longer vector over multiple short criss-cross vectors that risk bumps. For smooth threads in the crease, I stagger passes in a shallow lattice so collagen builds evenly without cord-like lines.
Patients also ask how many PDO threads for smile lines is typical. In a combined plan, it might be four to six barbed threads total across the midface, plus six to twelve smooth threads per side along the folds. Minimalist plans use less. More is not always better, and symmetry matters more than count.
The before and after you should picture
A realistic after shows a rested midface with a lighter fold shadow, a slightly higher cheek apex, and less bunching near the corner of the mouth. The upper lip and alar base still move naturally. At rest, the fold should look softer, not erased. In a broad smile, it should form, but with less depth.
Most people notice the change most when they see themselves in pdo threads near me casual photos or on video calls. That is the real test. Under overhead clinic lighting with a static face, perfection chasing is easy. In life, a believable 25 to 40 percent softening reads as youthful without calling attention to itself.
Who is not a good candidate right now
Caution helps avoid regret. I postpone or avoid nasolabial PDO threads in a few situations:
- Advanced laxity with expectation of surgical-level change. Active acne, dermatitis, or infection along the planned thread path. Unrealistic tolerance for the first two weeks of puckering and swelling. Unstable weight or heavy smoking, which both undermine collagen response. Recent major dental work or planned dental procedures in the next two weeks.
These are not permanent no’s. They are timing and expectation flags. Good outcomes start with the right moment and a clear plan.
Final thoughts from the chair
The debate between lifting the cheek and filling the fold misses the point when it becomes an either-or fight. The face is a system. If you lift a heavy cheek with a thoughtful PDO thread lift and gently support a stubborn crease where skin is etched, you honor that system. If you only push out a fold with filler when the cheek is the culprit, you will chase volume and lose character. If you only pull on loose, sun-fragile skin without building dermal health, you will get a short-lived win and a quick relapse.
PDO threads are tools. For nasolabial folds, they shine when the plan fits your anatomy, the vectors respect your smile, and the aftercare respects biology. The best result is the one no one can quite name, only that you look rested, balanced, and very much like yourself.