Synergistic Lower Blepharoplasty and Midface Lift: The Role of Multi-Directional Thread Fixation

Abstract BACKGROUND The periorbital region and midface age as a continuous anatomic unit. Standard approaches addressing these regions separately may overlook their functional linkage. We describe a combined transcutaneous lower blepharoplasty and midface lift using multi-directional barbed polydioxanone (PDO) threads via a shared subciliary incision. METHODS This preliminary prospective consecutive case series was conducted at a single plastic surgery clinic between October 2022 and May 2023 to evaluate the early clinical outcomes and safety of combined transcutaneous lower blepharoplasty with multi-directional PDO thread midface lift. The study included 84 patients undergoing combined lower blepharoplasty and midface suspension using Sihler Thread® (multi-directional barbed PDO). Standardized pre- and postoperative photographs (4 months) were evaluated by three blinded physician evaluators. Outcomes included perceived age (pragmatic early aesthetic endpoint) and supportive validated/commonly used scales (Global Aesthetic Improvement Scale [GAIS] and a standardized infraorbital/tear-trough grading tool (Allergan Infraorbital Hollows Scale [AIHS]). Safety outcomes and complications were recorded. Institutional review board approval was obtained from the Public Institutional Review Board of Republic of Korea (IRB No: P01-202511-01-072). RESULTS Mean perceived age decreased from 57.0 ± 7.5 years preoperatively to 50.0 ± 6.6 years at 4 months (mean reduction 7 years; p<0.001; 95% CI 6.2–7.8). The combined approach added approximately 5–7 minutes and required no additional incisions. No major complications (hematoma, infection, permanent nerve injury, thread extrusion/migration) were observed. CONCLUSIONS Combined transcutaneous lower blepharoplasty with multi-directional PDO thread midface lift via a shared incision is technically feasible and associated with early (4-month) improvement. Because perceived age is subjective and follow-up is short, results should be interpreted as preliminary; controlled comparative studies with longer follow-up and objective grading are warranted.