Dimpling and irregularity after threads: causes and management

A dimple after a thread is one of the first reasons a patient calls the office. They look in the mirror, smile and see a wave that was not there before. The scare is understandable, and the professional needs to know how to tell what belongs to the expected post-procedure course from what calls for intervention. Dimpling and irregularity are common events and, most of the time, transient, but not always.

This guide is a review. It explains why they appear, how to assess and which management approaches are described, without maneuver, insertion or removal technique, which are decisions for the qualified professional, according to the rules of their professional council. For the general overview of complications, see complications with PDO threads, and for the explanation to the patient, PDO threads: recovery.

What is dimpling and what is irregularity?

Dimpling is a pinpoint or small-area depression of the skin, like a small pit, which forms when a point of the skin is pulled inward. Irregularity is a broader term: waviness, uneven levels, lines or an "orange peel" look along the path of the thread. Both are usually more visible in motion (smiling, talking, chewing) and in side lighting, and can be almost invisible at rest and in the frontal photo.

This has a practical consequence: assess the patient at rest and in motion, with light that brings out the relief. A dimple that only appears when smiling is handled differently from a fixed depression at rest.

Why do they appear?

In many cases more than one cause is at work. The central point is that a dimple is not, in itself, a sign of error: it is part of the spectrum of the tissue's response to the thread. What defines management is the intensity, the time and the course.

How to assess?

A careful assessment avoids both excess and omission of action. A simple outline:

1. When it appeared: right after, in the first days or weeks later; the timing points to the cause.
2. Where it is: over the path, at the anchor point or at the thread entry.
3. How it behaves: appears only in motion or also at rest; improves or worsens over the days.
4. How it feels to the touch: whether there is hardening, pain, a palpable thread or warmth.
5. Comparison photo: against the standardized baseline photo, to tell it apart from a prior asymmetry.

A photo in side lighting and in motion is a cheap and useful tool. See standardized clinical photography. Keep the images and the course in the patient record.

What is the conservative approach?

When the dimple is mild, recent and without signs of inflammation, the usual approach is to observe. Many waves improve as the swelling subsides and the tissue settles, within days to a few weeks. During this period, some instructions are common: keep natural facial expression, avoid wide and forced facial movements, avoid manipulating the area without guidance and return within the agreed timeframes. As for massage or maneuvers of any kind, they should be indicated or performed by the professional following the case, who assesses whether there is an indication.

The important point is patience with judgment. Waiting without assessing is omission; intervening too early, on tissue that is still swollen, can make things worse. Written guidance helps; see post-PDO-thread instructions template.

When to reassess or consider intervention?

Some signs indicate that the dimple is not just part of the expected post-procedure course:

• a deep depression that persists at rest;
• worsening or no improvement after the settling period;
• localized pain, hardening or warmth, which suggest inflammation or infection;
• a palpable or visible thread associated with the depression;
• pulling that limits expression or deforms the smile;
• obvious and persistent asymmetry.

In these cases, the approaches described in the literature and in practice range from maneuvers performed by the professional to partial or total removal of the thread, in selected situations. The choice depends on the type of thread, the time since placement, the intensity and the clinical assessment. Indications for removal are in indications for thread removal. If there is inflammation, see infection and biofilm after filler.

How to reduce the chance of it happening?

Prevention starts with selection. Patients with thin skin, little subcutaneous tissue or fibrosis have a higher risk, and a thread with anchoring and traction is more prone to dimpling than a smooth thread. In technique, the choice of plane, the distribution of traction and the number of threads are decisions for the professional, and they influence this outcome. On the conversation side, preparing the patient for the possibility of transient dimples reduces anxiety and the number of panicked calls.

It is also worth reviewing the thread type: lifting threads with cones or barbs are more likely to produce irregularity than smooth threads. The comparison between types is in types of PDO threads.

What should you tell the patient?

The central message is: it is common, it is usually transient, and we will follow it. Avoid minimizing ("it's nothing") and avoid alarming. Give a timeframe and a contact channel.

What about Harmy?

Harmy does not assess or simulate threads. It can help in following up the patient by allowing you to save the post-procedure photo aligned by the eyes in "Add actual result", to compare with the projection and with the earlier record. The frontal photo at rest, however, does not show dynamic dimples or relief in side lighting, so it does not replace assessment in motion. The simulation is illustrative.

Summary

Dimpling and irregularity are common after threads, generally transient, but they require assessment in motion, comparison with baseline photos and attention to signs of inflammation. Observe when mild, reassess when persistent, consider removal in selected cases and prepare the patient from the consent stage.