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Won Lee Minimally Invasive Aesthetic Surgery Techniques Botulinum
Won Lee Minimally Invasive Aesthetic Surgery Techniques Botulinum
Won Lee Minimally Invasive Aesthetic Surgery Techniques Botulinum
Aesthetic Surgery
Techniques
Botulinum Toxin, Filler,
and Thread Lifting
Won Lee
Editor
123
Minimally Invasive Aesthetic Surgery
Techniques
Won Lee
Editor
Minimally Invasive
Aesthetic Surgery
Techniques
Botulinum Toxin, Filler, and Thread
Lifting
Editor
Won Lee
Yonsei E1 Plastic Surgery Clinic
Anyang, Kyonggi-do, Korea (Republic of)
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
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Preface
Minimally invasive plastic surgery has become the fastest growing cosmetic
field. However, the use of unscientific methods and misunderstood treatments
persist. Complications develop because of two causes: (1) the variations in
facial anatomy and (2) the doctor’s negligence. Continuous learning and
studying is essential for better results.
MIPS is a small group of board-certified Korean plastic surgeons who
innovate upon and study minimally invasive procedures. Our aim was to find
methods to constantly improve patient results and to consequently share the
knowledge to improve the patient results on a larger scale. We publish articles
and present at several conferences to share our experiences and findings. We
are publishing this book containing the latest scientific knowledge related to
botulinum toxin, filler injections, thread lifting, and other minimally invasive
esthetic procedures.
There are various innovative techniques for administering botulinum
toxin. While botulinum toxin type A has been used widely, type B and E will
also be used soon. Botulinum toxin microinjection techniques are also essen-
tial to know about. More and more techniques will be developed.
Filler injections are commonly used for increasing volume. Easy injec-
tions and immediate results have helped the technique grow rapidly. However,
several vascular and nonvascular complications can occur. The latest compli-
cations are discussed in this book.
Thread lifting is also a fast-growing technique for esthetic fields, with the
development of several techniques for the face, neck, and body area. We have
described many of the techniques in this book.
Patient safety is the most important aspect of these medical procedures
and should be performed using science-based knowledge. Extensive anatomi-
cal knowledge is crucial for successful minimally invasive esthetic proce-
dures. We have included several illustrations and cases to facilitate the
increase in anatomical knowledge.
I am greatly honored to work with Dong Wan Seo, Gi Woong Hong, Kyun
Tae Kim, Eun-Jung Yang, Jeongmok Cho, Hyun Woo Cho, Young Dae
Kweon, Bong-il Rho, Chang Woon Yun, Soo Yeon Park, Hyun Jin Yang, Jin
Young Kim, Won Kyung Kang, Kyu Hwa Jung, Yongwoo Lee, and Young
Choon Jung.
Finally, as always, with a lot of love, I am thankful to Seung Hyun, Hyun
Ji, and Jung Youn.
v
vi Preface
1 Artistic
Approach for Minimally Invasive Plastic Surgery���������� 1
Dong Wan Seo and Won Lee
2 Anatomical
Considerations for Botulinum Toxin Injections ������ 17
Gi Woong Hong and Won Lee
3 Clinical
Injection Techniques for Botulinum Toxin���������������������� 27
Kyun Tae Kim and Won Lee
4 Anatomical
Considerations for Filler Injection���������������������������� 35
Gi Woong Hong and Won Lee
5 Physical
Properties and Rheological Approach for Hyaluronic
Acid Fillers���������������������������������������������������������������������������������������� 47
Eun-Jung Yang and Won Lee
6 Practical
Techniques for Hyaluronic Acid Filler Injections�������� 57
Jeongmok Cho and Won Lee
7 Doppler
Ultrasound-Guided Hyaluronic Acid Filler Injection
Techniques���������������������������������������������������������������������������������������� 77
Hyun Woo Cho and Won Lee
8 Filler
Injection Complications and Hyaluronidase���������������������� 99
Won Lee
9 Anatomical
Considerations for Thread Lifting���������������������������� 115
Gi Woong Hong and Won Lee
10 H
istory, Principles, and Adjuvant Therapy
for Thread Lifting���������������������������������������������������������������������������� 123
Young Dae Kweon and Won Lee
11 The
Basic Techniques for Thread Lifting�������������������������������������� 131
Bong-il Rho, Chang Woon Yun, Soo Yeon Park, and Won Lee
12 The
Techniques and Considerations for Thread Lifting�������������� 145
Won Lee and Chang Woon Yun
13 Minimally
Invasive Rhinoplasty: Augmentation Rhinoplasty
with Cogged Threads ���������������������������������������������������������������������� 155
Hyun Jin Yang and Won Lee
vii
viii Contents
14 Submental
Contouring Using Elastic Threads������������������������������ 187
Jin Young Kim, Jeongmok Cho, and Won Lee
15 Submental
Liposuction and Thread Lifting���������������������������������� 197
Won Kyung Kang and Won Lee
16 Short
Scar Rhytidectomy Combined with PDO Threads������������ 203
Soo Yeon Park, Kyu Hwa Jung, and Won Lee
17 Complications
of Thread Lifting and Treatments������������������������ 213
Yongwoo Lee and Won Lee
18 Body
Contouring Using Threads and Fat Graft �������������������������� 223
Young Choon Jung and Won Lee
About the Editors
ix
x About the Editors
Plastic surgeons should offer satisfactory services patient’s expectations from the procedure. He
in their field and should carry out evaluation stud- should inform the patient about the limitations
ies of various reconstruction surgeries. In addi- of the procedure, and all the information given
tion, they should study beauty outcomes after should be recorded in a chart as this will be
procedures. The rapid development of new tech- helpful in case of any future conflict due to
nologies and products has improved beauty out- dissatisfaction.
comes. With the development of social media and
the rapid sociocultural changes, beauty trends
have also rapidly evolved. Esthetic physicians 1.1.2 Patient’s Past History
should always be aware of these rapid changes in
beauty trends and should obtain satisfactory out- Past surgeries/procedures could affect the future
comes with these newly developed products. procedure. Sometimes they potentiate each
In this chapter, we shall describe the general other, but in some scenarios, the previous proce-
considerations for satisfactory outcomes of esthetic dure hinders the latter. Previous scars and/or
procedures using minimally invasive approaches. contractures always affect future procedures, so
Additionally, we shall verify the basic abilities of verifying the patient’s past history is very impor-
the clients before performing the esthetic proce- tant before performing the new procedure
dures, so as to better analyze the outcomes. (Table 1.1).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 1
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_1
2 D. W. Seo and W. Lee
Fig. 1.1 QuantifiCare
3D photo analysis
Table 1.2 Symptoms and possible procedures (volumization, filler, fat graft; lifting, endotine, thread; neuromodula-
tion, botulinum toxin; tightening, micro-insulated needle radiofrequency system, microfocused ultrasound, energy-
based devices)
Symptom Method
Forehead Sunken, deflation, wrinkle, asymmetry Volumization, lifting, neuromodulator injection, tightening
Eyebrow Deflation Lifting, neuromodulator injection
Temple Sunken Volumization
Upper eyelid Sunken, deflation Volumization, lifting
Lower eyelid Sunken, deflation, wrinkle Volumization, lifting, neuromodulator injection, tightening
Nose Shape, volume, wrinkle Volumization, lifting, neuromodulator injection
Malar region Shape, volume, wrinkle Volumization, lifting, neuromodulator injection, tightening
Cheek Sunken, deflation, wrinkle Volumization, lifting, neuromodulator injection, tightening
Nasolabial fold Sunken, deflation, wrinkle, asymmetry Volumization, lifting, neuromodulator injection, tightening
Lip Shape, volume, wrinkle, asymmetry Volumization, lifting, neuromodulator injection, tightening
Marionette line Sunken, deflation, wrinkle, asymmetry Volumization, lifting, neuromodulator injection, tightening
Chin Shape, volume, wrinkle Volumization, lifting, neuromodulator injection
Neck Deflation, wrinkle, asymmetry Volumization, lifting, neuromodulator injection, tightening
4 D. W. Seo and W. Lee
1.4.4 Eyelid
1.4.5 Nose
Fig. 1.15 Sheens’
esthetic components of
the nose (redrawn) [19]
1.4.6 Lips
cess decreases lip volume. The aims of lip aug- The upper lip to lower lip proportion is also an
mentation procedures should be the improvement important determinant of lip attractiveness. Lips
of lip fullness, restoration of atrophic region, and are known to occupy 9.6% of the lower face sur-
the precision of the vermilion border and phil- face area, and the recommended upper lip to
trum [22]. lower lip proportion is 1:2 [23]. However, the
preferable ratio varies with race, country, and age
(Fig. 1.17).
Table 1.5 Lips morphological classification
[Lateral view].
1. The shape of the Cupid’s bow Ricketts’ E-plane is recommended to evalu-
(a) Straight
(b) Curve
ate the protrusion of lips. The upper lip and
(c) Deep curve lower lips should be behind the E-plane.
2. The shape of lip tail (mouth corner) Younger patients’ lips tend to be located more
(a) Straight adjacent to the E-plane. Esthetically, lips
(a) Dropped located anterior to the E-plane are not preferred
(a) Elevated
3. The shape of lower lip line.
[24] (Fig. 1.18).
(a) Straight Comparative analyses can be performed when
(b) Curved comparing upper lip and lower lip with facial
(c) Rounded convexity (G-Sn-Pg) [25] (Fig. 1.19).
Table 1.6 Global Aesthetic Improvement Scale (GAIS) 11. Yu L. Invited discussion on: anthropometry analy-
sis of beautiful upper eyelids in oriental: new eyelid
Degree Description
crease ratio and clinical application. Aesthet Plast
1 Exceptional Excellent corrective result Surg. 2020:1–3.
improvement 12. Serdev N. Miniinvasive face and body lifts: closed
2 Very improved Marked improvement of the suture lifts or barbed thread lifts. Norderstedt: BoD–
patient appearance, but not completely Books on Demand; 2013.
optimal 13. Chen C-C, Chen S-N, Huang C-L. Correction of
3 Improved Improvement of the sunken upper-eyelid deformity in young Asians by
patient appearance, which is better than minimally-invasive double-eyelid procedure and
the initial condition, but a simultaneous orbital fat pad repositioning: a one-
touch-up is advised year follow-up study of 250 cases. Aesthet Surg J.
4 Unaltered The appearance substantially 2015;35(4):359–66.
patient remains the same compared 14. Shin J-W, et al. The efficacy of micro-insulated
with the original condition needle radiofrequency system for the treatment of
5 Worsened The appearance has worsened lower eyelid fat bulging. J Dtsch Dermatol Ges.
patient compared with the original 2019;17(2):149–56.
condition 15. Jeon HC, et al. A new treatment protocol of micro-
focused ultrasound for lower eyelid fat bulging. J
Dermatol Treat. 2021;32(8):1005–9.
16. Morley AMS, Malhotra R. Use of hyaluronic acid
filler for tear-trough rejuvenation as an alternative to
lower eyelid surgery. Ophthalmic Plast Reconstr Surg.
References 2011;27(2):69–73.
17. Kane MAC. Treatment of tear trough deformity and
1. Synnott A. Francette PACTEAU, the symptom of lower lid bowing with injectable hyaluronic acid.
beauty, Cambridge, Mass.: Harvard University press, Aesthet Plast Surg. 2005;29(5):363–7.
1974. 232 pp. Culture. 1994;14(2):149–50. 18. Kim J, et al. Percutaneous autologous fat injection
2. Klopfer PH. Sensory physiology and esthetics: among following 2-layer flap lower blepharoplasty for the
many species play seems to be a guide for conscious correction of tear trough deformity. J Craniofac Surg.
action. Am Sci. 1970;58(4):399–403. 2018;29(5):1241–4.
3. Swift A, Remington K. BeautiPHIcation™: a 19. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed.
global approach to facial beauty. Clin Plast Surg. St Louis: Quality Med. Publ.; 1997.
2011;38(3):347–77. 20. Peck GC. Techniques in aesthetic rhinoplasty.
4. Brookes M, Pomiankowski A. Symmetry is Philadelphia: Lippincott Williams & Wilkins; 1990.
in the eye of the beholder. Trends Ecol Evol. 21. Daniel RK. Rhinoplasty: An atlas of surgical techniques.
1994;9(6):201–2. Berlin: Springer Science & Business Media; 2013.
5. Concar D. SEX AND THE SYMMETRICAL BODY- 22. Beer KR. Rejuvenation of the lip with injectables.
creating balanced bodies is one of nature's biggest Skin Therapy Lett. 2007;12(3):5–7.
challenges. New Sci. 1995;146(1974):40–4. 23. Popenko NA, et al. A quantitative approach to deter-
6. Enquist M, Arak A. Symmetry, beauty and evolution. mining the ideal female lip aesthetic and its effect
Nature. 1994;372(6502):169–72. on facial attractiveness. JAMA Facial Plast Surg.
7. Grammer K, Thornhill R. Human (Homo sapiens) 2017;19(4):261–7.
facial attractiveness and sexual selection: the role 24. Ricketts RM. Planning treatment on the basis of the
of symmetry and averageness. J Comp Psychol. facial pattern and an estimate of its growth. Angle
1994;108(3):233–42. Orthod. 1957;27(1):14–37.
8. Bashour M. An objective system for measuring facial 25. Coleman GG, et al. Influence of chin prominence on
attractiveness. Plast Reconstr Surg. 2006;118(3):757– esthetic lip profile preferences. Am J Orthod Dentofac
74; discussion 775–6. Orthop. 2007;132(1):36–42.
9. Fischer E. “Sternum und sterno-claviculargelenke.” 26. Aufricht G. Combined plastic surgery of the nose and
Skeletanatomie (Röntgendiagnostik)/Anatomy of Chin. Resume of twenty-seven Years’ experience.
the Skeletal System (Roentgen Diagnosis). Springer, Plast Reconstr Surg. 1958;21(6):495.
Berlin, Heidelberg, 1968;481–504. 27. Connor AM, Moshiri F. Advancement genioplasty:
10. Rodman R, Sturm AK. Hairline restoration: differ- an important part of combination surgery in black
ence in men and woman—length and shape. Facial American patients. Am J Orthod Dentofac Orthop.
Plast Surg. 2018;34(2):155–8. 1988;93(2):92–8.
16 D. W. Seo and W. Lee
28. Rosen HM. Aesthetic refinements in genioplasty: 31. Zide BM, Boutros S. Chin surgery III: revelations.
the role of the labiomental fold. Plast Reconstr Surg. Plast Reconstr Surg. 2003;111(4):1542–50.
1991;88(5):760–7. 32. Guyuron B. MOC-PS(SM) CME article: genioplasty.
29. Rosen HM. Aesthetics in facial skeletal surgery. Plast Reconstr Surg. 2008;121(4 Suppl):1–7.
Perspect Plast Surg. 1992;6(2):1–25. 33. Byrd HS, Hobar PC. Rhinoplasty: A practical
30. Guyuron B, Michelow BJ, Willis L. Practical clas- guide for surgical planning. Plast Reconstr Surg.
sification of chin deformities. Aesthet Plast Surg. 1993;91(4):642–54; discussion 655–6.
1995;19(3):257–64.
Anatomical Considerations
for Botulinum Toxin Injections 2
Gi Woong Hong and Won Lee
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 17
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_2
18 G. W. Hong and W. Lee
Frontalis
Orbicularis oculi
Depressor supercilii
Temporalis Corrugator
Risorius Masseter
Mentalis
The depth of the injection should be deter- The medial part of the corrugator supercilii
mined. The frontalis muscle is usually located muscle originates about 2.9 mm lateral from mid-
about 3–5 mm below the skin. Its width is vari- line and 9.8 mm above the nasion. It runs in the
able, so it is better to tell the patient to wrinkle upward lateral direction to attach to the skin sur-
his forehead before administering the injection. face. There are interpersonal variations in the
The frontalis muscle is the only muscle that muscle’s insertion point, but the latter could be
raises the eyebrows. Thus, a complete block estimated by following the skin dimpling when
might result in severe eyebrow ptosis. Recently, the patient is asked to frown. The muscle’s loca-
beginning with lower doses of botulinum toxin tion is approximately lateral to the skin dimpling.
for the initial injection and providing additional The portion of the muscle with the greatest thick-
doses subsequently based on the need has been ness is about 2–3 mm thick and is located between
recommended. the medial canthal line and the mid-pupillary line
(Fig. 2.4).
When administering botulinum toxin injection
2.1.2 Corrugator Supercilii Muscle in the corrugator muscle, the doctor should
consider the “gliding plane” (the space between
The frowning vertical wrinkle look at the glabella the muscle and periosteum). Botulinum toxin can
is achieved by the deepest depressor muscle,
which is the corrugator supercilii muscle. This
muscle can be divided into a transverse and an
oblique head, but what is most important is the
pattern of the wrinkles on the skin surface. The
wrinkles appear when frowning for the first time;
then repetitive movement of the muscle can result
in scars that resemble wrinkles. Once the wrinkle
groove appears, it is not easy to solve the problem
just by injecting botulinum toxin. It is therefore
recommended to inject botulinum toxin in a
dynamic wrinkle state (Fig. 2.3) [3].
Fig. 2.4 Position and muscle thickness of corrugator
supercilii muscle
Both muscles act to pull up and laterally the cor- 2.1.13 Mentalis Muscle
ners of the mouth. The zygomaticus minor mus-
cle is located on the virtual line running from the The mentalis muscle originates from the mandi-
lateral canthal area to the mouth corner; however, ble mentum and inserts on the skin of the chin. It
the zygomaticus major muscle is located on the consists of two fibers separated by the midline of
crossline of vertical lines from the lateral canthal the face. When the muscle contracts, the chin
area and horizontal lines from nasal base skin moves upward and assumes a “cobblestone
(Fig. 2.9). appearance” (Fig. 2.10) [14].
2 Anatomical Considerations for Botulinum Toxin Injections 23
Fig. 2.11 The two layers of the masseter muscle and Fig. 2.12 Deep inferior tendon between the layers of the
toxin injection points masseter muscle
tance. The parotid gland is known to be bordered Submandibular gland hypertrophy can be
superiorly by the zygomatic arch, posteriorly by detected on the surface of the face. It is also
the earlobe, and inferiorly by the mandibular bor- deeply located and surrounded by deep fascia.
der. However, in cases of parotid gland hypertro- The mylohyoid muscle passes through the sub-
phy, the gland tends to be located more posteriorly mandibular gland. Therefore, care should be
to the mandibular ramus. The masseter muscle taken to avoid swallowing disturbances, when
does not usually cross the mandibular border and injecting botulinum toxin [19].
is therefore distinguishable (Fig. 2.13) [17].
The parotid gland is divided into a superficial
and a deep lobe, with the facial nerve running 2.3 Vessels of the Face
between the two lobes. There could also exist an
accessory parotid gland near Stensen’s duct area. Botulinum toxin injection hardly causes vascular
The parotid gland is a deeply located structure, problems. Filler injection can cause arterial
which is covered by the deep fascia of the embolism and serious complications such as skin
SMAS. The gland’s capsule wraps its paren- necrosis and ocular complications. However,
chyma. Therefore, when injecting botulinum even when botulinum toxin gets into vessels, it
toxin into the parotid gland, the parotid capsule does not cause systemic problems. Hence, bruis-
might offer some resistance. This sometimes ing might be the only vascular complication of
occurs during masseter muscle injection as there botulinum toxin injection. Botulinum toxin is
are situations where the parotid gland surrounds usually administered by needle injection, and
the masseter muscle [18]. even though the doctor may know the anatomy of
The submandibular gland is usually located on vessels, it is impossible to detour all variations.
the posterior 2/3 of the mandible border Nonetheless, the main facial vessels are easily
(Fig. 2.13). identifiable.
The facial artery passes between the middle of
the inferior border of the mandible and the ante-
gonial notch and runs to the upper medial portion
of the face (Fig. 2.14).
Where the artery runs near the mandible area,
it is deeply located and therefore safe [20]. For
example, when injecting botulinum into the
DAO muscle, vascular injury hardly occurs
since the muscle is superficially located. Near
the nasolabial fold area, the facial artery gives
multiple branches to the nose and lips [21].
These branches tend to run superficially, so care
should be taken when injecting the LLSAN
muscle [22].
Bruising usually is a consequence of venous
rather than arterial injury. During crow’s feet
correction procedures, bruising occurs quite
often. The intercanthal vein can be ruptured
when administering botulinum toxin injection.
Veins are easily detectable in the supine rather
than upright position, so careful inspection is
needed [23].
Fig. 2.13 Position of parotid and submandibular glands
2 Anatomical Considerations for Botulinum Toxin Injections 25
study with an emphasis on the effective zone of botu- 20. Lee JG, Yang HM, Choi YJ, Favero V, Kim YS, Hu
linum toxin a injections in masseter. J Plast Reconstr KS, et al. Facial arterial depth and relationship with
Aesthet Surg. 2014;67:1663–8. the facial musculature layer. Plast Reconstr Surg.
16. Lee JY, Kim JN, Yoo JY, Hu KS, Kim HJ, Song WC, 2015;135(2):437–44.
et al. Topographic anatomy of the masseter muscle 21. Lee SH, Lee M, Kim HJ. Anatomy-based image pro-
focusing on the tendinous digitation. Clin Anat. cessing analysis of the running pattern of the peri-
2012;25:889–92. oral artery for minimally invasive surgery. Br J Oral
17. Nasr MW, Jabbour SF, Sidaoui JA, Haber RN, Maxillofac Surg. 2014;52(8):688–92.
Kechichian EG. Botulinum toxin for the treatment 22. Nakajima H, et al. Facial artery in the upper lip
of excessive gingival display: a systematic review. and nose: anatomy and a clinical application. Plast
Aesthetic Surg J. 2016;36:82–8. Reconstr Surg. 2002;109:855–61.
18. Kim HJ, Seo KK, Lee HK, Kim J. Clinical anatomy 23. Lee HJ, et al. Description of a novel anatomic venous
for the face for filler and botulinum toxin injection. structure in the nasoglabellar area. J Craniofac Surg.
Singapore: Springer; 2016. 2014;25:633–5.
19. Shan XF, Xu H, Cai ZG, Wu LL, Yu GY. Botulinum
toxin a inhibits salivary secretion of rabbit subman-
dibular gland. Int J Oral Sci. 2013;5:217–23.
Clinical Injection Techniques
for Botulinum Toxin 3
Kyun Tae Kim and Won Lee
Botulinum toxin injection is the most common Its use has been approved to correct the glabellar
esthetic procedure performed worldwide. In this frown line and crow’s feet in the field of esthetic.
chapter, we shall discuss about the use of botuli-
num toxin in the field of esthetics. We shall also
discuss about the history, types, products, mecha- 3.2 Botulinum Toxin Types,
nisms, and injection techniques. Finally, we shall Mechanism, and Usages
elaborate on the microbotox injection technique.
Botulinum toxin is made from the neurotoxin of
Clostridium botulinum. Seven serotypes (A, B,
3.1 History C, D, E, F, and G) are known. Type A is the most
commonly used type, and type B is also manu-
Botulinum toxin type A (BTA) was reported to be factured. Types C and D are not suitable for
used in the extraocular muscle to treat strabismus human, and type E can also be manufactured but
in the early 1970s [1]. In 1987, Jean Carruthers has a short duration of action. BTA is composed
noticed crow’s feet wrinkles during botulinum of two chains, a 100 kDa heavy chain and a 50 kD
toxin injection in a patient with blepharospasm, light chain, conjugated by disulfide bonds. BTA
and Alastair Carruthers reported its use in reduc- is known to conjugate to SNARE (soluble
ing glabellar frown line for esthetic purpose [2]. N-ethylmaleimide-sensitive factor attachment
In 1989, Clark and Berris reported the use of protein receptor) proteins at nerve endings to
BTA for correcting asymmetry induced by face- inhibit the secretion of acetylcholine, resulting in
lifts [3]. In the same year, the FDA approved the a loss of motor end potential at neuromuscular
use of botulinum toxin A (Botox) to correct junctions. Usually, clinical paralysis of muscle
movement disorders of eyelid muscles. BTA has develops approximately a week after injection.
been used for “off-label” indications such as uro- The vesicular SNARE (v-SNARE) targets synap-
logic disorders, gastrointestinal disorders, oph- tobrevin (VAMP) receptors; furthermore, the
thalmologic disorders, and neurologic disorders. t-SNARE (target SNARE) targets SNAP25
(synaptosomal- associated protein, 25 kDa) or
K. T. Kim syntaxin, to cause paralysis. BTA functions by
Yonsei Dain Plastic Surgery Clinic, targeting SNAP25.
Seoul, Republic of Korea The most commonly used botulinum toxin
W. Lee (*) products are onabotulinumtoxinA (Botox;
Yonsei E1 Plastic Surgery Clinic, Allergan, Irvine, CA, USA), a bobotulinumtoxinA
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 27
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_3
28 K. T. Kim and W. Lee
(Dysport; Ipsen, Ltd., Berkshire, UK), incobotu- B. Technique: The goal is to reduce the dynamic
linumtoxinA (Xeomin; Merz Pharmaceuticals, wrinkles of the forehead while preserving
Frankfurt, Germany), and rimabotulinumtoxinB natural eyebrow movement. The power of the
(Myobloc; Solstice Neurosciences, San frontalis muscle is variable, but it is recom-
Francisco, CA). Their clinical actions are similar, mended to inject between 10 and 20 units at
but they differ in chemical composition, associ- four to six points (Fig. 3.1). It is recom-
ated protein, and purification process. Their con- mended to avoid injecting 1–2 cm above the
version ratio is thus as follows: 1 unit of eyebrows. When the contralateral side is not
onabotulinumtoxinA = 1 unit of incobotulinum- injected, “Mephisto” or “Spock” eyebrow
toxinA = 3 units of abobotulinumtox-
inA. Myobloc, which is a B serotype, is known
for its short duration of muscle paralysis. The
most commonly used products in Korea are
shown in Table 3.1.
The products are usually formulated in pow-
der form, and it is recommended to mix with
0.9% NaCl solution before use. Once mixed, the
solution loses its effectiveness after 6 weeks. The
effect of the product is known to last for
3–4 months, and 20% of injected patients report
prolonged effects (duration beyond 4 months).
When the dosage is increased, the effect lasts a
little longer. Usually, 0.5 mL or 1 mL syringes
are used with 30 G, 1/2 in. (13 mm) needles.
a b
Fig. 3.4 Crow’s feet wrinkle correction injection points. eyebrow. Conversely, when the eyebrow is highly arched,
When the eyebrow is lowly arched, it is better to inject it is recommended to inject below the lateral canthus
above the lateral canthus to ensure the elevation of the
3.5.1 Depressor Anguli Oris Muscle deeply located than the orbicularis oris and
depressor labii inferioris muscles.
A. Anatomy: The mouth corner descends and B. Treatment: It is recommended to inject 5–10 U
accentuates the melomental fold and mario- 2 cm above mandible border (Fig. 3.8).
nette line when the DAO is contracted. DAO
muscle botulinum toxin injection results in a
lifting of the mouth corner and an increase 3.5.3 Masseter Hypertrophy
in smiling expression. The DAO originates
from the mandible and inserts on the A. Anatomy: Females have a masculine appear-
modiolus. ance when masseter muscle hypertrophy
B. Techniques: The modiolus is known to be develops. Therefore, BTA injection is recom-
located 11 mm lateral and 9 mm below the mended especially among the Asians. The
mouth corner in Asians, and it spreads to the masseter is a masticatory muscle that origi-
mandible border [4]. It is recommended to nates from the zygomatic process of the max-
inject 2–2.5 U subcutaneously at a distance of illa and inserts on the mandibular ramus and
1–1.5 cm below the modiolus (Fig. 3.7). angle. It is made up of a superficial and a
deep head and works in synergy with the
medial and lateral pterygoid muscles to pull
3.5.2 Mentalis the chin upward.
B. Techniques: Muscle volume should be
A. Anatomy: A cobblestone appearance devel- reduced to resolve the hypertrophy. 25–35 U
ops when the mentalis muscle is hyperacti- is administered ipsilaterally at the thickness
vated and is also called “peau d’orange” point of the muscle. Be cautious not to inject
appearance. The mentalis muscle has two into the risorius and zygomaticus muscles
opposite arms, and it originates from the inci- because their location overlaps with that of
sive fossa and inserts on the subcutaneous the masseter muscle. Three ipsilateral points
layer and frenulum of the chin. It is more of injection are recommended (Fig. 3.9).
32 K. T. Kim and W. Lee
Fig. 3.8 Mentalis injection techniques. Inject deeper at Fig. 3.9 Masseter hypertrophy injection technique. Deep
the central point than the lateral points. Inject subcutane- injections are recommended at three points (where muscle
ous layer if needed hypertrophy is most prominent)
Fig. 3.10 Platysma band injection techniques. Three points on the medial band and four points on the lateral band are
recommended
Microbotox injection technique is used to: Volume loss can be treated using HA filler.
Overactive muscles should be corrected by botu-
1. Decrease the pore sizes and improve the tex- linum toxin injection. Not just the lower face por-
ture of the forehead. tion requires a combination of the two treatment
2. Decrease the pore sizes and improve the tex- methods; the upper face is also a candidate. In
ture of the cheek. addition, microbotox can be used. Recently,
3. Improve jawline. mesotherapy and skin boosters have been used
4. Reduce crow’s feet and lifting the eye tail. concomitantly to treat some conditions. The
5. Reduce perioral wrinkles. choice of the technique depends on the patient’s
age, gender, race, and budget.
Filler injection is one of the frequently practiced important factor to consider before filler injection
minimally invasive procedures in the field of is the level of mastery of vascular anatomy.
esthetics. It is a relatively easy procedure The external carotid artery divides into inter-
employed to correct wrinkles and for augmenta- nal and external branches. The facial artery and
tion. However, filler injection could have tragic the superficial temporal artery are the main
complications (mostly vascular). The most branches of the external branch. Branches of
important tool of prevention is a good knowledge these arteries supply the lower face, midface, lat-
of vascular anatomy. Although there are vascular eral nose, and temple areas. The internal branch
variations, it is important to know the basic anat- of the external carotid artery runs into the skull
omy. Furthermore, it is important to have a good area. The maxillary artery is one its branches, and
knowledge of the nerves of the face and the fat it supplies the lower eyelid and periorbital area
compartment of the face. In this chapter, we shall through the infraorbital and zygomaticofacial
describe arteries, veins, nerves, and fat compart- arteries [1]. The internal branches also supply the
ments of the face, taken into account during filler face through branches of the ophthalmic artery. It
injection procedures. vascularizes the forehead, glabella, and nose
through branches of the supratrochlear artery,
supraorbital artery, and dorsal nasal artery
4.1 Arteries of the Face (Figs. 4.1 and 4.2) [2].
The facial artery branches from the external
Dermal fillers are injected into the dermis and/or carotid artery and runs along the mandible bor-
upper subcutaneous layer and are therefore rela- der; it then crosses the mandible at the masseter
tively safe from vascular complications. However, muscle border to run across antegonial notch. It
recently, firm consistent fillers are being used for runs toward the medial canthus, where it branches
volumizing. They are injected into the deeper horizontally giving rise to the labiomental, infe-
layers, posing a relative danger because of pos- rior labial, and superior labial arteries. From
sible vascular complications. Therefore, the most here, it extends upward near the nasolabial fold.
It further branches to give rise to the inferior alar
G. W. Hong and lateral nasal arteries and continues on the lat-
SAMSKIN Plastic Surgery Clinic, eral border of the nose, where it is called the
Seoul, Republic of Korea angular artery [3].
W. Lee (*) The facial artery has some anatomical varia-
Yonsei E1 Plastic Surgery Clinic, tions. Only 36% of Koreans have the previously
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 35
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_4
36 G. W. Hong and W. Lee
Zygomaticofacial artery
Supra-orbital artery
Supratrochlear artery
Zygomatico-orbital artery
Parotid gland
described anatomical pattern. In 44% of the The internal branch of the external carotid
population, it does not run to the angular artery artery branches into the maxillary artery which
but rather ends as the lateral nasal artery. Only later gives rise to the infraorbital, buccal, and
50% of population have a symmetrical arterial mental arteries [10].
supply [4].
It is known that in 30% of the population, the
facial artery does not run along the nasolabial 4.1.1 Arteries of the Perioral Region
fold. Rather, it branches vertically toward the
infraorbital foramen and runs with the facial vein The horizontal labiomental artery (which origi-
along the border of orbicularis oculi muscle. nates from the facial artery) runs horizontally
Tortuous facial arteries are located just beneath along with the labiomental crease in the middle
the skin near the mouth corner, between the of mandible border. It branches into the vertical
zygomaticus major and the risorius muscles. labiomental artery which anastomoses with the
Therefore, precautions should be taken when per- inferior labiomental artery or submental artery.
forming filler injection in this area [5]. It is known The inferior labial artery branches from the facial
that the facial artery runs near the nasolabial fold artery near the mouth corner and runs along the
in 40% of the population and crosses the nasola- vermillion border. It is known that 50% of the
bial fold in 33% of the population [6]. population have the horizontal labiomental but
The supraorbital, supratrochlear, and dorsal no inferior labial artery. The inferior labial artery
nasal arteries, which are branches of the ophthal- is located near the wet mucosa, deep below the
mic artery, anastomose with the facial artery in orbicularis oris muscle, and runs to the dry muco-
the glabellar and nasal areas [7]. sal area where it runs medially [11].
Another branch of the external carotid artery The superior labial artery bifurcates from the
is the superficial temporal artery (STA). It runs facial artery at approximately 1 cm above the
upward and divides into anterior and posterior mouth corner and runs horizontally about 0.5–
branches. The anterior branch of the STA runs to 1.2 cm above the upper lip vermilion border
the lateral forehead area where it anastomoses (Fig. 4.3).
with branches of the ophthalmic artery [8]. The It is uncommon for the superior and inferior
pathway of the STA will be discussed in Chap. 9 labial arteries to originate from a common
when describing the anatomical considerations of branch. The superior labial artery tends to run
thread lifting. Before the STA divides into ante- beneath the orbicularis oris muscle and branches
rior and posterior branches, it gives rise to two to give the nasal septal artery near the philtrum
arteries near zygomatic arch. These are the trans- area. The nasal septal artery divides into deep
verse facial artery (which arises below zygomatic and superficial branches separated by the orbicu-
arch and vascularizes the midface area) and the laris oris muscle. Its superficial branch runs to
zygomaticoorbital artery (which arises below the the columella where it becomes the columellar
zygomatic arch) [9]. artery [12].
Supratrochlear artery
Superior marginal
arterial arcade
Angular artery
Angular artery
Infraorbital trunk of
duplex type facial artery
Facial artery on
antegonial notch
The STA runs toward the temple area. After per- the STA is the zygomaticoorbital artery which
forating the parotid gland area, it divides into runs toward lateral canthus and then upward to
anterior and posterior branches at a point approx- the lateral eyebrow end [19].
imately 18 mm anterior to and 37 mm above the The zygomaticotemporal artery originates
tragus (Fig. 4.6). from the lacrimal artery and runs to the anterior
The anterior branch of the STA is wrapped by part of the temple area. The middle temporal and
the superficial temporal fascia and runs superfi- deep temporal arteries supply the temporalis
cially to the frontalis muscle. Another branch of muscle (Fig. 4.7) [20].
40 G. W. Hong and W. Lee
Lacrimal nerve
Supraorbital nerve
Zygomaticotemporal nerve Supratrochlear nerve
Auriculotemporal nerve
Infratrochlear nerve
Zygomaticofacial nerve
Infraorbital nerve
Buccal nerve
Mental nerve
Great auricular nerve
Transverse cervical nerve
4.3.2 Motor Nerves of the Face sor labii inferioris, and mentalis muscles [38].
The cervical branch innervates the platysma
The facial nerve innervates the expression muscle [39].
muscles of the face, and the mandibular nerve
innervates the masticatory muscle. The facial nerve
divides into five branches in the parotid gland and 4.4 Fat Compartments
runs to supply the facial expression muscles. It is of the Face
wrapped by the SMAS (Fig. 4.13) [35].
The temporal branch of the facial nerve fur- Previously, the subcutaneous fat layer was
ther branches into multiple nerves to innervate reported to be made up of a huge cushion-like
the frontalis, corrugator supercilii, and orbicu- layer and a simple layer. However, as studies of
laris oculi muscles, after passing through the facial anatomy evolved, it was found to be made
parotid [36]. The zygomatic branch innervates up of multiple fat compartments [40]. It is divided
the lower portion of the orbicularis oculi mus- into superficial fat compartments (located above
cle, and the zygomatic major and minor mus- to the SMAS) and deep fat compartments (located
cles. The buccal branch runs along with the below the SMAS).
parotid duct to innervate the lip elevator mus- In the middle face region, the superficial and
cles. The zygomatic and buccal branches meet deep compartments are easily distinguishable.
together on the lateral part of the nose and However, these two fat layers have varied thick-
innervate the nasalis, procerus, and corrugator nesses and distributions in the upper and lower
supercilii muscles [37]. The marginal mandib- face regions. Hence, these differences in distribu-
ular branch innervates the lower part of the tion should be taken into consideration during
orbicularis oris, depressor anguli oris, depres- filler injection [41].
44 G. W. Hong and W. Lee
Recently, the forehead and glabellar area fat 7. Cong LY, Phothong W, Lee SH, Wanitphakdeedecha
R, Koh I, Tansatit T, Kim HJ. Topographic analysis of
compartment have been found to be associated the supratrochlear artery and the supraorbital artery.
with wrinkles [44]. The middle face and lower Plast Reconstr Surg. 2017;139:620e–7e.
face fat compartments are also associated with 8. Lee J-G, Yang H-M, Hu K-S, et al. Frontal branch of
wrinkles in these areas. the superficial temporal artery: anatomical study and
clinical implications regarding injectable treatments.
Specifically, periorbital fat compartments, Surg Radiol Anat. 2015;37(1):61–8.
such as orbital fat, medial and middle cheek fat, 9. Sykes JM, Cotofana S, Trevidic P, Solish N, Carruthers
sub-orbicularis oculi fat, and deep medial cheek J, Carruthers A, et al. Upper Face: Clinical Anatomy
fat (lateral parts), are associated with a tear and Regional Approaches with Injectable Fillers.
Plast Reconstr Surg. 2015;136(5 Suppl):204s–18s.
trough, palpebromalar groove, and midcheek 10. Kim H-S, et al. Topographic Anatomy of the
groove [45]. The nasolabial fat and the medial Infraorbital Artery and Its Clinical Implications for
part of the deep medial cheek fat are associated Nasolabial Fold Augmentation. Plast Reconstr Surg.
with nasolabial folds [46]. 2018;142:273e.
11. Lee SH, Lee M, Kim HJ. Anatomy-based image pro-
In the lower face area, the labiomental crease or cessing analysis of the running pattern of the peri-
sulcus is associated with the lower lip region and oral artery for minimally invasive surgery. Br J Oral
mental region fat compartments. The marionette Maxillofac Surg. 2014;52(8):688–92.
line (static labiomandibular fold) is associated with 12. Tansatit T, Apinuntrum P, Phetudom T. A typical
pattern of the labial arteries with implication for lip
the labiomandibular fat superomedially, and to the augmentation with injectable fillers. Aesth Plast Surg.
inferior jowl fat laterally. As the aging process pro- 2014;38:1083.
gresses, the labiomandibular fat decreases while 13. Saban Y, Amodeo CA, Bouaziz D, et al. Nasal arterial
jowl fat increases, causing winkles to deepen [47]. vasculature. Arch Facial Plast Surg. 2012;14(6):429.
14. Choi DY, Bae JH, Youn KH, Kim W, Suwanchinda
Interestingly, superficial fat compartments’ A, Tanvaa T, Kim HJ. Topography of the dorsal nasal
borders tend to align with skin wrinkles; more- artery and its clinical implications for augmenta-
over, the deep fat compartments do not. Exploiting tion of the dorsum of the nose. J Cosmet Dermatol.
this phenomenon, deep fat compartments would 2018;17(4):637–42.
15. Lee J-H. Giwoong Hong Definitions of groove and
be the target of filler injection for the correction hollowness of the infraorbital region and clinical
of wrinkles. treatment using soft-tissue filler. Arch Plast Surg.
2018;45:214–21.
16. Lee SH, Lee HJ, Kim YS, Tansatit T, Kim HJ. Novel
Anatomic Description of the Course of the Inferior
References Palpebral Vein for Minimally Invasive Aesthetic
Treatments. Dermatol Surg. 2016;42(5):618–23.
1. Pessa JE, Rohrich RJ. Facial topography: clinical 17. Ugur MB, Savranlar A, Uzun L, Küçüker H, Cinar
anatomy of the face. St. Louis: Quality Medical; F. A reliable surface landmark for localizing supra-
2012. p. 266–8. trochlear artery: Medial canthus. Otolaryngol Head
2. Marur T, et al. Facial anatomy. Clin Dermatol. Neck Surg. 2008;138:162–5.
2014;32:14–23. 18. Janis JE, Ghavami A, Lemmon JA, Leedy JE,
3. LaTrenta G. Atlas of aesthetic face and neck surgery. Guyuron B. The anatomy of the corrugator supercilii
New York: SAUNDERS; 2003. muscle: part II. supraorbital nerve branching patterns.
4. Yang HM, Lee JG, Hu KS, Gil YC, Choi YJ, Lee Plast Reconstr Surg. 2008;121:233–40.
HK, Kim HJ. New anatomical insights on the course 19. Lei T, et al. Using the Frontal Branch of the Superficial
and branching patterns of the facial artery: clinical Temporal Artery as a Landmark for Locating the
implications of injectable treatments to the nasola- Course of the Temporal Branch of the Facial Nerve
bial fold and nasojugal groove. Plast Reconstr Surg. during Rhytidectomy: An Anatomical Study. Plast
2014;133(5):1077–82. Reconstr Surg. 2005;116:623.
5. Lee JG, Yang HM, Choi YJ, Favero V, Kim YS, Hu 20. Kim HJ, Seo KK, Lee HK, Kim J. Clinical anatomy
KS, et al. Facial arterial depth and relationship with for the face for filler and botulinum toxin injection.
the facial musculature layer. Plast Reconstr Surg. Singapore: Springer; 2016.
2015;135(2):437–44. 21. Lee JY, Kim JN, Yoo JY, Shin KJ, Song WC, Koh KS,
6. Kim YS, Choi DY, Gil YC, Hu KS, Tansatit T, Kim et al. Topographic relationships between the trans-
HJ. The anatomical origin and course of the angular verse facial artery, branches of the facial nerve, and
artery regarding its clinical implications. Dermatol the parotid duct in the lateral midface. Ann Plast Surg.
Surg. 2014;40(10):1070–6. 2014;73:321–4.
46 G. W. Hong and W. Lee
22. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman facial nerve: a cadaveric and clinical study. Br J Oral
AA, Campbell CF, Rohrich RJ. Facial danger zones: Maxillofac Surg. 2019;57:232–5.
techniques to maximize safety during soft-tissue filler 35. Hwang K. Surgical anatomy of the facial nerve relat-
injections. Plast Reconstr Surg. 2017;139(5):1103–8. ing to facial rejuvenation surgery. J Craniofac Surg.
23. Lee HJ, et al. Description of a novel anatomic venous 2014;25:1476–81.
structure in the nasoglabellar area. J Craniofac Surg. 36. Agarwal CA, Mendenhall SD 3rd, Foreman KB,
2014;25:633–5. Owsley JQ. The course of the frontal branch of the
24. Jung W, Youn KH, Won SY, Park JT, Hu KS, Kim facial nerve in relation to fascial planes: an anatomic
HJ. Clinical implications of the middle temporal vein study. Plast Reconstr Surg. 2010;125:532–7.
with regard to temporal fossa augmentation. Dermatol 37. Dorafshar AH, Borsuk DE, Bojovic B, Brown EN,
Surg. 2014;40(6):618–23. Manktelow RT, Zuker RM, et al. Surface anatomy of
25. Standring S. Gray’s anatomy. 41st ed. Edinburgh: the middle division of the facial nerve. Plast Reconstr
Elsevier; 2016. Surg. 2013;131:253–7.
26. Moore KL, Dalley AF, Agur AM. Clinically oriented 38. Huettner F, Rueda S, Ozturk CN, Ozturk C, Drake R,
anatomy. 8th ed. Philadelphia: Wolters Kluwer; Langevin CJ, et al. The relationship of the marginal
2018. mandibular nerve to the mandibular o sseocutaneous
27. Chung MS, Kim HJ, Kang HS, Chung IH. Locational ligament and lesser ligaments of the lower face.
relationship of the supraorbital notch or foramen and Aesthet Surg J. 2015;35:111–20.
infraorbital and mental foramina in Koreans. Acta 39. Domet MA, Connor NP, Heisey DM, Hartig
Anat (Basel). 1995;154:162–6. GK. Anastomoses between the cervical branch of
28. Gil YC, Lee SH, Shi KJ, Song WC, Koh KS, Shin the facial nerve and the transverse cervical cutaneous
HJ. Three-dimensional topography of the supra- nerve. Am J Otolaryngol. 2005;26:168–71.
trochlear nerve with reference to the lacrimal car- 40. Rohrich RJ, Pessa JE. The fat compartments of the
uncle, and its danger zone in Asians. Dermatol Surg. face: Anatomy and clinical implications for cosmetic
2017;43:1458–65. surgery. Plast Reconstr Surg. 2007;119:2219–27.
29. Hu KS, Kwak HH, Song WC, Kang HJ, Kim HC, 41. Nakajima H, et al. Anatomical study of subcutaneous
Fontaine C, et al. Branching patterns of the infraor- adipofascial tissue: A concept of the protective adipo-
bital nerve and topography within the infraorbital fascial system (PAFS) and lubricant adipofascial sys-
space. J Craniofac Surg. 2016;17:1111–5. tem (LAFS). Scand J Plast Reconstr Surg Hand Surg.
30. Kim HS, Oh JH, Choi DY, Lee JG, Choi JH, Hu KS, 2004;38(3):261–6.
et al. Three-dimensional courses of zygomaticofa- 42. Gierloff M, Stohring C, Gassling V. Aging changes
cial and zygomaticotemporal canals using micro- of the midfacial fat compartments: a computed tomo-
computed tomography in Korean. J Craniofac Surg. graphic study. Plast Reconstr Surg. 2012;129:263.
2013;24:1565–8. 43. Gierloff M, Stohring C, Buder T, et al. The subcuta-
31. Namking M, Boonruangsri P, Woraputtaporn W, neous fat compartments in relation to aesthetically
Güldner FH. Communication between the facial and important facial folds and rhytides. J Plast Reconstr
auriculotemporal nerves. J Anat. 1994;185(Pt 2):421– Aesthet Surg. 2012;65:1292.
6. Surg. 2015;68:351–355 44. Cotofana S, et al. An update on the anatomy of
32. Song WC, Kim SH, Paik DJ, Han SH, Hu KS, Kim the forehead compartments. Plast Reconstr Surg.
HJ, et al. Location of the infraorbital and mental fora- 2017;139(4):864e–72e.
men with reference to the soft-tissue landmarks. Plast 45. Rohrich RJ, et al. The anatomy of suborbicularis
Reconstr Surg. 2007;120:1343–7. fat: Implications for periorbital rejuvenation. Plast
33. Lefkowitz T, Hazani R, Chowdhry S, Elston J, Reconstr Surg. 2009;124:946–51.
Yaremchuk MJ, Wilhelmi BJ. Anatomical landmarks 46. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek
to avoid injury to the great auricular nerve during and the deep medial fat compartment. Plast Reconstr
rhytidectomy. Aesthetic Surg J. 2013;33:19–23. Surg. 2008;121:2107–12.
34. Brennan PA, Mak J, Massetti K, Parry 47. Rohrich RJ, Pessa JE. The anatomy and clinical impli-
DA. Communication between the transverse cervical cations of perioral submuscular fat. Plast Reconstr
nerve (C2,3) and marginal mandibular branch of the Surg. 2009;124:266–71.
Physical Properties
and Rheological Approach 5
for Hyaluronic Acid Fillers
Eun-Jung Yang and Won Lee
HA filler is the most commonly used filler world- water. It thus serves as a lubricant in the human
wide. HA filler has the advantages of being an body [2].
easy procedure, and the substance used degrades HA filler is a gel-like structure which is com-
easily. However, HA filler injection could cause posed of HA and a crosslinker. HA also exist in
nonvascular complications such as granuloma animal and bacteria. The raw materials for HA
and delayed-type hypersensitivity reactions. In used to be extracted from roosters’ combs, but
this chapter, we shall discuss about HA filler recently, it has been frequently extracted from
properties, rheology, and manufacturing process Streptococcus equi or zooepidemicus [3].
to understand its usages. Furthermore, we shall Animal- based HA is usually extracted from
discuss about some possible nonvascular compli- roosters’ comb, while non-animal-based HA or
cations related to HA filler properties. nonanimal stabilized HA is usually extracted
from bacteria. The structural differences are in
the length of the polymer chain. Non-animal-
5.1 Hyaluronic Acid based HA usually contain between 4000 and
6000 monomeric units and have an average
HA is part of the composition of the skin, joints, molecular weight of 1.5–2.5 MDa. Contrarily,
and vitreous bodies. A 70 kg human body con- animal-based HA is made up of 10,000–15,000
tains about 12 g of HA; 3 g of HA is produced monomeric units and weighs 4–6 MDa.
and degraded daily [1]. HA is a disaccharide Hyaluronidase is the normal human enzyme
composed of glucuronic acid and glucosamine which degrades HA (Fig. 5.2). HA filler is com-
(it is a glycosaminoglycan) (Fig. 5.1). HA is a posed of a crosslinker which protects the HA
very polar substance and has high affinity for from hyaluronidase.
E.-J. Yang
Plastic and Reconstructive Surgery, Yonsei University
College of Medicine, Seoul, Republic of Korea
e-mail: enyang7@yuhs.ac
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 47
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_5
48 E.-J. Yang and W. Lee
OH NH
C=0
CH3
Na qlucuronate N-acetylqlucosamine
O
CH3 CH3
C=O C=O
NH NH
O
O OH O OH
O O
O O O O
CH2OH COO–Na+ CH2OH COO–Na+
monomeric unit
eter of rheology which defines the ability of the The coefficient of kinematic viscosity is
filler to resume its normal shape after a deforma- another filler property to take into consideration.
tion by a shear stress (Fig. 5.5). Usually, a high Viscosity is a measure of how fast a filler can be
G′ value corresponds to a high restoration ability deformed by a constant stress such as compres-
after a deformation and known as “gel elastic sive stress or shear stress (Fig. 5.6). Viscosity is a
hardness” [13]. rheological term for easy spread by external
Elastic modulus measures the degree of resto- forces. The filler is injected by needle or cannula,
ration after a deformation and is calculated as so viscosity affects the passing of the filler
shear stress divided by shear strain through the needle or cannula. Understanding
shear stress shear rate and viscosity is helpful, when consid-
G′ = ering filler property, during injection into face.
shear strain .
The filler is type of non-Newtonian fluid
Recently, fillers are have been increasingly (Fig. 5.7), and viscosity changes with the rate of
used for augmentation. Hence, the vertical elastic shear strain (Fig. 5.8).
modulus should also be considered in these cases. Prefilled filler inside a syringe is likely to be a
G′ is related to gel hardness. However, the filler solid product with high viscosity. When the filler
substance should not only be hard but should also is injected, the shear stress increases and viscos-
be elastic. This is also important to tackle the sen- ity decreases giving the filler a fluid-like aspect.
sation of the presence of a foreign body. Hard After the injection, shear stress decreases, and
filler substances can make the patient to feel the filler resumes its solid-like aspect. Complex
uncomfortable as he/she might easily perceive it viscosity is a measure of resistance against
as a foreign body. changes in shear stress rate, and when the com-
plex viscosity is high, it is difficult to inject the
SHEAR STRESS
filler.
Injection force is parameter that determines
how softly the filler is injected (Fig. 5.9). Small
Not needle diameter coupled with high injection force
can induce a high ejection force [14]. When nee-
dle diameter and the injection force are constant,
Aligned ejection force increases with increase in viscos-
ity. High ejection pressures increase the risk for
Fig. 5.5 Shear stress. A force against the side of the solid
vascular complication such as skin necrosis, ocu-
is called “shear stress,” and the degree of deformation is
called “shear strain” lar complications, and stroke [15, 16].
SQUEEZE
COMPRESSIVE TENSILE
STRESS STRESS
5 Physical Properties and Rheological Approach for Hyaluronic Acid Fillers 51
V is
co
si t
Va
y
ri e
s
Fig. 5.7 Newtonian fluids and non-Newtonian fluids. Water and oil are like Newtonian fluids because of their low
viscosity. The viscosity of Non-Newtonian fluids can be changed by applying an external force such as shear stress
Fluid-like at High
Shear Rates
FLUID-LIKE
Fig. 5.8 Hyaluronic acid filler viscosity changes with shear stress rate
5.3.2 Cohesiveness
Even if the filler spreads due to external shear Table 5.1 Hyaluronic acid gel-associated rheological
stress, when shear stress disappears the filler par- and physical properties
ticle should aggregate. An ideal filler should have Parameter Description
enough cohesiveness and an appropriate balance Elastic modulus Storage modulus, restoration of
(G′) deformation after an external stress
of viscosity and elasticity. Biphasic fillers, in par- • Unit: pascals, Pa
ticular, have hard particles and therefore possess • High G′ has high potency for
a relatively better elasticity. This implies a higher restoration from deformation
elastic modulus against vertical shear stress. Viscous modulus Loss modulus of external stress
Consequently, biphasic fillers are known to be (G″) • High G″ higher power is
needed to extrude from the needle
good candidates for chin augmentation and nose
Tan delta (tan δ) Relative ratio of viscous modulus
augmentation. On the contrary, monophasic fill- and elastic modulus (G″/G′)
ers are known to possess a relatively low elastic- • High elastic gel (e.g., gelatin);
ity but a high cohesiveness. If a manufacturer tan δ is near 0
• High viscous gel (e.g.,
desires to produce monophasic fillers with better honey); tan δ is near 1
elasticity, HA should be mixed in higher concen- Complex Total resistance to deformation
tration, or more crosslinking will be needed. modulus (G*) • Most HA filler G′ > G″,
However, high concentration or high crosslinking
( G′ ) + ( G′′ )
2 2
G∗ =
can cause additional complications. High cohe-
siveness is important in maintaining the gel state • Most HA filler G* is near G′
Gel cohesion Aggregation property resisting
against vertical stress. High cohesive fillers are dispersion by an external force
recommended in the forehead and cheek area • Attractive force by each
because the particles aggregate with each other molecules
against external stress. Recently, few fillers have • Low cohesiveness filler
disperses easily
been manufactured with high elasticity and high
Concentration Total hyaluronic acid mounted in a
cohesiveness. HA filler properties can be esti- (mg/mL) 1 mL product
mated using a rheometer. Physical parameters • Crosslinked HA maintains
(Table 5.1) and rheological parameter can be dis- shape in the human body
played by a rheometer (Fig. 5.11). • Pendant-linked HA or free
HA degrades faster in the human
body
HA [19]. On the contrary, high MoD means HA ficult to inject. In addition, high MoD filler might
is highly deformed and is therefore subject to less induce rejection, capsular formation, and granu-
degradation inside the human body (prolonged loma formation [20]. Another point of concern is
longevity). incomplete crosslinking. Pendant-type BDDE is
However, the MoD should not be extremely useless and does not contribute to the elasticity of
high because it will lead to increase in gel hard- the filler product. Recently, the degree of cross-
ness and low affinity to water, making the gel dif- linking (CrR) is now being measured. It is a mea-
sure of the ratio of fully modified HA to HA
disaccharide and can provide an estimate of the
elasticity of the product [19].
O O
OH H3C-C H3C-C
OH
HO NH NH
O HO O
O O O
NaOOC O HO O O HO O
NaOOC
O O OH O Epoxide group
HO HO
OH
O O O
O
a b c d
(<2ppm)*
O O O
O
OH OH
HO HO HO O
O CH2OH
COONa O COONa
O O O
O O O O O
OH HN
HN HO HO
C CH3 C CH3
O O
Fig. 5.12 Hyaluronic acid and crosslinker. (a) Fully crosslinked type. (b) Pendant type. (c) Inactivated type. (d)
Native-type BDDE
54 E.-J. Yang and W. Lee
is usually recommended for periocular and lip 5.3.5 Hyaluronic Acid Raw Materials
regions, Volift is recommended for cheek and and Water Affinity
forehead, and Volume is recommended for the
nose and chin. Particle sizes are measured using a HA concentration is the amount of HA in 1 mL of
particle size analyzer (Fig. 5.13). product. The higher the concentration, the harder
Fig. 5.13 Hyaluronic acid particle size. (a) Particle size analyzer. (b) Average particle size detected was 432 μm. (c)
Microscopic view of particles
5 Physical Properties and Rheological Approach for Hyaluronic Acid Fillers 55
the product and the longer it exists. However, water ments in composition and performance. Carbohydr
Polym. 2013;96(2):536–44.
affinity also has to be considered. HA is known to 8. Schante CE, Zuber G, Herlin C, Vandamme
have more than ten times water affinity compared TF. Chemical modifications of hyaluronic acid for the
to its molecular weight. Therefore, HA filler might synthesis of derivatives for a broad range of biomedical
induce edema due to its affinity for water. The filler applications. Carbohyd Polym. 2011;85(3):469–89.
9. Lee W, Hwang SG, Oh W, Kim CY, Lee JL, Yang
conjugates with water and increases in volume EJ. Practical guidelines for hyaluronic acid soft-
after being injected into the human body. tissue filler use in facial rejuvenation. Dermatol Surg.
High filler concentration will have higher 2020;46(1):41–9.
affinity for water and induce edema [20]. 10. Edwards PC, Fantasia JE. Review of long-term adverse
effects associated with the use of chemically-modified
Therefore, an ideal filler should induce less animal and nonanimal source hyaluronic acid dermal
edema and assume the desired shape by the con- fillers. Clin Interv Aging. 2007;2(4):509–19.
tribution of the HA filler itself. It is known that 11. Fagien S, Bertucci V, von Grote E, Mashburn
5.5 mg/mL of HA is equivalent to 1 mL of water JH. Rheologic and physicochemical properties used
to differentiate injectable hyaluronic acid filler prod-
HA filler and induces less edema. Unfortunately, ucts. Plast Reconstr Surg. 2019;143(4):707e–20e.
a good elasticity cannot be conferred by 5.5 mg/ 12. Pierre S, Liew S, Bernardin A. Basics of dermal filler
mL HA [21]. For a good elasticity to be obtained, rheology. Dermatol Surg. 2015;41(Suppl 1):S120–6.
the raw concentration should be increased to val- 13. Lorenc ZP, Ohrlund A, Edsman K. Factors affecting
the rheological measurement of hyaluronic acid gel
ues, such as 15 mg, 20 mg, or 25 mg, and will fillers. J Drugs Dermatol. 2017;16(9):876–82.
thus result in edema. Routinely, concentrations 14. Lee Y, Oh SM, Lee W, Yang EJ. Comparison of hyal-
higher than the hydration equilibrium concentra- uronic acid filler ejection pressure with injection
tions are used. High concentration HA products force for safe filler injection. J Cosmet Dermatol.
2021;20(5):1551–6.
(such as 20–24 mg/mL) pull adjacent water and 15. Sito G, Manzoni V, Sommariva R. Vascular com-
augment tissue. plications after facial filler injection: a literature
review and meta-analysis. J Clin Aesthet Dermatol.
2019;12(6):E65–72.
16. Jones DH, Fitzgerald R, Cox SE, Butterwick K,
References Murad MH, Humphrey S, et al. Preventing and treat-
ing adverse events of injectable fillers: evidence-
1. Volpi N, Schiller J, Stern R, Soltes L. Role, metabo- based recommendations from the American Society
lism, chemical modifications and applications of for Dermatologic Surgery multidisciplinary task
Hyaluronan. Curr Med Chem. 2009;16(14):1718–45. force. Dermatol Surg. 2021;47(2):214–26.
2. Knopf-Marques H, Pravda M, Wolfova L, Velebny 17. De Boulle K, Glogau R, Kono T, Nathan M, Tezel
V, Schaaf P, Vrana NE, et al. Hyaluronic acid and its A, Roca-Martinez JX, et al. A review of the metabo-
derivatives in coating and delivery systems: appli- lism of 1,4-butanediol diglycidyl ether-crosslinked
cations in tissue engineering, regenerative medi- hyaluronic acid dermal fillers. Dermatol Surg.
cine and immunomodulation. Adv Healthc Mater. 2013;39(12):1758–66.
2016;5(22):2841–55. 18. Guarise C, Barbera C, Pavan M, Panfilo S, Beninatto
3. Mei JF, Dong ZH, Yi Y, Zhang YL, Ying GQ. A simple R, Galesso D. HA-based dermal filler: down-
method for the production of low molecular weight stream process comparison, impurity quantitation
hyaluronan by in situ degradation in fermentation by validated HPLC-MS analysis, and in vivo resi-
broth. E-Polymers. 2019;19(1):477–81. dence time study. J Appl Biomater Funct Mater.
4. Sall I, Ferard G. Comparison of the sensitivity of 11 2019;17(3):2280800019867075.
crosslinked hyaluronic acid gels to bovine testis hyal- 19. Kenne L, Gohil S, Nilsson EM, Karlsson A, Ericsson
uronidase. Polym Degrad Stabil. 2007;92(5):915–9. D, Helander Kenne A, et al. Modification and cross-
5. Micheels P, Sarazin D, Tran C, Salomon D. Effect linking parameters in hyaluronic acid hydrogels--def-
of different crosslinking technologies on hyaluronic initions and analytical methods. Carbohydr Polym.
acid behavior: a visual and microscopic study of 2013;91(1):410–8.
seven hyaluronic acid gels. J Drugs Dermatol. 20. Keizers PHJ, Vanhee C, van den Elzen EMW, de
2016;15(5):600–6. Jong WH, Venhuis BJ, Hodemaekers HM, et al. A
6. Gold MH. Use of hyaluronic acid fillers for the high crosslinking grade of hyaluronic acid found in
treatment of the aging face. Clin Interv Aging. a dermal filler causing adverse effects. J Pharmaceut
2007;2(3):369–76. Biomed. 2018;159:173–8.
7. La Gatta A, Schiraldi C, Papa A, D’Agostino A, 21. Grimes PE, Thomas JA, Murphy DK. Safety and
Cammarota M, De Rosa A, et al. Hyaluronan scaffolds effectiveness of hyaluronic acid fillers in skin of color.
via diglycidyl ether crosslinking: toward improve- J Cosmet Dermatol. 2009;8(3):162–8.
Practical Techniques
for Hyaluronic Acid Filler 6
Injections
Jeongmok Cho and Won Lee
J. Cho
Incline Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 57
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_6
58 J. Cho and W. Lee
More specifically, there are differences in volume 6.3 Purpose of Filler Injection
loss, and an understanding of the sequence of fat
reduction can enable doctors to make better plans Filler injection has a dual purpose: volume aug-
for the filler injection (Fig. 6.2) [5]. mentation and volume restoration [2]. For 20s–
30s, filler augmentations are performed to obtain
a smooth contour, and so, the superficial fat com-
partment tends to be target for the augmentation.
Sometimes, the deep compartment is congeni-
tally absent, so injection should be made consid-
ering superficial or deep fat layer deficiency. In
the 40s–50s, the deep fat compartments tend to
lose volume, causing a descent of the superficial
fat compartment. Thus restoration of deep fat
compartments volume will provide a support
structure, and thus, additional volume restoration
will be a more convincing procedure.
Fig. 6.2 Clinical trends show that the periorbital and malar fat pads tend to be affected first in life, followed by the
lateral cheek, deep cheek, and lateral temporal areas
6 Practical Techniques for Hyaluronic Acid Filler Injections 59
6.4 Wrinkle Evaluation Apart from wrinkles, laxity can also be evalu-
ated using scales. Filler injection has a limitation
Several evaluation scales have been introduced. in improving soft tissue laxity, and so thread lift-
The GAIS and Wrinkle Severity Rating Scale are ing or surgical rhytidectomy might be needed to
among the most commonly used scales. Some complement the effects. Taking the patient’s sta-
companies also make use of other scales such as tus and the limitation of procedure into consider-
the Merz Aesthetic Scale (Figs. 6.3 and 6.4) [6]. ation can be helpful in achieving successful
Scales are more objective in the evaluation of results (Fig. 6.5).
symmetry. It is useful to discuss and tell patients Volumetric scales are also used (Figs. 6.6 and
the limitation of the procedure, when the 6.7). When volume augmentation by filler injec-
improvement in the scale will be less than 2 units tion seems limited, microfat injection should also
after the first filler injection. be considered.
0 1 2 3 4
No folds Mild folds Moderate folds Severe folds Very severe folds
0 1 2 3 4
No lines Mild lines Moderate lines Severe lines Very severe lines
0 1 2 3 4
No sagging Mild sagging Moderate sagging Severe sagging Very severe sagging
0 1 2 3 4
Full upper cheek Mildly sunken Moderately sunken Severely sunken Very severely sunken
upper cheek upper cheek upper cheek upper cheek
0 1 2 3 4
Full lower cheek Mildly sunken Moderately sunken Severely sunken Very severely sunken
lower cheek lower cheek lower cheek lower cheek
6.5 Safe Injection Techniques layer bolus method, the filler can be injected layer
by layer. Sunken areas at specific locations are
6.5.1 Sharp Needle Vs. Blunt Cannula also good candidates for needle injection. Needle
injection is also useful for superficial wrinkle cor-
Needle and cannula are used for filler injections. rection since the injection is administered into the
Product package usually includes a sharp needle dermal layer or subdermal layer precisely.
as this is often used for basic procedures. Usually, However, bruising and swelling are more com-
needle injection is performed perpendicularly to monly observed than with cannula injections.
the skin at the desired location, and an aspiration The diameter and length of the blunt cannula are
test is often recommended. The advantage here is chosen by the person who does the injection.
that the filler is injected at a precise location. Usually, they create entry points on the skin area
More specifically, when injecting using the deep for the cannula insertion. The cannula hole is usu-
6 Practical Techniques for Hyaluronic Acid Filler Injections 61
a b
6.5.2 Choice of the Appropriate ensure better results (Fig. 6.11). Most authors use
Needle or Cannula the 23 G 50 mm cannula, and for precise injection
(such as injection in the tear trough area), they use
To ensure good results, appropriate needle and can- a 25 G 40 mm cannula.
nula are needed. The needle or cannula diameter is
often gauged and written, but the measurement
usually corresponds to the outer diameter. The size 6.6 Regional Injection Techniques
of the inner diameter is rather more important
(Fig. 6.10). When the inner diameter is larger, less 6.6.1 Forehead
pressure is applied, and a smoother injection can be
performed. In addition, there are some differences The forehead area usually occupies 1/3 of the face
in hole distances from the tip, hole shapes, and hole and is the widest area for facial filler injection. A
sizes. These parameters should always be consid- large amount of filler is needed to cover all the
ered when choosing the appropriate cannula, to forehead. The strategy is to use a needle with
6 Practical Techniques for Hyaluronic Acid Filler Injections 63
Fig. 6.12 Forehead
augmentation. (a)
a
Design. (b) Anatomy
small amounts of the filler to fill the sunken areas. the frontal bone. Regional nerve blocks at the
Many patients have a prominent supraorbital supraorbital nerve and supratrochlear nerve are
ridge with bilateral frontal bossing and a sunken useful (Fig. 6.13). Local anesthesia could be
glabella area. It is relatively easier to use a needle done using lidocaine plus epinephrine, but since
to inject perpendicularly and then perform mold- the pH is low, bicarbonate can be added to lessen
ing to spread the filler. But since the forehead area pain [10]. Ice pack application before the proce-
is wide, a cannula is recommended (Fig. 6.12). dure is also helpful.
Authors make the entry point at the upper border Two entry points are made, puncturing bilater-
area of the medial brow for esthetic reasons. ally on the medial eyebrow. The cannula is posi-
Most often, the patient feels uncomfortable tioned into the subgaleal level (Figs. 6.14, 6.15
when the cannula tip scratches the periosteum of and 6.16) and the injection administered into the
64 J. Cho and W. Lee
before the procedure; space between virtual line tion (Fig. 6.26). The medial side of the vertical
running from the lateral side of the orbital rim to lateral canthal line is recommended for injection.
the mouth corner and vertical midpupil line Caution should be taken to avoid injecting later-
should be the projection area (Fig. 6.24). The ally because of the adjacent wide zygoma
entry point should be at least 1 cm away from the (Figs. 6.27, 6.28, 6.29 and 6.30).
desired filling area (Fig. 6.25). Orbital retaining
ligament should be considered during the proce-
dure. Filler injection in the orbital retaining liga-
ment might result in hardness and dimpling. It is
therefore preferable to inject above the ligament.
The ligament can also help to prevent filler migra-
Fig. 6.20 Temple area augmentation design Fig. 6.22 Gentle injection after touching the bone
Fig. 6.24 Anterior malar area augmentation. (a) Design. (b) Anatomy
6.6.4 Tear Trough Deformity ner, and the subcutaneous space is smaller.
Correction Hence, irregularities might appear after filler
injection. When overcorrection occurs, the
A softer filler is recommended for tear trough patient might look artificial. Consequently, mul-
deformity correction (Fig. 6.31). The skin is thin- tiple suboptimal corrections are recommended. It
is difficult to dissolve HA partially. Therefore,
when overcorrection occurs, the HA should be
dissolved completely and the procedure repeated.
Authors prefer relatively short cannulas (25 G
40 mm) (Fig. 6.32). It is essential to use the left
hand to feel the anatomical structures when per-
forming the injection. The pre-septal space is the
anatomical target for the injection [11]; it is
located below the orbital rim and above the liga-
ment (Fig. 6.33).
also recommended. Intradermal injection using a used and multiple undercorrections are recom-
needle should also be considered when there are mended (Fig. 6.39). Patients should be informed
many wrinkles. Usually, 0.5–1 mL of filler is of the possibility of filler migration to areas above
the nasolabial fold.
6.6.7 Lips
Fig. 6.37 Nasolabial fold correction design Fig. 6.38 Two-layer approach is recommended
6.6.8 Chin
Fig. 6.41 Upper lip injection
Microgenia is an indication for chin augmenta-
tion by filler injection. The basic procedure
highly vascular structures, so there is a relatively involves using a needle to inject perpendicularly
lower risk of skin necrosis. However, there exist into the desired area. However, this method can
high risks of bruising and swelling in this area. induce filler aggregation and lead to an artificial
Needle injection has the advantage of precision, look. Using a 23 G 50 mm cannula can help to
while cannula injection has the advantage of obtain an even (regular) chin augmentation and a
causing less bruising. It is therefore recom- more natural look (Figs. 6.45, 6.46, 6.47 and
mended to use the cannula for natural augmenta- 6.48). A cannula can also help to obtain a
tion of the whole lip area and to use a needle for smoother mandibular contour line. When the
border contour lines and specific asymmetry cor- injection is made superficially, a small amount of
rections. Authors use 25 G 40 mm cannula. The filler can be used. Yet, it might result into irregu-
entry point is made 3 mm away from the lateral larities because of the movement of the mentalis
mouth corner, and cannula tip can be approached muscle. 1–2 mL of filler can be used, and botuli-
easily (Figs. 6.40, 6.41 and 6.42). Usually, 1 mL num toxin is administered concomitantly to
of filler is used, and an ointment is applied for induce mentalis muscle hypoactivation.
74 J. Cho and W. Lee
Fig. 6.45 Chin augmentation design Fig. 6.46 Submental approach using a cannula
5. Wan D, Amirlak B, Rohrich R, et al. The clinical 9. Griepentrog GJ, Lemke BN, Burkat CN Jr, JGR,
importance of the fat compartments in midfacial Lucarelli MJ. Anatomical position of hyaluronic acid
aging. Plast Reconstr Surg Glob Open. 2014;1:e92. gel following injection to the infraorbital hollows.
6. Stella E, Petrillo AD. Injections in aesthetic medicine, Ophthal Plast Reconstr Surg. 2013;29(1):35–9.
Atlas of Full-face and Full-body Treatment. Berlin: 10. Frank SG, Lalonde DH. How acidic is the lidocaine
Springer Science & Business Media; 2013. p. 33–50. we are injecting, and how much bicarbonate should
7. Pavicic T, Webb KL, Frank K, Gotkin RH, Tamura we add? Can J Plast Surg. 2012;20(2):71–3.
B, Cotofana S. Arterial Wall penetration forces 11. Wong C-H, Mendelson B. The long-term static
in needles versus cannulas. Plast Reconstr Surg. and dynamic effects of surgical release of the tear
2019;143(3):504e–12e. trough ligament and origins of the orbicularis oculi
8. JAJ VL, Humzah D, Kerscher M. Cannula ver- in lower eyelid blepharoplasty. Plast Reconstr Surg.
sus sharp needle for placement of soft tissue fill- 2019;144(3):583–91.
ers: an observational cadaver study. Aesthet Surg J.
2018;38(1):73–88.
Doppler Ultrasound-Guided
Hyaluronic Acid Filler Injection 7
Techniques
Hyun Woo Cho and Won Lee
HA filler could have tragic complications such as middle forehead compartment. Clinically, fore-
skin necrosis and ocular complications. To pre- head depressions are found in the central portion
vent these tragic vascular complications, it is and lateral portions, and these phenomena are a
essential to know the vascular anatomy. Doppler consequence skull shape rather than volume of
ultrasound is a well-known device used in detect- the superficial fat. Usually, HA filler is injected
ing arteries of the face. In this chapter, we shall into the subgaleal space, also known as the deep
discuss about Doppler ultrasound-guided HA fat compartment [1].
filler injection techniques.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 77
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_7
78 H. W. Cho and W. Lee
7.1.2 Techniques
a b
c d
Fig. 7.5 Forehead HA filler of 3 mL in a 23-year-old female patient. (a) Pre-op frontal view. (b) Post-op frontal view
after 2 weeks. (c) Pre-op lateral view. (d) Post-op lateral view after 2 weeks
80 H. W. Cho and W. Lee
7.2 Temple Augmentation nula can puncture the STF easily. Therefore, a
relatively safe plane is exposed. Compared to
7.2.1 Anatomy and Considerations deep injection, small amounts of HA filler can
yield better results.
The temple area is a juncture where four skull Important vessels of the temple area are the
bones (frontal, parietal, temporal, and sphenoid STA, sentinel vein, middle temporal vein, and the
bones) fuse together and is covered by a multiple- deep temporal artery. The pulsations of the STA
layer thick soft tissue. From the outer surface, the can be felt during palpation of the temple area
layers are the skin, subcutaneous layer, superficial [16]. The STA is a branch of the external carotid
temporal fascia (STF), deep temporal fascia artery; it runs vertically anterior to the ear. The
(DTF), temporalis muscle, and bone (Fig. 7.6). In frontal branch of the STA runs superficially in the
addition, there exists a loose areolar tissue between temple area. The STA is a relatively large vessel
the STF and DTF, and the innominate fascia and and is therefore easily detectable by Doppler
parotid temporal fascia may also be found depend- ultrasound (Fig. 7.7).
ing on the height of the temple area [11].
There are three possible layers within which
HA fillers may be injected. These include the sub- Table 7.1 Disadvantages of deep injection of the temple
cutaneous layer (for superficial injection), the area
space between the STF and DTF, and the space 1. Case report of penetration of the temporal bone by a
between the temporalis muscle and the bone (deep needle [13]
injection) [12]. The easiest technique is to inject 2. Needle should be used for deep injections, so there
is a possibility for vascular injury (superficial
deeply in a way to touch the bone with the needle temporal artery, anterior branch of deep temporal
end. However, multiple shortcomings have been artery, and middle temporal vein) to occur [14]
found recently with this technique (Table 7.1). 3. Relative larger amounts of fillers are needed
Authors like to inject between the STF and 4. Impossibility to inject into the submuscular layer, so
DTF because the STA and the temporal branch of longevity decreases due to muscle action [4]
facial nerve are shielded by the STF, and the can- 5. Difficult to eliminate when a granuloma occurs [15]
a b
c d
Fig. 7.12 Bilateral injection of HA filler of 0.8 mL in a procedural three-quarter view. (d) Post-procedural three-
29-year-old patient. (a) Pre-procedural front view. (b) quarter view after 3 months
Post-procedural front view after 3 months. (c) Pre-
7 Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 83
a b
c d
Fig. 7.13 Bilateral injection of HA filler of 1 mL in a procedural three-quarter view. (d) Post-procedural three-
23-year-old patient. (a) Pre-procedural front view. (b) quarter view after 2 weeks
Post-procedural front view after 2 weeks. (c) Pre-
Concerning the aspect of the nose, there are little One of the most common filler procedures is aug-
differences between oriental patients and western mentation of the dorsum of the nose. There are
patients. Western patients usually have a higher two possible layers for filler injection (the sub-
nasal dorsum. Thus, HA filler is mostly adminis- dermal and supraperiosteal layers). In cadaveric
tered to correct deviations and small depressions. studies, arteries and veins are run above the fibro-
In addition, small amounts of the filler are usu- muscular layer. Therefore, the supraperiosteal
ally injected, and needle is mostly used [20]. In layer could be considered to be a safe injection
oriental patients however, HA injection is usually plane [23]. However, when using Doppler ultra-
performed because of their lower nasal dorsum sound, some branches of the dorsal nasal artery
[21]. Therefore, relatively larger amounts of filler are detected in the supraperiosteal layer. One
are injected, and extreme care should be taken could therefore conclude that there is no 100%
about the vascular anatomy. The nose can be safe plane of injection [21]. We can estimate that
divided into the radix, rhinion, supratip, and tip blood pressure in the nasal arteries is not high
area, and it is important to know vascular anat- because branches of external carotid artery (oph-
omy and layers of each zone of injection [22]. thalmic artery) and branches of internal carotid
84 H. W. Cho and W. Lee
Nose injection is one of the commonest proce- inject slowly [28]. Appropriate needle and filler
dures in the oriental population, but it is com- should be chosen considering the filler rheology
monly associated with vascular accidents. [29]. Pre- and post-procedure photographs are
Usually, the ejection pressure is higher than seen in Fig. 7.18.
blood pressure. It is therefore very important to
a b c
d e f
Fig. 7.18 Pre- and post-procedure photographs: Lorient front view. (c) Pre-procedure three-quarter view. (d) Day
No. 6 dorsum supraperiosteal layer 0.5 mL, Lorient No. 2 2 post-procedure three-quarter view. (e) Pre-procedure
dorsum subdermal layer 0.1 mL, Lorient No. 2 tip 0.2 mL. lateral view. (f) Day 2 post-procedure lateral view
(a) Pre-procedure front view. (b) Day 2 post-procedure
86 H. W. Cho and W. Lee
7.4 Midface Augmentation the orbital fat area). Sometimes, festoon forma-
tion is a consequence of the aging phenomenon
Filler injection at the midface is usually per- [32]. If there are only nasojugal grooves, filler
formed on multiple locations at once. For exam- injection can yield good results. However, when
ple, tear trough, anterior malar, and lateral cheek the muscle fibers extend to the orbital rim or the
are corrected concomitantly. The total amount of tear trough ligament is tightly attached, good
filler needed should be taken into consideration esthetic results cannot be obtained. In such cases,
(Fig. 7.19). There are risks of provoking a delayed surgical correction would be the only solution
hypersensitivity when large amounts are injected. [33]. Thus, the tear trough is not just ligament,
but is a complex deformity, and it is important to
consider all these factors before performing filler
7.4.1 Tear Trough Deformity injection. It is quite safe when deep injections are
administered into the suborbicularis oculi fat
The nasojugal groove is formed by complex (SOOF), but tear trough area does not contain
structures such as tear trough ligament and orbital SOOF (Fig. 7.20). Therefore, considering the
septal fat and is found between the preseptal por- anatomical layers, a deep injection (between the
tion and the orbital portion of orbicularis oculi orbicularis oculi muscle and bone) and a superfi-
muscle [30]. The orbicularis retaining ligament cial injection (between OOM and skin) could be
can be divided into a medial and a lateral side by performed concomitantly.
the midpupillary line. The medial side is tighter The angular artery runs on the medial side of
and forms a hard structure called the “tear trough the angular vein in the tear trough area and there-
ligament.” However, its anatomical nomenclature fore is relatively safe. However, when the angular
is not defined. The medial side has a tight struc- artery branches from a detoured branch of the
ture because the orbicularis retaining ligament facial artery, the facial artery runs toward the
and the zygomaticocutaneous ligament tend to inferior orbital artery and anastomoses with
aggregate at the medial side [31]. angular artery. Consequently, the angular artery
In addition, the groove can become prominent might be located very closely to the angular vein,
because the pretarsal or preseptal areas have a and so extreme caution will need to be taken
low fat content (subcutaneous fat exists mainly in (Fig. 7.21) [34].
Fig. 7.19 Midface
augmentation after
2 weeks. A total of
3.9 mL of hyaluronic
acid filler was injected
7 Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 87
a b
Fig. 7.23 Tear trough deformity correction, Lorient No. 2 0.3 mL. (a) Pre-injection. (b) Postinjection
Fig. 7.24 Vessel
anatomy of anterior
malar area
7.4.3 Lateral Cheek Correction upright position. When using a cannula to inject, a
helpful tip will be to make small spaces (by feel-
There are abundant fibrous bands between the ing) to cut the fibrous band (Fig. 7.26). The trans-
skin and the SMAS in the lateral cheek area. verse facial artery branches from the STA or
Because of these fibrous bands, filler might external carotid artery and runs between the zygo-
migrate to undesired spaces. Therefore, it is rec- matic arch and the parotid duct. Therefore, it may
ommended to administer the injection in the be encountered when performing lateral cheek
7 Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 89
a b
c d e f
Fig. 7.27 35-year-old patient midface filler injection. (a) (d) Post-procedural three-quarter view after 2 weeks. (e)
Pre-procedural frontal view. (b) Post-procedural frontal Pre-procedural lateral view. (f) Post-procedural lateral
view after 2 weeks. (c) Pre-procedural three-quarter view. view after 2 weeks
90 H. W. Cho and W. Lee
7.5 Nasolabial Fold Correction are some variations, such as the detoured branch
that runs toward the infraorbital foramen. There
7.5.1 Anatomy and Considerations are also variations in its position with respect to
muscle layers (beneath or above the muscle) [47].
Nasolabial fold correction is one of the most Generally, the supraperiosteal layer is known to
common filler injection procedures. When a new be safe for injections. However, there exist varia-
filler is placed on the market, most authors pro- tions; so the layer is not 100% safe [48]. The
pose the use of the WSRS correction scores to facial artery is easily detected by Doppler ultra-
prove the effectiveness of the filler [41]. One of sound (Fig. 7.29).
the causes of various types of nasolabial folds is
descent of the nasolabial fat (superficial fat com-
partment) [42]. The aging process results in sag- 7.5.2 Techniques
ging of the superficial fat and decrease in dermal
elasticity [43]. Another cause is diminished vol- When performed using a cannula, the entry point
ume of the deep medial cheek fat. The aging pro- used for augmentation of the anterior malar area
cess decreases the volume of the deep fat can be used. Injection in the supraperiosteal layer
component and causes deep nasolabial folds [44]. is possible (Fig. 7.30). However, even if the deep
This is one of the main reasons why injections layer is corrected, skin indentations can appear,
are administered into the deep medial cheek fat and subdermal needle injections might be needed.
compartment. The area between the deep medial Dual-plane injection yields better results, but the
cheek fat and the periosteum is called “Ristow’s
space” [44], and from the theory of the 1 cm
space, it is the same as the deep pyriform space
[45]; however, authors think the Ristow’s space is
a kind of potential surgical space. The Ristow’s
space is the first target for the correction of naso-
labial fold. Another cause of nasolabial folds is
the repetitive movement of muscles attached to
the dermal layer of the nasolabial fold. These are
the so-called lip elevators and are made up of the
LLSAN, levator labii superioris, zygomaticus
major, and zygomaticus minor muscles [46].
The trajectory of the facial artery follows that
of the nasolabial fold (Fig. 7.28). However, there Fig. 7.29 Doppler ultrasound probe detection
Fig. 7.28 Vascular
anatomy of the
nasolabial fold. The
facial artery can be
located at the nasolabial
fold (right). The facial
artery can detour the
nasolabial fold (left)
7 Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 91
a b
Fig. 7.32 35-year-old female patient, 0.5 cm3 injected each. (a) Pre-procedural. (b) Post-procedural after 2 weeks
92 H. W. Cho and W. Lee
Fig. 7.36 Nomencla-
ture of the lips
a b
Fig. 7.37 Upper lip border enhancement. (a) Start laterally. (b) Move to the medial location
tion. Plast Reconstr Surg Glob Open. 2018;6(9):e1858. and its clinical implications for augmentation of the dor-
https://doi.org/10.1097/GOX.0000000000001858. sum of the nose. J Cosmet Dermatol. 2018;17(4):637–
10. Tansatit T, Apinuntrum P, Phetudom T. A dark side of 42. https://doi.org/10.1111/jocd.12720.
the cannula injections: how arterial wall perforations 24. Beleznay K, Carruthers JD, Humphrey S, Jones
and emboli occur. Aesthet Plast Surg. 2017;41(1):221– D. Avoiding and treating blindness from fillers:
7. https://doi.org/10.1007/s00266-016-0725-7. a review of the world literature. Dermatol Surg.
11. Davidge KM, van Furth WR, Agur A, Cusimano 2015;41(10):1097–117. https://doi.org/10.1097/
M. Naming the soft tissue layers of the temporopa- DSS.0000000000000486.
rietal region: unifying anatomic terminology across 25. Beleznay K, Carruthers JDA, Humphrey S, Carruthers
surgical disciplines. Neurosurgery. 2010;67(3 Suppl A, Jones D. Update on avoiding and treating blind-
Operative):120–9. ness from fillers: a recent review of the world litera-
12. Breithaupt AD, Jones DH, Braz A, Narins R, ture. Aesthet Surg J. 2019;39(6):662–74. https://doi.
Weinkle S. Anatomical basis for safe and effec- org/10.1093/asj/sjz053.
tive volumization of the temple. Dermatol Surg. 26. Harb A, Brewster CT. The nonsurgical rhinoplasty:
2015;41(Suppl 1):S278–83. https://doi.org/10.1097/ a retrospective review of 5000 treatments. Plast
DSS.0000000000000539. Reconstr Surg. 2020;145(3):661–7. https://doi.
13. Philipp-Dormston WG, Bieler L, Hessenberger org/10.1097/PRS.0000000000006554.
M, Schenck TL, Frank K, Fierlbeck J, et al. 27. Moon HJ, Lee W, Do Kim H, Lee IH, Kim SW. Doppler
Intracranial penetration during temporal soft tis- Ultrasonographic anatomy of the midline nasal dor-
sue filler injection-is it possible? Dermatol Surg. sum. Aesthet Plast Surg. 2021;45(3):1178–83. https://
2018;44(1):84–91. doi.org/10.1007/s00266-020-02025-1.
14. Carruthers J, Humphrey S, Beleznay K, Carruthers 28. Lee Y, Oh SM, Lee W, Yang EJ. Comparison of hyal-
A. Suggested injection zone for soft tissue fillers in uronic acid filler ejection pressure with injection
the Temple? Dermatol Surg. 2017;43(5):756–7. force for safe filler injection. J Cosmet Dermatol.
15. Lee JM, Kim YJ. Foreign body granulomas after 2021;20(5):1551–6. https://doi.org/10.1111/jocd.14064.
the use of dermal fillers: pathophysiology, clinical 29. Lee W, Oh W, Moon HJ, Koh IS, Yang EJ. Soft tis-
appearance, histologic features, and treatment. Arch sue filler properties can be altered by a small-diameter
Plast Surg. 2015;42(2):232–9. needle. Dermatol Surg. 2020;46(9):1155–62. https://
16. Lee J-G, Yang H-M, Hu K-S, et al. Frontal branch of doi.org/10.1097/DSS.0000000000002220.
the superficial temporal artery: anatomical study and 30. Lee JH, Hong G. Definitions of groove and hollowness
clinical implications regarding injectable treatments. of the infraorbital region and clinical treatment using
Surg Radiol Anat. 2015;37(1):61–8. soft-tissue filler. Arch Plast Surg. 2018;45:214–21.
17. Sykes JM, Cotofana S, Trevidic P, Solish N, Carruthers 31. Wong CH, Mendelson B. Facial soft-tissue spaces and
J, Carruthers A, et al. Upper face: clinical anatomy retaining ligaments of the midcheek: defining the pre-
and regional approaches with injectable fillers. Plast maxillary space. Plast Reconstr Surg. 2013;132(1):49–
Reconstr Surg. 2015;136(5 Suppl):204s–18s. 56. https://doi.org/10.1097/PRS.0b013e3182910a57.
18. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: 32. Kpodzo DS, Nahai F, McCord CD. Malar mounds and
an important reference point for surgery in the tempo- festoons: review of current management. Aesthet Surg
ral region. Plast Reconstr Surg. 1998;101(1):27–32. J. 2014;34(2):235–48. https://doi.org/10.1177/10908
https://doi.org/10.1097/00006534-199801000-00006. 20X13517897.
19. Jung W, Youn KH, Won SY, Park JT, Hu KS, Kim 33. Lee W, Cho JK, Koh IS, Kim HM, Yang EJ. Infraorbital
HJ. Clinical implications of the middle temporal vein groove correction by microfat injection after lower
with regard to temporal fossa augmentation. Dermatol blepharoplasty. J Plast Reconstr Aesthet Surg.
Surg. 2014;40(6):618–23. 2020;73(4):777–82. https://doi.org/10.1016/j.
20. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman bjps.2019.11.016.
AA, Campbell CF, Rohrich RJ. Facial danger zones: 34. Kim YS, Choi DY, Gil YC, Hu KS, Tansatit T,
techniques to maximize safety during soft-tissue filler Kim HJ. The anatomical origin and course of the
injections. Plast Reconstr Surg. 2017;139(5):1103–8. angular artery regarding its clinical implications.
https://doi.org/10.1097/PRS.0000000000003309. Dermatol Surg. 2014;40(10):1070–6. https://doi.
21. Lee W, Kim JS, Oh W, Koh IS, Yang EJ. Nasal dor- org/10.1097/01.DSS.0000452661.61916.b5.
sum augmentation using soft tissue filler injection. 35. DeLorenzi C. Complications of injectable fillers, part
J Cosmet Dermatol. 2019. https://doi.org/10.1111/ I. Aesthet Surg J. 2013;33(4):561–75. https://doi.org/
jocd.13018. Epub ahead of print. PMID: 31157508. 10.1177/1090820X13484492.
22. Moon HJ. Injection rhinoplasty using filler. Facial 36. Landau M. Hyaluronidase caveats in treating filler com-
Plast Surg Clin North Am. 2018;26(3):323–30. plications. Dermatol Surg. 2015;41(Suppl 1):S347–53.
https://doi.org/10.1016/j.fsc.2018.03.006. https://doi.org/10.1097/DSS.0000000000000555.
23. Choi DY, Bae JH, Youn KH, Kim W, Suwanchinda A, 37. Shamban A, Clague MD, von Grote E, Nogueira
Tanvaa T, Kim HJ. Topography of the dorsal nasal artery A. A novel and more aesthetic injection pattern
7 Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 97
for malar cheek volume restoration. Aesthet Plast 48. Lee W, Kim JS, Moon HJ, Yang EJ. A safe Doppler
Surg. 2018;42(1):197–200. https://doi.org/10.1007/ ultrasound-guided method for nasolabial fold cor-
s00266-017-0981-1. rection with hyaluronic acid filler. Aesthet Surg J.
38. Lee SH, Lee HJ, Kim YS, Tansatit T, Kim HJ. Novel 2021;41(6):NP486–92. https://doi.org/10.1093/asj/
anatomic description of the course of the inferior sjaa153.
palpebral vein for minimally invasive aesthetic treat- 49. Moon HJ, Lee W, Kim JS, Yang EJ, Sundaram
ments. Dermatol Surg. 2016;42(5):618–23. https:// H. Aspiration revisited: prospective evaluation of a
doi.org/10.1097/DSS.0000000000000700. physiologically pressurized model with animal cor-
39. Mendelson BC, Jacobson SR. Surgical anatomy of the relation and broader applicability to filler complica-
midcheek: facial layers, spaces, and the midcheek seg- tions. Aesthet Surg J. 2021;41(8):NP1073–83. https://
ments. Clin Plast Surg. 2008;35(3):395–404.; discus- doi.org/10.1093/asj/sjab194.
sion 393. https://doi.org/10.1016/j.cps.2008.02.003. 50. Braz A, Humphrey S, Weinkle S, Yee GJ, Remington
40. Toure G, Nguyen TM, Vlavonou S, Ndiaye BK, Lorenc ZP, et al. Lower face: clinical anatomy
MM. Transverse facial artery: its role in blindness after and regional approaches with injectable fillers. Plast
cosmetic filler and botulinum toxin injections. J Plast Reconstr Surg. 2015;136(5 Suppl):235s–57s.
Reconstr Aesthet Surg. 2020;S1748-6815(20):30717– 51. Lee SH, Lee M, Kim HJ. Anatomy-based image pro-
8. https://doi.org/10.1016/j.bjps.2020.12.042. cessing analysis of the running pattern of the peri-
41. Day DJ, Littler CM, Swift RW, Gottlieb S. The wrin- oral artery for minimally invasive surgery. Br J Oral
kle severity rating scale: a validation study. Am J Clin Maxillofac Surg. 2014;52(8):688–92.
Dermatol. 2004;5(1):49–52. 52. Ricketts RM. Perspectives in the clinical appli-
42. Gierloff M, Stöhring C, Buder T, Gassling V, Açil cation of cephalometrics. The first fifty years.
Y, Wiltfang J. Aging changes of the midfacial fat Angle Orthod. 1981;51(2):115–50. https://doi.
compartments: a computed tomographic study. Plast org/10.1043/0003-3219(1981)051<0115:PITCAO>2
Reconstr Surg. 2012;129(1):263–73. https://doi. .0.CO;2.
org/10.1097/PRS.0b013e3182362b96. 53. Hur MS, Kim HJ, Choi BY, Hu KS, Kim HJ, Lee
43. Ezure T, Amano S. Involvement of upper cheek KS. Morphology of the mentalis muscle and its rela-
sagging in nasolabial fold formation. Skin tionship with the orbicularis oris and incisivus labii
Res Technol. 2012;18(3):259–64. https://doi. inferioris muscles. J Craniofac Surg. 2013;24(2):602–
org/10.1111/j.1600-0846.2011.00567.x. 4. https://doi.org/10.1097/SCS.0b013e318267bcc5.
44. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek 54. de Maio M, Wu WTL, Goodman GJ, Monheit G;
and the deep medial fat compartment. Plast Reconstr Alliance For the future of aesthetics consensus
Surg. 2008;121(6):2107–12. https://doi.org/10.1097/ committee Facial assessment and injection guide
PRS.0b013e31817123c6. for botulinum toxin and injectable hyaluronic acid
45. Surek CK, Vargo J, Lamb J. Deep pyriform space: fillers: focus on the lower face. Plast Reconstr Surg.
anatomical clarifications and clinical implications. 2017;140(3):393e–404e. https://doi.org/10.1097/
Plast Reconstr Surg. 2016;138(1):59–64. https://doi. PRS.0000000000003646.
org/10.1097/PRS.0000000000002262. 55. Peng JH, Peng HP. Classifications and injection
46. Beer GM, Manestar M, Mihic-Probst D. The causes strategy for lip reshaping in Asians. J Cosmet
of the nasolabial crease: a histomorphological Dermatol. 2020;19(10):2519–28. https://doi.
study. Clin Anat. 2013;26(2):196–203. https://doi. org/10.1111/jocd.13635.
org/10.1002/ca.22100. 56. Jeong TK. Mouth corner lift with botulinum toxin
47. Lee JG, Yang HM, Choi YJ, Favero V, Kim YS, Hu type a and hyaluronic acid filler. Plast Reconstr Surg.
KS, et al. Facial arterial depth and relationship with 2020;145(3):538e–41e.
the facial musculature layer. Plast Reconstr Surg.
2015;135(2):437–44.
Filler Injection Complications
and Hyaluronidase 8
Won Lee
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea Fig. 8.1 Signs of infection after nose filler injection
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 99
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_8
100 W. Lee
a b
Fig. 8.2 (a) Upward filler migration. (b) Downward filler migration. (c) A second image depicting upward filler
migration
itive molding, and their properties influence the cation has been highlighted recently because of
migration [3]. Repetitive muscle action, previous recent reports after COVID-19 vaccinations
filler injections, and pre-tunneling space are pos- [6], causing type IV hypersensitivity.
sible causes of filler migration (Fig. 8.2). Hyaluronic acid filler is a foreign substance,
The properties of fillers should be considered but since the main constituent is hyaluronic
when injected to the nasal area. Usually, filler acid, inflammation is usually minimal.
injections are recommended at the supraperios- However, hyaluronic acid fillers can be recog-
teal layer [4], but some hyaluronic acid fillers nized as an antigen, and consequently an
tend to migrate because of compression forces. inflammatory reaction may develop, mediated
The hardest filler should be considered for nose by macrophages and T lymphocytes. If the
injections [5]. patient is immunosuppressed, delayed-type
hypersensitivity might develop.
Vascular complications occur through the
8.2.3 Tyndall Effect same mechanism across different filler products.
In addition, delayed-type hypersensitivity might
The Tyndall effect is the phenomenon when the be induced by raw filler products. To fully com-
fillers are visible under thin skin, as light is scat- prehend the properties of a filler, the manufactur-
tered by the particles in a colloid. This can be pre- ing process must be known.
vented by injecting small amounts of fillers. Hyaluronic acid fillers are composed of raw
Clinicians should also consider the thickness of hyaluronic acid and a crosslinker (Fig. 8.3).
the dermis. The manufacturing process is complicated
because of proper pH, mixing time, mixing tem-
perature, and so on. The following images show
8.2.4 Delayed-Type Hypersensitivity the manufacturing process of monophasic fillers
(Fig. 8.4).
Delayed-type hypersensitivity usually occurs at Impurities introduced during the manufactur-
least 2 weeks after filler injection. This compli- ing process can be made either by BDDE or by
8 Filler Injection Complications and Hyaluronidase 101
Fig. 8.3 Hyaluronic acid filler, which consists of raw hyaluronic acid powder and a crosslinker (BDDE 1,4-butanediol
diglycidyl ether)
Fig. 8.4 The a b c
manufacturing process
for hyaluronic acid
production. (a)
Weighing. (b)
Dissolve in NaOH. (c)
After reaction with
BDDE. (d) Cutting.
(e) After washing. (f)
Filling. (g) Autoclave
d e
f g
102 W. Lee
O O
OH H3C-C H3C-C
OH
HO NH NH
O HO O
O O O
NaOOC O HO O O HO O
NaOOC
O O OH O Epoxide group
HO HO
OH
O O O
O
a b c d
(<2ppm)*
O O O
O
OH OH
HO HO HO O
O CH2OH
COONa O COONa
O O O
O O O O O
OH HN
HN HO HO
C CH3 C CH3
O O
Fig. 8.5 Various BDDEs. (a) Well-crosslinked. (b) Pendant type. (c) BDPE (1,4-butanediol di-(propan-2,3-diolyl)
ether). (d) Native type
8.3.1 Cause
O
CH3 CH3
C=O C=O
NH NH
O
O OH O OH
O O
O O O O
CH2OH COO–Na+ CH2OH COO–Na+
monomeric unit
The dermal layer consists of glycosaminogly- varying potencies, which also differ between
can (which includes HA); the hyaluronidase can countries. Hylenex and Vitrase have concentra-
degrade the HA for hypodermoclysis. Off-label tions of 150 USP (United States Pharmacopeia)
dissolved HA fillers are used here [7]. and 200 USP, respectively, and products in Korea
usually contain 1500 IU (Fig. 8.9).
8.3.2.2 Types
Hyaluronidase is made by different manufactur- 8.3.2.3 Duration
ing processes using ovine, bovine testicular, or Usually, hyaluronidase is injected at the subcuta-
human recombinant sources. The products have neous layer, where its half-life is 30 min. The
104 W. Lee
a b c
Fig. 8.9 The different brands of hyaluronidase. (a) Hylenex (150 USP). (b) Vitrase (200 USP). (c) Hyalose (1500 IU)
half-life drastically reduces to 2–3 min in the considerations before administering different
blood, which is attributed to the antibody theory. treatments, summarized in Table 8.2.
Below, we have discussed the treatment strat-
8.3.2.4 Hyaluronidase for Nonvascular egy for an actual skin necrosis case (Fig. 8.11). A
Complications 30-year-old patient developed skin necrosis after
Low-dose hyaluronidase can be used for nonvas- nasolabial fold filler injections. The following
cular complications, such as nodule degradation. factors were taken into consideration:
Approximately 30–60 IU can be used for mouse
nodules [8]. It is also possible to reinject hyal- 1. Time of the filler injection: The onset is
uronic acid fillers 6 h after the hyaluronidase extremely important, as within 48–72 h of the
injection [9]. A high dose of hyaluronidase can onset, hyaluronidase should be injected.
be used for capsule formatted granuloma cases. 2. Properties of the filler: It is impossible to
know all the MoD of the fillers in the market.
8.3.2.5 Hyaluronidase for Vascular However, knowledge of whether the filler is
Complications a monophasic or biphasic product is essen-
The most severe complications are vascular, like tial. Biphasic fillers usually have minimal
skin necrosis and ocular complications. Despite MoD and rapid degradation times. The dos-
adequate anatomical knowledge, features vary age of hyaluronidase must be based on the
across individuals. How is hyaluronidase injected properties of the HA product for effective
to resolve vascular complications? treatment.
A previous study recommended specific dos- 3. Amount of injected hyaluronidase: As
ages of hyaluronidase for specific areas of treat- described previously, hyaluronidase products
ments (Fig. 8.10) [10]. However, there are some have variable potency. Usually 1500 IU is
8 Filler Injection Complications and Hyaluronidase 105
Table 8.2 Factors to consider before administering HYAL injections to resolve vascular complications
Injected MoD Monophasic and biphasic fillers have different modification of degree (MoD) and
degradation time
Potency of HYAL Variable products have different potencies
Dosage 150 USP, 200 USP, 1500 IU
Affected vessel Subcutaneous injection nearby affected vessel
Degradation time Injected HYAL should spread to affected vessel and it should be remembered that hyaluronic
acid filler does not degrade immediately
Repetitive injection Injected HYAL subcutaneously has half-life, so repetitive injection should be performed
Among these considerations, repetitive injections are essential. A previous experiment revealed that 30 min–1 h of
repetitive HYAL injections is most effective [11]
106 W. Lee
a b
c d
8.4 Vascular Complications (2): then moves to the ophthalmic artery retrograde
Ocular Complications pathway, followed by the central retinal artery
(Fig. 8.13). So extreme caution is crucial when
8.4.1 Incidence fillers are injected at internal carotid artery sites.
Table 8.3 The ABCs for prevention of filler-induced ultrasonography when injecting the glabella area
ocular complications [13] [14]. The dorsal nasal artery can also be detected
An – Anatomy (Doppler ultrasonography) using Doppler ultrasonography when injecting
As – Aspiration with proper technique filler at the nose [5, 15]. One common site for
B – Big cannulas
C – Compression
filler injection is the nasolabial fold, which can
D – Direction of injection be encountered through the facial artery. The
E – Emergency kit facial artery can be easily detected using Doppler
F – Filler technique for augmentation or wrinkle ultrasonography [16]. When filler injections are
correction
G – Gentle injection of a small amount
performed for temple augmentation, the frontal
H – History of prior operations or injections branch of superficial temporal artery can be
encountered, detected using Doppler ultrasonog-
raphy [17, 18]. The most definite prevention is to
bital, and facial arteries are very important ves- use the Doppler ultrasonography to locate the
sels from the external carotid artery. It is arteries before filler injection.
impossible to know the exact pathway as they
may vary circumstantially. Recently, detecting 8.4.3.2 Aspiration Test
arteries using the Doppler ultrasound has been When the needle ends perforate the arteries and
gaining importance as a preventive technique. syringe regurgitation is performed, blood can be
seen. This is called an “aspiration test.” The aspi-
Doppler Ultrasonography-Guided Filler ration test remains controversial but is theoreti-
Injections cally an effective procedure performed by many
Detailed techniques are described in Chap. 7. The doctors. However, the possibility of false nega-
supratrochlear artery can be detected by Doppler tives is increased when the needle end is located
8 Filler Injection Complications and Hyaluronidase 109
inside the arterial lumen, but no blood is seen. The 8.4.3.3 B: Big Cannula
needle prime substance, retraction time, retraction Almost all doctors recommend cannulas as safer
pressure, and needle lumen diameter also affect options than needles. However, the cannula is not
the risk of false negatives. One experiment 100% safe. The author recommends using can-
assessed the aspiration test with the needle- nulas with diameters comparable to those of the
priming substance [19]. Both in vitro and in vivo dorsal nasal or supratrochlear arteries (Fig. 8.15).
tests were performed and when the needle was
filled with the filler, false negatives might occur 8.4.3.4 C: Compression
(Fig. 8.14). Thus, it is important to detect the nee- Compression of the periocular region can occur
dle lumen before the aspiration test is performed. during filler injections. For example, the supra-
trochlear pathway compresses during glabella
wrinkle correction using filler injections
(Fig. 8.16).
Fig. 8.15 The comparison between the diameters of arteries and cannulas
110 W. Lee
8.4.4 Treatments
Fig. 8.18 The instrumental setup for the ejection force experiment. S1 denotes the filler-filled syringe, S2 denotes an
additional syringe connected to S1, and A1 denotes the internal cross-sectional area of S1
References
1. American Society of Plastic Surgeons. National
Plastic Surgery Statistics. 2018. https://www.plas-
ticsurgery.org/documents/News/Statistics/2018/top-
five-cosmetic-plastic-surgery-procedures-2018.pdf.
Accessed 9 May 2019.
2. Lee W, Koh IS, Oh W, Yang EJ. Ocular complications
of soft tissue filler injections: a review of literature. J
Cosmet Dermatol. 2020;19(4):772–81.
3. Jordan DR, Stoica B. Filler migration: a number of
mechanisms to consider. Ophthal Plast Reconstr Surg.
2015;31(4):257–62.
4. Tansatit T, Moon H-J, Rungsawang C, et al. Safe
planes for injection rhinoplasty: a histological analy-
sis of midline longitudinal sections of the Asian nose.
Fig. 8.20 The retrobulbar injection technique
Aesthet Plast Surg. 2016;40(2):236–44.
5. Lee W, Kim J-S, Oh W, Koh I-S, Yang E-J. Nasal dor-
sum augmentation using soft tissue filler injection. J
8.4.4.3 Subtenon Retrobulbar Cosmet Dermatol. 2019;2019:1–7.
Hyaluronidase Injection 6. Ortigosa LCM, Lenzoni FC, Suárez MV, Duarte AA,
A subtenon injection is another solution described Prestes-Carneiro LE. Hypersensitivity reaction to
recently, which offers greater permeability [25]. hyaluronic acid dermal filler after COVID-19 vacci-
nation: a series of cases in São Paulo, Brazil. Int J
However, the technique is relatively difficult and Infect Dis. 2022;116:268–70.
there are no case reports describing it. 7. Lee W. Comments on “Hyaluronidase: an overview
of its properties, applications, and side effects”.
8.4.4.4 Intra-Arterial Thrombolysis Arch Plast Surg. 2020;47(6):626–7. https://doi.
org/10.5999/aps.2020.01571.
(IAT) 8. Hwang E, Song YS. Quantitative correlation between
A catheter, starting from the femoral artery hyaluronic acid filler and hyaluronidase. J Craniofac
extending to the ophthalmic artery, should be Surg. 2017;28(3):838–41. https://doi.org/10.1097/
used to inject hyaluronidase and urokinase. A SCS.0000000000003411.
9. Kim HJ, Kwon SB, Whang KU, Lee JS, Park YL,
recent case report was published where this Lee SY. The duration of hyaluronidase and optimal
approach was used for successful resolution of timing of hyaluronic acid (HA) filler reinjection
complications [26]. However, there are also case after hyaluronidase injection. J Cosmet Laser Ther.
reports describing unsuccessful resolutions using 2018;20(1):52–7.
10. DeLorenzi C. New high dose pulsed hyaluronidase
this technique [27]. As previously described, protocol for hyaluronic acid filler vascular adverse
time is one important factor when performing events. Aesthet Surg J. 2017;37(7):814–25.
this treatment. It is almost impossible to perform 11. Lee W, Oh W, Oh SM, Yang EJ. Comparative effec-
within 90 min after blindness occurred. tiveness of different interventions of perivascular hyal-
uronidase. Plast Reconstr Surg. 2020;145(4):957–64.
According to the author, the most important https://doi.org/10.1097/PRS.0000000000006639.
factors for effective treatment are as follows: (1) 12. Cho KH, Dalla Pozza E, Toth G, Bassiri Gharb B, Zins
the treatment should be administered as soon as JE. Pathophysiology study of filler-induced blindness.
possible, (2) a high dose of hyaluronidase should Aesthet Surg J. 2019;39(1):96–106.
13. Lee W. Prevention of hyaluronic acid filler-induced
be injected, and (3) hyaluronidase cannot degrade blindness. Dermatol Ther. 2020;33(4):e13657.
HA filler immediately, so repeated injections 14. Lee W, Moon HJ, Kim JS, Yang EJ. Safe glabellar
should be performed. Soon a definite treatment wrinkle correction with soft tissue filler using Doppler
will be established. ultrasound. Aesthet Surg J. 2020;41:1081–9.
8 Filler Injection Complications and Hyaluronidase 113
15. Moon HJ, Lee W, Do Kim H, Lee IH, Kim SW. Doppler 22. Lee W, Oh W, Ko HS, Lee SY, Kim KW, Yang
ultrasonographic anatomy of the midline nasal dor- EJ. Effectiveness of retrobulbar hyaluronidase injec-
sum. Aesthet Plast Surg. 2021;45(3):1178–83. https:// tion in an iatrogenic blindness rabbit model using
doi.org/10.1007/s00266-020-02025-1. hyaluronic acid filler injection. Plast Reconstr Surg.
16. Lee W, Kim JS, Moon HJ, Yang EJ. A safe Doppler 2019;144(1):137–43.
ultrasound-guided method for nasolabial fold cor- 23. Chesnut C. Restoration of visual loss with retrobulbar
rection with hyaluronic acid filler. Aesthet Surg J. hyaluronidase injection after hyaluronic acid filler.
2021;41(6):NP486–92. Dermatol Surg. 2018;44(3):435–7.
17. Lee W, Moon HJ, Kim JS, Chan BL, Yang EJ. Doppler 24. Goodman GJ, Clague MD. A rethink on hyaluroni-
ultrasound-guided thread lifting. J Cosmet Dermatol. dase injection, intraarterial injection, and blindness:
2020;19(8):1921–7. is there another option for treatment of retinal artery
18. Lee W, Moon HJ, Kim MS, Cheon GW, Yang EJ. Pre- embolism caused by intraarterial injection of hyal-
injection ultrasound scanning for treating temporal uronic acid? Dermatol Surg. 2016;42(4):547–9.
hollowing. J Cosmet Dermatol. 2021;21(6):2420–5. 25. Choe HR, Woo SJ. Subtenon retrobulbar hyaluroni-
19. Moon HJ, Lee W, Kim JS, Yang EJ, Sundaram dase injection for ophthalmic artery occlusion fol-
H. Aspiration Revisited: Prospective evaluation of a lowing facial filler injection. Int J Ophthalmol.
physiologically pressurized model with animal cor- 2020;13(7):1170–2.
relation and broader applicability to filler complica- 26. Zhang LX, Lai LY, Zhou GW, Liang LM, Zhou YC, Bai
tions. Aesthet Surg J. 2021;41(8):NP1073–83. XY, Dai Q, Yu YT, Tang WQ, Chen ML. Evaluation
20. Prado G, Rodriguez-Feliz J. Ocular pain and of intraarterial thrombolysis in treatment of cosmetic
impending blindness during facial cosmetic injec- facial filler-related ophthalmic artery occlusion. Plast
tions: is your office prepared? Aesthet Plast Surg. Reconstr Surg. 2020;145(1):42e–50e.
2017;41(1):199–203. 27. Zhang L, Luo Z, Li J, Liu Z, Xu H, Wu M, Wu
21. Lee Y, Oh SM, Lee W, Yang EJ. Comparison of hyal- S. Endovascular hyaluronidase application through
uronic acid filler ejection pressure with injection superselective angiography to rescue blindness
force for safe filler injection. J Cosmet Dermatol. caused by hyaluronic acid injection. Aesthet Surg J.
2021;20(5):1551–6. 2021;41(3):344–55.
Anatomical Considerations
for Thread Lifting 9
Gi Woong Hong and Won Lee
Thread lifting is one of the most performed mini- However, usually small vessel perforation easily
mally invasive aesthetic procedures. Like all pro- attains hemostasis by compression. However,
cedures done in the face, basic anatomical thick thread for lifting usually starts from hair-
knowledge is essential for thread lifting. In this lines and approaches the SMAS layers, creating
chapter, we will discuss the important vessels, an increase for perforating bigger arteries.
nerves, and retaining ligaments important for The main artery at the hairline is the superfi-
thread lifting. We will discuss the fat components cial temporal artery (STA). The STA runs through
to understanding better results for thread lifting. the preauricular area and bifurcates into the ante-
Finally, we will discuss the parotid gland anatomy rior branch and posterior branch. The bifurcation
to prevent thread lifting-induced complications. usually occurs 64% above the supraorbital rim
and 36% below the supraorbital rim. The frontal
branch of the STA is usually at the superomedial
9.1 Vessels 60.8° and runs toward the lateral border of the
frontalis muscle. It is wrapped by a superficial
During thread lifting, the veins and arteries can be temporal fascia and then runs superficially at the
interrupted, possibly causing bruising and swell- lateral forehead area (Fig. 9.1) [1].
ing. It is safer for the lower face because only a few Despite anatomical knowledge of the STA,
arteries run through the superficial layer at certain perforations could occur due to anatomic varia-
areas of the lower face. Perforation of the larger tions. A temporal needle is used for the fixation
vessels at the temple area and the upper face is method. When the STA is perforated, a high
likely when fixation of thread is usually performed blood volume is regurgitated through the needle
in the upper face. Main vessels run within the sen- puncture area within 1–2 s. When this phenome-
sory nerves. Thus, when a patient complains of non occurs, compression should be done for
pain, it is recommended to pull the cannula back- >5 min, followed by making another entry point.
ward and then change the direction or layer. When hemostasis does not occur, sutures are
When performing thin polydioxanone (PDO) required with the adjacent tissue [2].
threads, there is a greater possibility for bruising. The superficial temporal vein (STV) also might
be perforated at the temple area and might cause
severe bruising, necessitating a gentle approach [3].
G. W. Hong
SAMSKIN Plastic Surgery Clinic, Seoul, Republic of Korea Severe bleeding might also be caused by the
facial artery. The facial artery usually runs between
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic, the mid-mandibular inferior border and the ante-
Anyang, Kyonggi-do, Republic of Korea rior border of the masseter muscle (Fig. 9.2) [4].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 115
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_9
116 G. W. Hong and W. Lee
Anterior branch
of superficial
temporal artery
Poterior branch
of superficial
temporal artery
Line of superior
orbital rim
Zygomatico-
orbital artery
Auriculotemporal
nerve
Transverse
facial artery Greater auricular nerve
Fig. 9.1 The anterior and posterior branches of the superficial temporal artery
Premasseteric branch
of facial artery
Facial artery
Facial vein
9 Anatomical Considerations for Thread Lifting 117
When the facial artery runs near the mandible The nerve location is important. However, the
area, it mostly runs in the deep layer. Thus, thread layer location is also significant to determine the
lifting at the superficial layer can be safe. The depth of thread lifting. Fortunately, the temporal
facial artery runs deep in the medial direction and branch of the facial nerve does not exist as only
superficial at the mimetic muscles and branches one, but as two to three branches. Therefore, con-
arteries at the nose and lips [5]. comitant damage does not occur [8].
The angular artery is the terminal portion of The actual disturbance associated with nerve
the facial artery and runs through variable layers, damage is the perioral sensory disturbance
necessitating extra caution for risks of perfora- when opening the mouth. When a cogged thread
tion. The STA is located at the temporal bone, is inserted at the perioral muscles, it likely
making compression possible. However, when causes disturbance or pain, which is most
the facial artery is lacerated, a hematoma occurs severe at 1 week and improves after 1–2 weeks
through the buccal area, and the patient could [9]. This phenomenon is usually not attributed
experience severe bruising and swelling [6]. to nerve damage itself but is sensorily
uncomfortable.
9.2 Nerves
9.3 Retaining Ligaments
Thread lifting is usually performed by a cannula,
causing minimal nerve damage. However, the The retaining ligaments of the face can be classi-
temporal branch of the facial nerve at the temple fied as follows: true retaining ligaments, which
area, usually located 0.5 cm below the tragus and start from the bone and attach to the skin, and
1.5 cm lateral to the eyebrow by the Pitanguy false retaining ligaments, which start from the
line, requires gentle procedures to be performed muscle or soft tissue layers. The true retaining
near this area (Fig. 9.3) [7]. ligaments are the orbital, zygomatic, maxillary,
and mandibular ligaments (Fig. 9.4) [10].
However, the retaining ligaments are useful as
fixation structures rather than ligaments. The
ligament-like structure is needed to make variable
expressions while preventing sagging. Whether
this structure is a true ligament or only ligament-
like, this hard tissue is useful for the cogged
thread to hold the soft tissues of the face [11].
The most important two ligaments are the
zygomatic and masseteric cutaneous ligaments.
They decussate a “T” shape and display hard-
bearing power for the skin and soft tissues. These
ligaments act as hard fixation structures when
multidirectional cogged threads are used
(Fig. 9.5) [12].
In contrast, when too many forces are applied
at the retaining ligaments, it is hard to release the
threads and form dimples. This should be noticed
at the location of maxillary ligament and man-
dibular ligament area, and massage should be
immediately performed to necessitate immediate
Fig. 9.3 The temporal branch of the facial nerve on the
Pitanguy line release when dimples occur [13].
118 G. W. Hong and W. Lee
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 123
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_10
124 Y. D. Kweon and W. Lee
10.2 Developments
a b
Fig. 10.5 Differences in facial structure by position. (a) Upright position. (b) Patient’s desire. (c) Photographs taken at
upright and supine positions
lifting maturation process. The lifting effect is formed within the incision at temple area and fix-
visible for 1–1.5-year duration. During this time, ated at the deep temporal fascia. Later,
neocollagenesis occurs and matures, and fixation non-incisional deep temporal fascia fixation was
by the thread loses strength because of muscle performed.
activity for expressions and descent due to grav-
ity. The duration is variable based on the patient’s
condition but can be prolonged by adjuvant 10.4.2 Cogged Thread vs Plain Thread
therapy.
Cogged threads are relatively thick threads such
as 2, 1, 0, and 2-0 used for tissue lifting. Plain
10.4 Classification of Threads thread is absorbable thread and made 5-0 to 7-0.
It is embedded at the dermal and/or subdermal
Threads can be classified based on the following layer as a meshed type. Usually, the improvement
techniques: of fine wrinkles is seen.
Fixation at the deep temporal fascia technique is Prolene has been used previously. It has been
done using anchoring-type thread lifting. Non- replaced to absorbable threads such as PDO,
fixation thread lifting is known as the floating PLLA, and PCL. However, nonabsorbable
type. Previously, the anchoring type was per- threads are still also used.
10 History, Principles, and Adjuvant Therapy for Thread Lifting 127
chin. Lipolysis with laser and thread lifting can 10.5.8 Fractional Laser
be used simultaneously. The author likes to use a
980-nm laser for inducing fibrosis before thread Laser can be classified as ablative and non-
lifting. Irradiation can induce inflammation and ablative. Fractional laser is used for reduced heal-
fibrosis. Wound healing and scar maturation pro- ing time and at fine wrinkles, acne scars, and
cess might induce tighter tissues for thread lift- pores. Absorbable plain thread can be concomi-
ing. The longevity of the thread lifting might be tantly used for better results.
prolonged using laser. The author also uses the
980- nm laser for breast ptosis with thread
lifting. 10.5.9 Radiofrequency Devices
10.5.7 High-Intensity Focused
Ultrasonography (HIFU) 10.6 Considerations for Effective
Thread Lifting
Energy-based devices, such as HIFU, are used
for mechanisms like those of the interstitial laser. 10.6.1 Limitations of Minimally
Thread lifting can be used to achieve an immedi- Invasive Procedures
ate lifting effect. HIFU is additionally used for
increased tightening and effectiveness of threads. Thread lifting has limited effectiveness compared
HIFU is a noninvasive procedure. Effective pro- to traditional face lifting. It is used to plicate soft
cedures are performed with the combined use of tissue, limiting the results. The sum of linear trac-
thread and HIFU. tion can be explained for thread lifting.
10 History, Principles, and Adjuvant Therapy for Thread Lifting 129
10.6.2 Understanding of Thread the thread. The delivery time from the raw thread
company to manufacturing company is also cru-
PDO absorbs within 6–8 months. However, trac- cial. Even though they are similar in shape, the
tion forces start decreasing only a few weeks exposure time of humidity is different, which is
after insertion. As previously described, the PDO an important factor affecting effectivity and lon-
hydrolyses 8 weeks after insertion. Some patients gevity. Therefore, using freshly manufactured
complain of painful sensations, nearly extrusion, thread is recommended.
but these complications disappear by 2–3 months
after as the thread softens and loses strength.
Thus, the patient should exercise precaution for References
2–3 months while performing certain activities
like opening the mouth wide, facial massages, 1. Alcamo JH. Surgical suture. US Patent 3,123,077.
1964.
etc. 2. Sulamanidze MA, Fournier PF, Paikidze TG,
Sulamanidze G. Removal of facial soft tissue ptosis
with special threads. Dermatol Surg. 2000;28:367–71.
10.6.3 Understanding 3. The Korea Herald. Petit’ surgery promises ‘natural’
look. In: Demand on rise for non-invasive cosmetic
Manufacturing Process treatments that promise instant rejuvenation. Seoul:
The Korea Herald; 2013.
Absorption depends on the manufacturing pro- 4. Yun Y-H, et al. Narrative review and propose of
cess because PDO thread is prone to hydrolysis thread embedding acupuncture procedure for facial
wrinkles and facial laxity. J Korean Med Ophthalmol
by the environment. High humidity can increase
Otolaryngol Dermatol. 2015;28(1):119–33.
the thread’s fragility. Packing is also important. 5. Yun Y, Choi I. Effect of thread embedding acu-
Nitrogen gas is usually filled inside the package. puncture for facial wrinkles and laxity: a single-
Vacuum packing seems to maintain the thread arm, prospective, open-label study. Integr Med Res.
2017;6(4):418–26.
properties better. 6. Vieira AC, et al. Degradation and viscoelastic proper-
When the package has been opened, the thread ties of PLA–PCL, PGA–PCL, PDO and PGA fibres.
inside should be used as soon as possible. In: Materials science forum, vol. 636. Bach: Trans
Re-sterilization should not be performed after Tech Publications Ltd; 2010.
7. Lee CG, et al. Histological evaluation of biore-
opening the package. Once the package is
sorbable threads in rats. Korean J Clin Lab Sci.
opened, external humidity causes hydrolysis of 2018;50(3):217–24.
The Basic Techniques for Thread
Lifting 11
Bong-il Rho, Chang Woon Yun, Soo Yeon Park,
and Won Lee
Thread lifting is a commonly used technique in based on the direction of the cogs, the threads can
minimal aesthetic fields. However, the proce- be unidirectional, bidirectional, and multidirec-
dures are not standardized, resulting in technical tional. Based on the technique types, thread lift-
variations. In this chapter we will discuss several ing can be floating or anchoring type. APTOS
types of threads and basic procedures of thread thread is a well-known floating thread made from
lifting. polypropylene (PP), made for gathering tissue
[2], usually 7–10 cm long and bidirectional.
Recently, comparable products have been manu-
11.1 Introduction factured by polydioxanone (PDO) threads.
However, for patients of Asian origin, the zygoma
Thread lifting is a relatively easy, frequently per- is relatively wide and prominent. The use of bidi-
formed technique resulting in minimally invasive rectional threads for gathering tissue can make
lifting effects. However, it is also disadvanta- the zygoma look more prominent [3].
geous in terms of its short-lived, minimal lifting Multidirectional cogged threads have been devel-
effects [1]. Several types of cogged threads have oped to overcome these issues. Multidirectional
been developed to increase the lifting effect and cogged threads are suitable for fixation, but not
longevity of the technique. tissue gathering at one point. Therefore, adjuvant
The cogged threads can be classified into a fixation with bidirectional thread lifting is recom-
few categories based on certain properties. First, mended [4].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 131
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_11
132 B.-i. Rho et al.
a b
Fig. 11.7 Fixation at the deep temporal fascia (DTF). (a) Thread insertion at the temporal needle end. (b) Pulling the
same length to locate the center at the DTF
4. The thread is inserted to the end hole of the should be performed only after pulling the
temporal needle and rewound for thread fix- thread to prevent thread extrusion
ation (Fig. 11.7a). Two threads can be (Fig. 11.11b).
inserted concomitantly, but considering the 8. After removing the excess thread, dimples
directionality, more than two entry points might occur at the exit site. Gentle massage is
may be necessary. The two ends of the performed to resolve these dimples
thread are pulled by the same length to (Fig. 11.11c).
locate the center of the thread at the DTF 9. The patient is made to sit in an upright posi-
(Fig. 11.7b). tion and examined for symmetry and
5. The cannula is inserted at the entry point. The dimples.
cannula is maneuvered such that the end is at
the deep subcutaneous layer of the lower face
and penetrates the exit site (Fig. 11.8). The 11.3.5 Considerations
cannula must not be located at the dermal
layer. This can be tested by shaking the can- 1. The patient might experience postoperative
nula end. pain after 1–2 weeks. Overexpression or
6. The thread is inserted through the cannula. opening the mouth too wide should be
When the thread is visible at cannula exit, avoided.
the cannula is removed from the exit site, 2. Postoperative swelling might be observed at
thus leaving only the thread. It must be the zygoma area until 2–3 weeks after the
ensured that hair does not enter the entry procedure.
point (Fig. 11.9). The remaining half of the 3. Discomfort during opening the eyes in the
thread is inserted using the same methods perioral area might occur for 1 day due to the
(Fig. 11.10). local anesthesia. Preoperative explanations
7. When both ends of the thread are inserted, the regarding the same are recommended.
skin is stretched for face lifting (Fig. 11.11a). 4. Exit site dimples are a common complication
The excess threads are cut. Notably cutting requiring early intervention. If the dimples
11 The Basic Techniques for Thread Lifting 135
Fig. 11.9 Thread insertion through the cannula and subsequent removal of cannula
a b c
Fig. 11.11 Thread cutting. (a) Skin lifting. (b) Cutting remaining threads. (c) Gentle massage
Fig. 11.12 Thread lifting using anchoring cogged thread techniques. Patient images taken preoperatively (Lt) and
1 month postoperatively (Rt)
persist for 4 weeks, a permanent dimple might 11.4 Thread Lifting Technique:
occur. To avoid these cases, follow-up visits The Floating Technique
are recommended 3–4 weeks after the
operation. The floating technique involves multidirec-
tional thread insertions and is relatively easy.
However minimal immediate lifting is seen,
11.3.6 Pre- and Postoperative Photo and the effects are short-lived. The APTOS
(Figs. 11.12 and 11.13) thread is a well-known floating thread. Recently,
numerous cog- shaped PDO threads have
Case 1 been manufactured for different purposes.
See Fig. 11.12. Bidirectional cogged threads are commonly
used, specifically for gathering soft tissue at the
Case 2 center area. A lifting effect is achieved because
See Fig. 11.13. the lower face is relatively mobile. Compared
11 The Basic Techniques for Thread Lifting 137
Fig. 11.13 Anchoring fixation cogged thread lifting. Patient images taken preoperatively (Lt) and 1 month postopera-
tively (Rt)
11.4.4 Techniques
Fig. 11.19 Removal of the cannula while holding the 11.4.5 Considerations
thread in the left hand
Fig. 11.21 55-year-old woman. Photographs taken preoperatively (Lt), 2 weeks postoperatively (center), and 3 months
postoperatively (Rt)
11 The Basic Techniques for Thread Lifting 141
Fig. 11.22 The floating-type technique. Images were taken preoperatively (Lt) and 1 month postoperatively (Rt)
Fig. 11.23 A 56-year-old woman. Images taken preoperatively (Lt), 1 week postoperatively (center), and 3 months
postoperatively (Rt)
142 B.-i. Rho et al.
Fig. 11.24 A 62-year-old woman. Photographs taken at pre-op (Lt), 1 week post-op (center), 3 months post-op (Rt)
Fig. 11.25 A 53-year-old woman. Images were taken preoperatively (Lt), 2 weeks postoperatively (center), and
3 months postoperatively (Rt)
11 The Basic Techniques for Thread Lifting 143
Won Lee and Chang Woon Yun
The results of thread lifting are dependent on the A thick thread provides a more significant lift
doctor’s expertise, vectors, and the patient’s con- in the tissue but might leave the patient with an
dition. Thread lifting can be done by either increased foreign body sensation-associated dis-
cogged thread or plain thread, dependent on the comfort. Thick threads also require cannulas with
required mechanical traction force and chemical larger diameters, resulting in increased pain and
effects. The cogged threads can be further divided tissue damage. Thin threads provide compara-
into the fixed type and floating type. In this chap- tively inferior lifting effects.
ter, we will discuss the crucial factors and various Considering the thickness of thread, thicker
techniques for thread lifting. thread should be inserted deeper. The insertion of
thick threads near the facial retaining ligaments is
not recommended, as doing so can cause compli-
12.1 Thread Thickness cations like dimple formation.
Every thread is labeled by the United States
The thread thickness is a crucial factor to be con- Pharmacopeia (USP). The criteria vary between
sidered for thread lifting, in addition to the thread the synthetic absorbable surgical sutures and
length, thread count, shape, and the insertion nonabsorbable surgical sutures [1]. There are dif-
layer. Thread thickness is a basic component for ferences between the USP and European
physical strength. The considerations for choos- Pharmacopoeia (EP). Here, we summarize the
ing the appropriate thickness includes the thread thicknesses based on the USP labeling
patient’s skin thickness, degree of soft tissue system (Fig. 12.1).
descent, prior operations, the desired lifting vec-
tor, and so on.
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
C. W. Yun
View Plastic Surgery Clinic,
Seoul, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 145
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_12
146 W. Lee and C. W. Yun
USP METRIC Sutures Diamater in mm effect early phase and chemical effect late phase.
Thread lifting techniques are developed using
3 6 effective cogged designs and better packing pro-
0.600-0.699
cesses. The thread insertion layer is important to
ensure the best results.
When the thread is inserted near the dermal
2 5 layer, the chemical effect will be superior.
0.500-0.599 However, thread visibility and dimples can occur
as unwanted side effects. The threads are there-
fore inserted into the deep subcutaneous layer,
1 4
but unfortunately, unintentional thread insertion
0.400-0.499
can occur at the SMAS and sub-SMAS layers.
0 3.5
0.350-0.399
12.2.1 Uni-Layer Insertion
2/0 3
0.200-0.249
From the entry point to exit, thread is inserted at
3/0 2 a uni-layer, like the subcutaneous layer. Facial
0.150-0.199 soft tissue contains the septum, fascia, and
lubricating layer. Lifting is more effective when
4/0 1.5
0.100-0.149 these components are less interrupted
(Fig. 12.2). More lifting can be performed using
5/0 1
0.070-0.099 the uni-layer insertion as compared to multi-
layer insertions.
6/0 0.7
0.050-0.069
7/0 0.5
0.040-0.049 12.2.2 Multilayer Insertion
8/0 0.4
0.030-0.039
Inserting thread into a unilateral layer such as the
9/0 0.3 subcutaneous fat layer or SMAS layer can be
0.030-0.039
challenging (Fig. 12.3). When a multilayer inser-
10/0 0.2
0.020-0.029
tion is performed, the effective lubricating layer
mobility can be interrupted. Also, multiple septa
Fig. 12.1 Thread thicknesses based on the United States can interrupt the mobility and cause soft tissue
pharmacopeia system accumulation (Fig. 12.4). Doctors are typically
experienced in dealing with zygoma area protru-
12.2 Different Layer, Different sions, also called the “bumping effect.” Patients
Results with breast or hip augmentations are good candi-
dates for bumping effect.
The facial layer is a crucial factor to be consid- Therefore, multilayer insertions result in facial
ered for thread lifting. Appropriate lifting must lifting and volume augmentation. The difference
be evaluated early and satisfy the patient, fol- caused by the choice of insertion layers can pro-
lowed by evaluations for longevity. The thread vide drastically better results and prevent
lifting effects can be classified by the traction complications.
12 The Techniques and Considerations for Thread Lifting 147
a b c
d e
Fig. 12.6 The vertical lifting technique. (a) The vertical lifting vector estimation. (b) Thread insertion after the cannula
insertion. (c) Another vector for the thread. (d) Soft tissue lifting. (e) Massage after cutting
The basic vector for lifting opposes gravity. Thread lifting can result in zygoma protrusions and
This vector lifting cannot be applied to all unnatural expressions when done in the upper lat-
faces due to factors like scars, depression, and eral direction. Vertical lifting directly opposes the
possible damages of the nerves and vessels. force of gravity using a small number of threads.
Thus, the recommended direction for lifting
vectors is usually oblique, toward the upper
lateral. Vertical lifting can be performed at the 12.5 Reverse Insertion
periocular area using short-length cogged
threads [3]. Similar techniques are described as Thread lifting is usually recommended at the
follows: upper area, like the temple area for anchoring a
fixed point and the lower face lifting, which is a
150 W. Lee and C. W. Yun
Fig. 12.8 Reverse a b
technique. (a) Thread
insertion for the reverse
technique for eyebrow
lifting. (b) Four threads
are used for one side.
(c) Four thread reverse
insertions to improve
the nasolabial fold and
anterior malar
augmentation. (d) Plain
threads are used for the
mattress-type fixation
c d
movable area. The reverse insertion technique is essential to prevent dimples. Short cogged
to insert thread from the lower to the upper area idirectional or multidirectional threads are usu-
b
of the face. It is a relatively easy procedure but ally recommended (Fig. 12.7).
soft tissue dimples might occur. Preoperative and First, four to five multidirectional thread inser-
postoperative treatments, such as deep insertions tions are performed and plain threads are used for
at the entry point or postoperative massages, are the mattress pattern (Fig. 12.8).
12 The Techniques and Considerations for Thread Lifting 151
Fig. 12.9 The frontal branch of the superficial temporal artery pathway can be detected by Doppler ultrasound. Thread
lifting should be performed detecting the superficial temporal artery
Fig. 12.11 Volumizing
threads
Fig. 12.13 Micro-focused ultrasound technology gener- ous layer for face contouring. Ultrasound energy at 7 MHz
ates thermal coagulation in the musculocutaneous layer reaches a shallower depth than at 4 MHz, and thus, a
for skin tightening or destroys fat cells in the subcutane- higher intensity is needed to reach the same depth
lifting purposes. Therefore, these can be improved 7. Fabi SG. Noninvasive skin tightening: focus on
new ultrasound techniques. Clin Cosmet Investig
to develop novel techniques and more varieties of Dermatol. 2015;8:47–52.
cogged designs. Inefficient products with short- 8. Moon HJ, Chang D, Lee W. Short-term treatment out-
lived results need to be optimized for better comes of facial rejuvenation using the mint lift fine.
results. Plast Reconstr Surg Glob Open. 2020;8(4):e2775.
9. Rezaee Khiabanloo S, Jebreili R, Aalipour E,
Saljoughi N, Shahidi A. Outcomes in thread lift for
face and neck: a study performed with Silhouette
References soft and promo happy lift double needle, innova-
tive and classic techniques. J Cosmet Dermatol.
1. http://ftp.uspbpep.com/v29240/usp29nf24s0_c861. 2019;18(1):84–93.
2. Song JK, Chang J, Cho KW, Choi CY. Favorable 10. Kim J, Kim HS, Seo JM, Nam KA, Chung
crisscrossing pattern with polydioxanone: barbed KY. Evaluation of a novel thread-lift for the improve-
thread lifting in constructing fibrous architecture. ment of nasolabial folds and cheek laxity. J Eur Acad
Aesthet Surg J. 2021;41(7):NP875–86. https://doi. Dermatol Venereol. 2017;31(3):e136–79.
org/10.1093/asj/sjab153. 11. Suh DH, Jang HW, Lee SJ, Lee WS, Ryu HJ. Outcomes
3. Kang SH, Byun EJ, Kim HS. Vertical lifting: a new of polydioxanone knotless thread lifting for facial
optimal thread lifting technique for Asians. Dermatol rejuvenation. Dermatol Surg. 2015;41(6):720–5.
Surg. 2017;43(10):1263–70. 12. Lee H, Yoon K, Lee M. Outcome of facial rejuvena-
4. Lee W, Moon HJ, Kim JS, Chan BL, Yang EJ. Doppler tion with polydioxanone thread for Asians. J Cosmet
ultrasound-guided thread lifting. J Cosmet Dermatol. Laser Ther. 2018;20(3):189–92.
2020;19(8):1921–7. 13. Tong LX, Rieder EA. Thread-lifts: a double-edged
5. Yoon JH, Kim SS, Oh SM, Kim BC, Jung W. Tissue suture? A comprehensive review of the literature.
changes over time after polydioxanone thread inser- Dermatol Surg. 2019;45(7):931–40.
tion: an animal study with pigs. J Cosmet Dermatol. 14. Sarigul Guduk S, Karaca N. Safety and complica-
2019;18(3):885–91. tions of absorbable threads made of poly-l-lactic
6. Lee W, Oh W, Kim HM, Chan BL, Yang EJ. Novel acid and poly lactide/glycolide: experience with
technique for infraorbital groove correction using 148 consecutive patients. J Cosmet Dermatol.
multiple twisted polydioxanone thread. J Cosmet 2018;17(6):1189–93.
Dermatol. 2020;19(8):1928–35.
Minimally Invasive Rhinoplasty:
Augmentation Rhinoplasty 13
with Cogged Threads
Hyun Jin Yang and Won Lee
Rhinoplasties are very frequently performed pro- between the nasal soft tissue. Cogged threads are
cedures on patients of Asian origin due to their used for immediate and efficient fixation. PP and
relatively low dorsum of the nose. Filler and PDO threads are superior for exerting restoration
thread can also be used for augmentation of the forces as compared to nylon or polycaprolac-
nose. In this chapter, we will discuss the applica- tone. The author used thread in conjunction with
tion of short, cogged threads for nose augmenta- a micro fat transfer, first reported in 2003.
tion using numerous techniques. Multiple applications were available for this
procedure.
The author uses PP and PDO threads because
13.1 Introduction of their high elasticity and restoration forces. Both
threads can be used individually or together. The
Patients of Asian descent commonly have a rela- use of two to three USP threads together is highly
tively low dorsum, low nasal tip, short nose, effective. A 19 G needle (outer diameter, 1.10 mm;
wide alar, and short columella. The nasal tip skin inner diameter, 0.9 mm) is typically suitable for
is relatively thick and has dense fibroadipose tis- these threads. A thread labelled USP 0 can be
sue. The cartilage in the alar is small and fragile, inserted into a 21 G (OD, 0.8 mm; ID, 0.6 mm)
making the results of invasive rhinoplasties needle. In contrast, thermal molded cogged
unsatisfactory and with complications like threads are typically already solidified, such that
implant deviations or protrusions. Autologous even USP 0 thread requires 12 G needles.
rib cartilage can also be used as an alternative, The thread strength is dependent on the thread
but insufficient skin results in unsatisfactory thickness, cog angle, and cog length. The author
results. Therefore, the elongation of skin elastic- usually uses threads that are ~0.4–0.7 mm thick.
ity and hard structures should be performed. In The thread end is bifurcated at a ~ 2–4 mm dis-
this chapter we discuss the applications of PP tance, with cogs located in the opposite direction.
and PDO threads in embedded structures The thread axis is typically anti-compressive and
H. J. Yang
BaroYL Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 155
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_13
156 H. J. Yang and W. Lee
a b
Fig. 13.2 The types of anti-compressive barbed threads. (a) Three threads pushing each other between the nasal tip and
maxilla. (b) Multiple types of push-type barbed threads
not anti-tension (Fig. 13.1). The bifurcated thread 2. The ideal ratio of columella and infra-tip lob-
end is key to attain the anti-compression effect ule (2:1) can be achieved using thread lifting
(Fig. 13.2). (Fig. 13.3).
3. Soft tissue changes develop after tip plasties
The advantages for cogged thread rhino- and cause irregularities of the lobule and ala.
plasties as compared to conventional rhino- Cogged threads can be inserted in the alar
plasties are described below extension direction.
4. The nasal tip area elasticity can be main-
1. Major prominence of the tip is attained using tained when compared to conventional
a minimally invasive technique. rhinoplasties.
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 157
a b c
Fig. 13.3 Base changes using cogged threads. Photographs were taken: (a) preoperatively. (b) Immediately postopera-
tively. (c) 2 months postoperatively
b c
Fig. 13.4 The materials required for the operation. (a) The thread inserted at the disposable needle. (b) The injector.
(c) Disposable all-in-one needle and injector
a b
Fig. 13.6 The design. (a) The pre-op design. (b) Post-op results
26mm
13.4.3 Anesthesia
28mm
Epinephrine (1:100,000) with lidocaine is
used at the ala, columella, anterior spine, max-
30mm
illa, and nose dorsum area. Approximately
4–7 cc is used. The epinephrine is used for
32mm
vasoconstriction.
34mm
13.4.4 Thread Size Selection
Fig. 13.7 The length of the threads
and Injector Assembly
The thread is made of PP and PDO. PDO is used author usually uses threads that are 30 and 32 mm
for (1) increased length, (2) increased thickness long (Fig. 13.7).
(USP 2) resulting in immediate effects, and (3)
increased number of threads. PP is used for (1)
shorter lengths, (2) thinner threads (USP 0), and 13.4.5 The Locations of Thread
(3) a smaller number of threads. PP is used for and Direction of the Cogs
the elongation of the nasal tip, for which four to
six threads are inserted. The thread type and The insertion directions are as follows (Fig. 13.8)
length (usually around 26–34 mm) must be
decided based on the intended application. The 1. Tip projection direction.
160 H. J. Yang and W. Lee
a b
Fig. 13.8 The insertion direction. (a) Green arrows indicate the tip projection direction, blue arrows indicate the nose
length elongation, and yellow arrows indicate the alar extension direction. (b) The postoperative view
a b
Fig. 13.9 The insertion direction. (a) Supratip depression. (b) Postoperative results
The thread can be inserted multi-directionally When the cannula reaches the periosteum, the
for preoperative evaluations (Fig. 13.10). nasal tip must be pulled using the pinching hand.
The left hand is usually recommended to feel the
cannula end (Fig. 13.12).
13.4.6 Searching the Dense Tissues
(Periosteum, Perichondrium,
Cartilage, and Scar) 13.4.8 Thread Implantation
and Thread Tucking
The plunger is approached to the thread end
The cannula is inserted and approached until the and the injector pulled posteriorly for thread
periosteum area by pinching with the left hand. implantation. When the thread is implanted at
The fourth finger is used to feel the end of the approximately 12 mm, the plunger is released.
cannula (Fig. 13.11). The tip should be pulled using the left hand,
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 161
13.4.9 Multiple Implantation
13.4.10 Alar Extension
13.4.11 Adjunctive Procedures
Fig. 13.10 Preoperative evaluations using the pinching
technique
13.4.11.1 Fat Grafts (Fig. 13.17)
Fat grafts performed after tip projection using
threads can supplement the results. The nose dor-
sum soft tissue is relatively thin, making a multi-
layer graft challenging. The author prefers using
crushed fat injections at the superficial layer so
that multilayer grafts are easier to perform. These
grafts can be performed at the tip and columella
area after thread insertions (Fig. 13.18).
Fig. 13.12 Thread
implantation techniques
for tip projection
5~10mm
Central
12mm
Fig. 13.14 A tip plasty using cogged threads. (a) Preoperative images. (b) Immediate after the procedure. (c) At
1 month post-procedure. (d) At 1 year post-procedure
164 H. J. Yang and W. Lee
a b c
Fig. 13.16 Alar asymmetry correction. (a) Preoperative. (b) At 2 days post-operation. (c) At 10 weeks post-op
Fig. 13.17 Cogged thread tip projection and alar extension with fat graft. (a) Preoperative; retracted alar. (b)
Postoperative 6 weeks. (c) Postoperative 6 months
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 165
Fig. 13.17 (continued)
a b c
Fig. 13.18 Cogged thread tip projections and fat grafts. (a) Preoperative image, which also shows excessive hyaluronic
acid filler use. (b) At 2 weeks post-operation. (c) At 8 months post-operation
166 H. J. Yang and W. Lee
a b c
Fig. 13.19 Cogged thread tip projection performed concurrently with HA filler injection. (a) Preoperative image. (b)
Immediately after the procedure. (c) At 4 months post-procedure
a b
Lymphoid System
Fillers
Micro canal
vein flow
Cells
lymphvessel
wall
a b c
Fig. 13.22 Dressing. (a) Preoperative image. (b) Hydrocolloid applied post-procedure. (c) Taping
Fig. 13.23 A repeated procedure. (a) Preoperative image. (b) At 5 days post-procedure. (c) At 11 months post-
procedure. (d) Immediately after the secondary procedure. (e) At 4 months after the secondary procedure
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 169
Fig. 13.23 (continued)
Fig. 13.24 Alloplastic implant at the dorsum. (a) Preoperative image. (b) At 4 months post-procedure. (c) At 6 years
and 4 months post-procedure
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 171
Fig. 13.25 Implant removal and fat graft with cogged thread insertion. (a) Preoperative image. (b) At 1 month post-
procedure. (c) At 6 years post-procedure
172 H. J. Yang and W. Lee
Fig. 13.26 Revisional
a
rhinoplasties because of
dorsum swelling and
implant visibility at the
right nostril rim. (a)
Preoperative image. (b)
At 1 day post-operation.
(c) At 6 months
post-operation
c
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 173
Fig. 13.27 Patient undergoing implant removal. (a) Preoperative. (b) At 3 weeks post-procedure. (c) At 12 months
post-procedure
174 H. J. Yang and W. Lee
Fig. 13.28 Dissection. A scar tension band (red line) should be noticed and cutting (blue line) should performed
accordingly
4. Soft tissue scar contractures can occur, to (Fig. 13.30), for which minimal incisions and
varying degrees, at 4–6 months post- dissections are needed (Fig. 13.31).
procedure, usually performed with minimal
incision–dissection and thread insertions. Fat 6. Unsatisfactory results in the nose.
grafts are effective in the reduction of contrac-
tures (Fig. 13.27). There are multiple cases where the revisional
5. Implants like bone or rib cartilage, Medpor, or rhinoplasty might give unsatisfactory results.
Gore-Tex are typically used, using minimal Usually, the patient is informed, the operation is
incisions and dissections (Fig. 13.28). The delayed by 1 year, and autologous implants are
extent of dissection is dependent on the exten- used, in addition to minimal dissection. ADSVF
sion and vascularity due to the tip plasty. are used for treatment (Fig. 13.32).
Slow arterial refill and venous congestion are 1. Liposuction and centrifugation are done to
indicators of ischemia. Accurate comparisons extract the ADSVF by enzyme treatment.
should be made before local anesthesia, immedi- 2. The ADSVF is injected for improved vascu-
ately after, and 20 min after. At 20 min after the larity. This treatment is recommended three to
administration of local anesthesia injections, arte- eight times for 3–8 months.
rial refill can be an indicator to judge the extent of 3. The contracture is minimally dissected. If vas-
the dissection. When the capillary refill slows, dis- cular insufficiency is encountered, ADSVF is
sections should be minimal, followed by few min- injected.
utes of waiting. Tip plasties using cogged threads 4. ADSVF injections are recommended two to
are performed at the localized area increasing the three times post-operation.
extent of the ischemia, necessitating well-distrib-
uted pressure. Dissections should be performed Tip plasties have advanced, especially for the
lower than the dermal layer. Dissections using patient of Asian descent, who typically has weak
sharp Metzenbaum scissors are preferred tip cartilages. Procedures can be performed
(Fig. 13.28). Fat grafts or adipose derived stromal using alloplastic implants, which can cause com-
vascular fractions (ADSVF) could be done to plications. To avoid this, the author prefers to
reduce the risk of necrosis (Fig. 13.29). perform ADSVF injections and tip plasties using
When the implant extends to the tip area, a cogged threads instead of revisional incisional
partial removal needs to be performed rhinoplasties.
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 175
Fig. 13.29 Gore-Tex implant removal and fat graft with a tip plasty using cogged threads. (a) Preoperative image. (b)
Immediately post-procedure. (c) At 16 months post-procedure
176 H. J. Yang and W. Lee
Fig. 13.30 A partial removal of the implant with cogged thread insertions
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 177
Fig. 13.31 A partial removal of the implant and fat graft with thread insertion. (a) An L-shaped silicone implant. (b)
At 5 days post-op. (c) At 6 months post-op
178 H. J. Yang and W. Lee
Fig. 13.32 Secondary rhinoplasty. (a) Contracted nose. Minimally incisional dissections with fat grafts. (f) At
(b) ADSVF injection. (c) At 19-days post-ADSVF injec- 5 days post-op. (g) At 7 months post-op. (h) At 32 months
tions. (d) At 10 months post-ADSVF injections. (e) post-op
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 179
Fig. 13.32 (continued)
13.5 Education and Follow-Up sages. If the threads are visible, the patient must
Periods visit the clinic. Postoperative photographs must
be taken on postoperative day 1 and 5; week 2;
The patient needs follow-ups at postoperative months 1, 2, 4, and 6; and 1 year to monitor and
day 1 and day 5, followed by self-stretching mas- document the progress.
180 H. J. Yang and W. Lee
13.6 Self-Stretching Massages pressure and reduce the chance of thread expo-
sure (Fig. 13.33).
The skin should be manually stretched for skin
elongation, followed by a 1-min hold. This should
be done one to two times a day to redistribute the 13.7 Methods for Photometric
Evaluation
a b c
Fig. 13.34 True lateral photos for the TC/TP ratio measurement. (a) 2’ inward rotated. (b) optimal. (c) 2’ outward rotated
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 181
Fig. 13.35 Barbed thread tip implantation in a 29-year-old woman. The TC/TP increased by 5% of the original ratio
Fig. 13.36 Tip implantation using barbed threads and an autologous micronized fat graft in a 54-year-old woman. The
TC/TP increased by 3.6% of the original ratio
If the head is axially rotated 10° inwardly or (a) At 2° inward axially rotated, TC/TP ratio
outwardly, the errors would be less than 2%. would increase 2%, which was not optimal.
The stars indicate the key structures to decide
(b) A neutral true lateral view, which was
the axial head rotation: the external auditory optimal.
canal, eyebrows, eyelashes, and the Cupid’s (c) At a 2° outward axial rotation, the TC/TP ratio
bow. would decrease 2%, which is not optimal.
182 H. J. Yang and W. Lee
Fig. 13.37 A barbed thread tip implantation and autologous micronized fat graft in a 43-year-old woman. The TC/TP
increased by 1.9% of the original ratio
a b c
Fig. 13.38 Thread extrusion. (a) At 5 weeks post-op. (b) At 1 day pot-removal. (c) At 10 months post-removal
a b c d
Fig. 13.39 Thread extrusion. (a) Preoperative. (b) Immediately post-procedure. (c) PDO thread extrusion at 7 weeks
post-op. (d) PP thread extrusion at 9 months post-op
a b c
Fig. 13.40 Thread extrusion-induced depressive scars. (a) The scars. (b) At 5 days post-op. (c) At 1 year post-op
erative columella asymmetry tends to initial period. When the skin is thinner, protru-
develop extrusions at the mucosa. It is eas- sions can occur (Fig. 13.39). If thread extru-
ier to remove the mucosa because of the cog sions occur, a 21 G needle is used to make a
direction. hole, followed by removal using forceps.
Prolonged extrusions might develop infections
PDO threads might protrude for 2 months, or depressed scars. Postoperative depression
after which it is absorbed. PP threads are scars can be cured by micro fat transfers
shorter, and hence do not extrude during the (Fig. 13.40).
184 H. J. Yang and W. Lee
Fig. 13.41 The histology of a tissue biopsy sample taken small dots with navy color. (b) Masson trichrome stain for
4 months after using polydioxanone (PDO) threads. (a) collagen shows a cobblestone matrix with blue color
Hematoxylin–eosin stain for infiltrated cells, seen as
13 Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 185
14.1 Introduction
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 187
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_14
188 J. Y. Kim et al.
Table 14.1 The causes of double chin deformities the supraplatysmal fat compartment as the supra-
1 Submental fat hyoid sub-compartment and infrahyoid sub-
2 Platysma laxity compartment. The suprahyoid sub-compartment
3 Skeletal malformation is from the submental crease to the hyoid bone,
4 Location of hyoid bone while the infrahyoid sub-compartment is from
the hyoid bone to thyroid cartilage. The second
layer is the subplatysmal fat compartment,
14.2 Causes of a Double Chin located between the platysma and submental
muscle (digastric muscle and mylohyoid mus-
Double chins can be caused by multiple factors. cle). Rohrich et al. made their classifications
The first cause is excessive fat tissue located at according to the central, medial, and lateral com-
the submental area, wherein subcutaneous fat or partments. The central compartment, located
subplatysmal fat accumulation occurs. The sec- between the bilateral digastric muscle, should
ond cause is laxity of the platysma muscle, often not be removed because of depressive deformi-
attributed to aging but also reported in young ties. Larson et al. describes the lateral sub-
patients. The third cause is skeletal underdevel- compartment same as the medial and lateral
opment. Microgenia causes decreased submental sub-compartments as described by Rohrich et al.
deepening, resulting in a double chin. Fourth, the This approach divides the lateral sub-compart-
hyoid bone is located beneath or anterior from ment into upper and lower based on the hyoid
the normal levels [2–4]. The hyoid bone is usu- bone. The deepest fat layer is located deeper
ally located at the level of the fourth cervical than the digastric and submandibular glands and
bone, horizontal from the menton line. When the consists of small amounts, making it clinically
hyoid bone is located below, a double chin defor- insignificant.
mity is apparent. It is impossible to operate upon
the hyoid bone for aesthetic results. Patients The neck fat compartment (Rohrich et al.)
should be informed of the same. The causes for
double chins are complex and require treatments 1. Supraplatysmal compartment.
specific to the cause (Table 14.1). 2. Subplatysmal compartment: central, bilateral
medial, and bilateral lateral sub-compartments.
14.4 Techniques for Double Chin Thread lifting for neck contouring supports
Deformity the platysma muscle [14, 15]. Absorbable threads
have gained popularity recently. As described
There are multiple methods for the correction of previously, the aim of thread lifting should be
double chin deformities, such as lipo-dissolving supporting the muscles, for which elastic thread
solution injections, liposuctions, and submental is better, especially for double chin deformities
fat excisions with neck lifting. Thread lifting and [16].
corset platysma plasties are used to correct mus- Elastic thread lifts are performed such that
cle laxity. Fillers and fat injections, implant inser- silicone thread is surrounded by a polyester
tions, and sliding genioplasties are used to correct thread, and the consequent elasticity results in
skeletal deformities. In this chapter, we discuss more natural facial expressions after insertion.
the minimally invasive techniques. The needle is shaped such that the thread is
The first step is the estimation of the quantity located at the center of the needle (Fig. 14.2). A
of fat, done by pinching. Liporeductions usually long length of the thread can be inserted without
give good results when the quantity and thickness protruding from the skin. The needle is bilater-
of fat are high. The injection of deoxycholic acid ally maneuvered such that the thread can locate
is another recently developed technique [9–11]. the subcutaneous layer, and the needle half end
The Food and Drug Administration approved the can then be rotated to continue the thread inser-
use of deoxycholic acid for fat reduction in 2015. tion inside the subcutaneous layer. Needle ends
Deoxycholic acid destroys the adipose cell walls have indicators to locate the same depth of the
without affecting the skin and muscle. Therefore, needle (Fig. 14.3). Usually, the last indicating
it destroys adipose tissue rather than decreasing mark can be used for confirmation that the needle
volume and stimulates neocollagenesis by fibro- can be turned in the other direction.
blast activation. Thread insertions performed at the neck area
Liposuction is the traditional technique for fat should be done along the cervicomental angle. A
reduction [12, 13]. It is more invasive, and the slit incision should be made at the posterior ear-
results are also better, compared to those with lobe and the needle inserted. Precaution should
injections. Using a small entry point, liposuction be taken to avoid the lobular branch of the great
can be performed using the tumescent solution. auricular nerve pathway (Fig. 14.4). The starting
Usually, the supraplatysmal fat compartment is point should be near the platysma-auricular liga-
targeted for liposuction. However, the technique
should be performed at the diffuse area for skin
contracture and smooth contour lines in addition
to the specific fat compartment. The technique
can be performed using one single entry point at
the submental crease, but bilateral entry points
are recommended to perform even liposuction.
Concomitant liposuction for the lower face can
be performed for mandible borderline and super-
ficial jowl fat reduction. Laser-assisted fat reduc- Fig. 14.2 Schematic depicting the elastic thread
tion is another option for lower face contouring. structure
Fig. 14.3 Schematic
depicting the elastic
thread needle end
190 J. Y. Kim et al.
Case 1
See Fig. 14.10
Case 2
See Fig. 14.11
Case 3
See Fig. 14.12
Case 4
See Fig. 14.13
Case 5
See Fig. 14.14
Fig. 14.8 Alternate strategy for an elastic thread lift for
the neck Case 6
See Fig. 14.15
orly; therefore, a 3–5 mm anterior location at the
desired cervicomental line is needed during the
operation. The insertion layer is the deep
subcutaneous layer because a superficial layer
can cause dimples, while a layer too deep to the
platysma can render the process ineffective.
When the elastic thread is used at the cheek area,
there are increased occurrences of dimple forma-
tion. However, when used at the neck area, dim-
ples subside after a few days.
Microgenia is also associated with double
chin deformities, which can be improved using
chin augmentations. Fat grafts or filler injections
are simple methods for chin augmentation. The
injection layers are the supraperiosteal layer and
subcutaneous layer. When liposuction of the dou- Fig. 14.9 Preoperative pattern of the thread insertion
strategy. The desired cervicomental line (dotted). Two
ble chin area is performed, fat graft at the chin
parallel lines depict the elastic thread insertion. After
area can also be performed concomitantly after inserting the threads, they are pulled and located at the
centrifuging to harvest the fat from the double desired cervicomental lines
192 J. Y. Kim et al.
a b
Fig. 14.10 A 43-year-old woman. (a) Pre-procedure image. (b) Image taken 3 months after liposuction and elastic
thread lifting
a b
Fig. 14.11 A 49-year-old woman. (a) Pre-procedure image. (b) Image taken 3 months after laser-assisted liposuction
and elastic thread lifting
a b
Fig. 14.12 A 53-year-old woman with double chin and jowl laxity. (a) Preoperation image. (b) Image taken 3 months
after laser-assisted liposuction and elastic thread lifting
14 Submental Contouring Using Elastic Threads 193
a b
Fig. 14.13 A 30-year-old woman with microgenia and double chin deformity. (a) Preoperation image. (b) Image at
3 months after liposuction, elastic thread lifting, and chin augmentation using a fat graft
a b
Fig. 14.14 A 29-year-old woman with a double chin and microgenia. (a) Preoperation image. (b) Image at 3 months
after liposuction, elastic thread lifting, and chin augmentation using fat graft
a b
Fig. 14.15 A 41-year-old woman with excessive fat at the neck. (a) Image at preoperation. (b) Image taken 3 months
after liposuction, elastic thread lifting, and fat graft on the chin
194 J. Y. Kim et al.
a b
Fig. 14.16 A 51-year-old female with excessive fat at the neck area and an obtuse cervicomental angle. (a) Image at
preoperation. (b) Image taken 6 months after liposuction and elastic thread lifting
a b
Fig. 14.17 A 22-year-old female with excessive fat at the neck. (a) Image at preoperation. (b) Image taken 1 week after
liposuction and elastic thread lifting
14 Submental Contouring Using Elastic Threads 195
a b c d
Fig. 14.18 A 26-year-old woman with microgenia and thread lifting. Additional images taken at (c) postopera-
excess fat at the neck area. (a) Image at preoperation. (b) tion day 1. (d) Postoperation week 1
Image taken immediately after liposuction and elastic
15. Tiryaki KT, Aksungur E, Grotting JC. Micro-shuttle Anatomical description and significance in rhytidec-
lifting of the neck: a percutaneous loop suspension tomy. Plast Reconstr Surg. 2017;139(2):371e–8e.
method using a novel double-ended needle. Aesthet 18. Seo YS, Song JK, Oh TS, Kwon SI, Tansatit T, Lee
Surg J. 2016;36:629–38. JH. Review of the nomenclature of the retaining liga-
16. Kang MS, Kim SH, Nam SM, et al. Evaluation of ments of the cheek: frequently confused terminology.
elastic lift for neck rejuvenation. Arch Aesthet Plast Arch Plast Surg. 2017;44(4):266–75.
Surg. 2016;22(2):68–73. 19. Rozen WM, Whitaker IS, Ashton MW. Lore’s fascia
17. Sharma VS, Stephens RE, Wright BW, Surek CC. What and the platysma-auricular ligament are distinct struc-
is the lobular branch of the great auricular nerve? tures. Br J Plast Surg. 2012;65(9):e241–5.
Submental Liposuction
and Thread Lifting 15
Won Kyung Kang and Won Lee
15.1 Introduction toid muscle, and anterior from the hyoid bone
(Fig. 15.1) [2].
Neck shape varies across individuals. Neck laxity
is most commonly a by-product of aging but is Previous literature has established the
also observed in young patients. A sagging neck following criteria for aesthetic neck contour
ages an individual. In contrast, a tight neck makes [3, 4]
one look young. Submental liposuction is one of
the best minimally invasive procedures for neck 1. Distinct inferior mandibular border from the
contouring. mentum to angle.
2. Subhyoid depression.
3. Visible thyroid cartilage.
15.2 Anatomical Considerations 4. Visible anterior border of SCM.
5. Cervicomental angle between 105° and 120°
Liposuction can be performed at multiple loca- [2, 4].
tions on the face. It is relatively simple and mini-
mally invasive and therefore a commonly Apart from these five requirements, two addi-
performed procedure in plastic surgery [1]. The tional points related to the hyoid bone have to be
neck area is one of the places where liposuction added: (1) when the hyoid bone is located higher
can be performed. The anatomical considerations and (2) when the posterior cervicomental angle is
for the central submental unit are its location acute [3]. This makes the neck look more
below the inferior border of the mandible, lateral attractive.
from the anterior border of the sternocleidomas-
W. K. Kang
BORA Plastic Surgery Clinic,
Ansan-si, Kyonggi-do, Republic of Korea
e-mail: kangwk@paran.com
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 197
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_15
198 W. K. Kang and W. Lee
Submandibular triangle
Diagastric muscle,
anterior belly
Submental triangle
Sternocleido-
mastoid
Lesser supra-
clavicular fossa
Fig. 15.1 Central submental unit is located posterior from the mandible border and anterior from the hyoid bone
The author has also experienced this issue in solution can be injected using a 25G needle or
cases and recommends evaluating the subman- cannula.
dibular gland preoperatively. Lipo-aspiration can be performed using 2 mm
When the adipose tissues are dense or hard, cannulas. Irregularity must be considered during
the outcome is not predictable. Dense or hard the process. A bilateral entry point is
adipose tissue can occur due to large amounts of recommended. An additional entry point can be
fat tissue at the subplatysmal muscle and is hard made at the center of the neck, which is useful as
to remove by liposuction. Liposuction can also a thread lifting tunnel.
induce bleeding or nerve damage [7]. Lipo-aspirated fat should be collected for
The patients should also be warned about the additional possible fat grafts at the chin area.
limitations of minimally invasive procedures as At least 20-mm-long cogged threads should
compared to incisional operations. be used. When the center entry point is made
during liposuction, it should be used for thread
lifting. A relatively thick thread, such as the
15.4 Operative Techniques number 1 or 0 thread, should be used. The thread
should be inserted at the center entry point and
Photographs of patients showing the preoperative pulled out through the lateral entry point. When
anatomical features and the operative strategy one site of surgery is finished, the opposite site
design are taken at an upright position. Local should be managed using the same method.
anesthesia can be used for liposuctions and thread When the bilateral-side surgery is finished, both
lifting. Preoperative informed consent of the threads should be gently pulled laterally. The
patients is essential and local infiltration can be laterally extruded thread should fixate at the
applied. The entry point area is injected with mastoid periosteum or the subcutaneous layer
lidocaine. The entry point is used for the injection by needle sutures. Dimples should not occur at
of tumescent solution (followed by a 20-min the center entry point when the bilateral thread
wait) and can also be used for thread lifting. At is pulled laterally. If a depression occurs, use
the lateral sides of the neck, a 3 mm incision is forceps to release the dermal layer. The entry
made for the entry point using a number 11 or 15 points are not sutured so that blood or exudates
knife. The tumescent solution is formulated using can be drained (Figs. 15.3, 15.4, 15.5, 15.5, 15.6
saline, lidocaine, and epinephrine. The tumescent and 15.7).
Fig. 15.4 Pre-procedure strategy design for liposuction Fig. 15.5 Immediately after the procedure. The neck
and thread lifting contour is improved and the entry point wound is not
closed
Fig. 15.6 At postoperative day 2. Mild bruising and tap- noticeable. Swelling is frequently observed without high
ing marks are visible. The central entry point is not notice- compression
able without sutures. The lateral entry point is also not
Fig. 15.7 Images taken 3 years postoperatively (frontal and lateral view). Sunken and senile eyelid correction was
performed 2 years prior using sub-brow lift and orbicularis oculi muscle turndown transposition technique
15 Submental Liposuction and Thread Lifting 201
15.5 Postoperative Care due to the thread and subcutaneous tissue adher-
ing to each other. Thus, complications such as
Immediately post-operation, the entry points are bruising, swelling, hematoma, or seroma are rare.
opened for blood and exudate drainage. Mild tap- Increased patient satisfaction is usually observed
ing is performed, along with the use of gauze. due to the immediate results attributed to thread
Compressive garment tape can be applied. lifting. The disadvantage is the increased pain
Follow-up appointment is made 2–3 days after associated with thread cogs when the neck rotates
the procedure to apply dressing and hydrocolloid. to the right and left sides. However, the pain sub-
No taping is needed after 2–3 days. sides after 1 week or 10 days.
A preoperative platysmal band, called the
“pseudo-cobra neck deformity,” might be visible
15.6 Complications after liposuction, typically corrected by platys-
maplasties. Poorly performed liposuctions can
Postoperative bruising might occur. Partial bruis- induce dermal scar contracture, which are diffi-
ing is common and resolves after 1–2 weeks. cult to resolve [12].
Swelling also disappears by that time. When Previous literature describes additional sec-
swelling disappears, minimal irregularities or ondary liposuctions, but based on the author’s
asymmetries might be visible, which disappear experience, this does not occur frequently, as the
after some time. Gentle and careful liposuction is patient is usually satisfied with their results com-
required to avoid these side effects. Hematomas pared to the preoperative condition [6].
or seromas are the most common complications
associated with liposuctions and can be prevented
using appropriate dressings. Entry point scars are 15.7 Adjunctive Procedures
typically not noticeable.
The post-liposuction area tends to initially Preoperative informed consent from the patients
harden and soften again after 2–3 months. The should be obtained regarding the hardness of the
author believes that the cannula thickness also influ- postoperative subcutaneous layer. However, if the
ences the postoperative subcutaneous layer hard- patients still complain, low-dose injections of triam-
ness. The use of thicker cannula to remove large cinolone and hyaluronidase can be helpful. This can
volumes of fat at once causes increased hardness. be also used to resolve postoperative irregularities.
The possibility of nerve damage is very low At 1-month post-operation, high-frequency
and resolves within a few weeks [10, 11]. radiofrequency devices can also be used.
Thread lifting performed immediately after When the fat removal is under-corrected,
liposuction has advantages and disadvantages. high-intensity focused ultrasound (HIFU) can be
One of the main advantages is that the thread can useful 2–3 months after. HIFU can also be applied
eliminate the possible spaces after liposuction after 1–2 years (Fig. 15.8).
a b c
Fig. 15.8 Submental liposuction and thread lifting. (a) Preoperation image. (b) Image taken at postoperative month 18.
(c) Image taken 2 weeks post-HIFU. Adjuvant therapy can be applied for additional thickness
202 W. K. Kang and W. Lee
Many patients who opt for neck liposuctions facial rejuvenation. Philadelphia: Saunders; 2007.
p. 229–30.
tend to have microgenia, for which immediate fat 3. Chung JH, Williams EF. Facial suction lipectomy. In:
grafts performed using the fat harvested from the Babak A, et al., editors. Master techniques in facial
neck area can be helpful. Microgenia can also be rejuvenation. Philadelphia: Saunders; 2007. p. 231–2.
corrected by fat grafts, filler injections, or implant 4. Ellenbogen R, Karlin JV. Visual criteria for success
in restoring the youthful neck. Plast Reconstr Surg.
insertions performed later to achieve an acute 1980;66(6):826–37.
cervicomental angle. 5. Hetter GP. Improved results with closed facial suc-
tion. Clin Plast Surg. 1989;2:319–32.
6. Dedo DD. Management of platysma muscle after
open and closed liposuction of the neck in face lift
15.8 Conclusion surgery. Facial Plast Surg. 1986;4(1):45–6.
7. Gryskiewicz JM. Submental suction-assisted lipec-
Liposuction is a commonly performed technique tomy without platysmaplasty: pushing the (skin)
in the field of plastic surgery, which can be per- envelope to avoid a face lift for unsuitable candidates.
Plast Reconstr Surg. 2003;112(5):1393–405.
formed at the neck area to increase the attractive- 8. Morrison W, Salisbury M, Beckham P, Schaeferle III
ness and youthfulness of the neck. Neck area M, Mladick R, & Ersek R. A. The minimal facelift:
liposuction results are comparable to those of liposuction of the neck and jowls. Aesthetic plastic
incisional operation, mostly because of skin surgery. 2001;25(2):94–99. https://doi.org/10.1007/
s002660010103.
accommodation and skin contracture effects [13]. 9. Fattahi TT. Management of isolated neck defor-
The author has performed neck liposuctions in mity. Atlas Oral Maxillofac Surg Clin N Am.
mid-1990s, followed by the use of cogged threads 2004;12(2):261–70.
in 2015, which has improved the results. 10. Knize DM. Limited incision submental lipec-
tomy and platysmaplasty. Plast Reconstr Surg.
2004;113(4):1275–8.
11. Tapia A, Ferreira B, Eng R. Liposuction in cervical
References rejuvenation. Aesthetic Plast Surg. 1987;11(2):95–100.
12. Chung JH, Williams EF. Facial suction lipectomy. In:
1. American Society for Aesthetic Plastic Surgery Babak A, et al., editors. Master techniques in facial
Statistics, 2020. rejuvenation. Philadelphia: Saunders; 2007. p. 243.
2. Chung JH, Williams EF. Facial suction lipectomy. 13. Joel JF. Neck lift. Saint Louis: Quality Medical
In: Babak A, et al., editors. Master techniques in Publishing, Inc.; 2006. p. 29–31.
Short Scar Rhytidectomy
Combined with PDO Threads 16
Soo Yeon Park, Kyu Hwa Jung, and Won Lee
Thread lifting has recently become one of the more specific operations of SMAS such as dual
most performed minimally invasive procedures. plane and deep plane techniques [1]. The supe-
However, it might have relative short longevity rior technique for operating on the SMAS layer
and less effectiveness as compared to conven- has been long questioned. However, the SMAS
tional facelifts. However, conventional facelifts operation is evidently superior to subcutaneous
frequently result in surgical scars. Here we intro- skin excision techniques. In contrast, skin-based
duce short scar rhytidectomies with thread lift- facelifts are advantageous in terms of short oper-
ing, which result in minimal scars and increased ation times and fast recovery times.
effectiveness. There are differences between conventional
facelifts and thread lifting. Incisional facelifts can
remove excessive skin. The main purpose of
16.1 Introduction thread lifting is the repositioning of descended fat
tissue, accompanied by skin tightening. Thus, to
Skin loosening, fat compartment descent, defla- maximize the effects of thread lifting, fat reposi-
tion, and bony absorption are the features of face tioning should be performed effectively. The pre-
aging. Bony absorption can be reinforced using vious literature has described that thread lifting
implant insertions; deflation can be corrected has relatively short longevity and is less effective,
using fat grafts or filer injections. Loose skin can and possible complications such as dimples occur.
be tightened by performing direct skin excisions Short scar rhytidectomies are the combination
such as conventional facelifts. Facelift techniques of traditional facelifts and thread lifting. It can be
are developed from subcutaneous face lifting, performed in patients who have already under-
which involves the excision of subcutaneous tis- gone conventional facelifts. Limited literature
sue, superficial musculoaponeurotic system exists describing the relevant techniques. The
(SMAS) plication, and MACS lift, in addition to pure suture suspension technique is minimally
invasive technique but has decreased long-term
S. Y. Park efficiency because of soft tissue stress relaxation
MadeYoung Plastic Surgery Clinic, Seoul, Republic [2]. Mesh-type thread suspension has been
of Korea described by another study [3]. Threads should
K. H. Jung be easy to use effectively for doctors. Thus, the
Liting Plastic Surgery Clinic, Seoul, Republic of Korea author uses floating-type bidirectional cogged
W. Lee (*) threads. The author made dissections for
Yonsei E1 Plastic Surgery Clinic, increased tissue mobility and used threads for
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 203
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_16
204 S. Y. Park et al.
distal part lifting, which can result in volume dis- Conventional facelifts should be used to address
tribution and quick facial tightening. Minimal prominent skin laxity. Patients with prominent
incisions combined with well-designed thread zygoma should also avoid this procedure.
lifting are advantageous in terms of subcutaneous The patients should be evaluated in the upright
dissection locking effect, which can be explained position. The fat compartments such as the malar
by supporting, anchoring, and tissue reaction fat pads, jowl fat pads, and cheek fats should be
using threads. considered for lifting. Incisions should be made
at the hairline horizontal line from the eyebrow
for thread fixation. Ascertaining the sagging
16.2 Operation Technique areas and tissue mobility should be done manu-
ally. A virtual line is typically drawn from the
16.2.1 A Schematic Depicting lateral canthus to mandibular angle. Two points,
the Preoperative Procedure most prominent by pinching, are made between
Design for Short Scar the arcus marginalis and zygomatic ligament,
Rhytidectomies (Fig. 16.1) considered for the malar fat pad. A line parallel to
the Frankfurt line from the otobasion inferius is
Preoperative evaluations are imperative. Mild made, followed by cross points between the line
skin laxity and/or mild to moderate fat sagging in and LM line. The most prominent area is ascer-
patients is/are indication(s) for this procedure. tained by pinching, to decide the need for jowl fat
lifting. Two points are marked between the oto-
basion inferius and the LM line point 4, which is
the lateral cheek fat. Reverse techniques are per-
formed in which the threads are directed to the
temple area, such that the gathered tissues accu-
mulate at the temporal fossa rather than the
zygoma area. Increased fixation can be done at
the temporal fascia.
16.2.2 Anesthesia
temporal medial
Fig. 16.4 Preoperative a b
and postoperative views
in a 59-year-old woman.
(a) The preoperative
frontal view. (b) The
frontal view at 2 weeks
postoperatively. (c) The
preoperative lateral view.
(d) The lateral view at
2 weeks postoperatively
c d
a b
c d
Fig. 16.5 Operative evaluation in a 65-year-old woman. (a) The preoperative frontal view. (b) The frontal view at
2 weeks postoperatively. (c) The preoperative lateral view. (d) The lateral view at 2 weeks postoperatively
a b c
d e f
Fig. 16.6 A 47-year-old woman who underwent short postoperatively. (d) The preoperative lateral view. (e) The
scar rhytidectomy using polydioxanone (PDO) threads. lateral view at 2 weeks postoperatively. (f) The lateral
(a) The preoperative frontal view. (b) The frontal view at view at 1 month postoperatively
2 weeks postoperatively. (c) The frontal view at 1 month
208 S. Y. Park et al.
a b c
d e f
Fig. 16.7 A 42-year-old woman who underwent short A preoperative three-quarter view. (e) A three-quarter
scar rhytidectomy with PDO threads. (a) A preoperative view at 2 weeks postoperatively. (f) A three-quarter view
frontal view. (b) A frontal view at 2 weeks postopera- at 6 months postoperatively
tively. (c) A frontal view at 6 months postoperatively. (d)
Infections can occur in the temporal incision 16.4.3 Malar Prominence and/or
area, mainly attributed to hair. When hair is mis- Worsening of Mid-Cheek
takenly inserted with thread into the subcutane- Groove
ous layer of the scalp, inflammation occurs. Short
scar rhytidectomies usually don’t require hair Malar prominence usually occurs due to tissue
shaving due to the short recovery times, necessi- gathering at the malar area. It is likely to subside
tating extra precaution. When the thread is over time, but the patients should be warned of
located near the dermal layer, granulomas can the symptoms 2–4 weeks prior to surgery
occur. Pulling and cutting the remnant threads is (Figs. 16.8 and 16.9). Thread lifting focused on
an effective preventive technique. Antibiotics sub-zygoma depression correction is likely when
should be administered for infections. If the the zygoma is prominent before surgery.
16 Short Scar Rhytidectomy Combined with PDO Threads 209
a b
c d
Fig. 16.8 Prominent zygoma in a 48-year-old woman. (a) A preoperative frontal view. (b) A frontal view at 2 weeks
postoperatively. (c) A preoperative three-quarter view. (d) A three-quarter view at 2 weeks postoperatively
a b c
d e f
Fig. 16.9 Prominent zygoma in a 66-year-old woman. (d) A preoperative three-quarter view. (e) A three-quarter
(a) A preoperative frontal view. (b) A frontal view at view at 2 weeks postoperatively. (f) A three-quarter view
2 weeks postoperatively showing the prominent zygoma. at 2 months postoperatively
(c) The prominence subsided at 2 months postoperatively.
210 S. Y. Park et al.
Thread must be checked for appropriate burying, This is the most frequently observed complica-
as it can protrude when thread is cut very shortly. tion. The superficial temporal artery can detour
At the temple area, thread loop fixation should be by palpation or Doppler ultrasound. Due to the
performed at the deep temporal fascia unless numerous blood vessels in the face, hematomas
there is a possibility of migration. When the or bruising might occur. Compressions must be
thread is palpable or protruded, immediate commenced immediately.
removal is required. If migration occurs, com-
plete removal is recommended.
16.4.6 Parotitis
16.4.4.1 Dimple Formation
Postoperative skin irregularities can Parotid gland injuries are rare but can occur, usu-
spontaneously resolve. However, dimples can ally identifiable through pin-like sensations dur-
occur at the entry point (Fig. 16.10). When ing eating and swelling after eating. When the
dimples occur minimally, spontaneous resolu- symptoms are prolonged, skin fistulas can
tion is likely. However, severe dimples should develop. Conservative treatment strategies such
be removed immediately, except for consequent as antibiotic and anti-inflammatory drugs are
fibrosis-
associated scars. Relative large cogs needed for 2–3 weeks.
tend to have higher possibilities of dimple
formation.
16.4.7 Neuropraxia
16.4.8 Relapse
Thread lifting is a popular minimally invasive When the patients have excess skin, conven-
procedure to achieve antiaging effects. However, tional rhytidectomies are recommended. When
the procedure is associated with several compli- patients have excess fat at the lower face, liposuc-
cations, which will be discussed in this chapter, tion is recommended. In patients with volume
in addition to methods of prevention and effec- deficiencies, fat grafts or filler injections are rec-
tive treatments. ommended [2]. Patients with sub-zygoma depres-
sions are also treated with fat grafts or filler
injections because the jowl fat reposition is usu-
17.1 Introduction ally not sufficient to fulfill the sub-zygoma
depression. Patients with prominent zygoma
Prevention is the most important factor for com- should exercise caution for thread lifting. Skin
plications associated with thread lifting. It is thickness is also a consideration. Patients with
important to evaluate the contraindications for irregularities after previous operations or thread
every patient. For example, excess skin laxity lifting should opt for thin threads rather than
patient is a contraindication of thread lifting. thick threads.
Excessive fat on the face also renders the proce- Dissatisfaction, bruising, sensory changes,
dure ineffective [1]. Who is the best candidate of and irregularities are the complications most fre-
thread lifting? The author has established an quently associated with thread lifting complica-
algorithm to evaluate the patient before the pro- tions [3]. The incidences are also dependent on
cedure (Fig. 17.1). the expertise of the person performing the proce-
Y. Lee
LIKE Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 213
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_17
214 Y. Lee and W. Lee
Liposuction
high Laser
lipolysis
Soft tissue
volume
Thick thread
average thick
low yes
Filler or fat Skin
injection thickness
yes
no refuse thin
Subzygoma
depression Thin thread
no
yes
Malar
protrusion
Fig. 17.1 Algorithm for selecting the optimal thread lifting procedure
a b
Fig. 17.2 Left buccal hematoma after thread lifting. (a) Immediately after thread lifting. (b) 7 days after thread
lifting
a b c d
Fig. 17.3 Zygoma prominence and swelling after thread lifting. (a) Preoperatively. (b) At 3 days postoperatively. (c)
At 2 weeks postoperatively. (d) At 5 months postoperatively
a b
Fig. 17.5 Irregularities at the thread pathway. (a) Preoperatively. (b) Immediately postoperatively
a b
Fig. 17.6 Dimple formation at the entry point of volumizing thread insertion. (a) Preoperatively. (b) At 7 days
postoperatively
17 Complications of Thread Lifting and Treatments 217
Ear
Useless
Best
Jowl
Deep
High irregularity risk fat
OO
GW
ON
EY
LE Deep fascia
SMAS
Skin
mended. The mechanism should lift jowl fat or When the thread is pulled hard to increase the
nasolabial fat which is superficial fat compart- lifting effect, dimples can occur, requiring mas-
ments, and when the thread is inserted in the deep sages. Appropriate pulling is preferred, i.e., pull
layer, the effectiveness is minimized (Fig. 17.7 until massage is not needed.
blue dot line). The ideal layer is near the SMAS Mild dimples, frequently observed immedi-
layer. However, insertions in the same layer con- ately after the procedure, tend to resolve after
stantly is difficult and the relationship with facial the swelling subsides because of facial
structure should also be considered. The thread expressions.
should be near the skin at the entry point and
should be inserted deeply when passing the zygo-
matic arch area to prevent dimples. Finally, the 17.2.4 Nerve Dysfunction
thread end should be located at the superficial fat
compartment, which is the main target for lifting. When nerve dysfunction occurs, both the patient
The fixation portion of the thread is defined as and doctor tend to panic. Nerve dysfunction due
the anchoring portion, and the lifting portion of to the thread can exceed a month and might
the thread can be defined as the soft tissue hold- require the removal of the inserted threads [6].
ing portion (Fig. 17.8). The lifting effect and However, cogged threads are not easy to remove,
complications are dependent on the balance necessitating extreme precautions to prevent this
between these two portions. The anchoring por- side effect. When thread insertion is performed at
tion should be less than the soft tissue holding the sub-SMAS layer, the insertion should be done
portion because it is usually a harder structure, more gently because the motor nerves tend to run
providing support and strength. In contrast, the through the sub-SMAS layer. However, as previ-
holding portion is usually near the skin, so large ously mentioned, insertions done too superfi-
amounts of thread should be at this portion. cially might result in dimples.
218 Y. Lee and W. Lee
Ear
Zygomatic arch
Anchoring
portion
Anchoring
portion
Soft
tissue
holding
portion Soft
tissue
Jowl holding
Deep portion
fat
OO
GW
ON
LE
EY Deep fascia
SMAS
Skin
Fig. 17.8 Balance between the anchoring portion and soft tissue holding portion of the thread
For anesthesia, lidocaine is injected, and con- procedures where multiple and thick cogged
sequent sensory dysfunction might occur. threads are used. Pain is reported in the perioral
However, sometimes motor dysfunction might area and neck area, lasting between 1 day to
occur and should resolve within a day. The 2 weeks post-procedure. Increased pain is associ-
possibility of motor dysfunction increases with ated with thread insertion into the premasseteric
increasing concentrations of lidocaine. Therefore, space because it is a gliding plane during masti-
the use of tumescent solution rather than the 2% cation or opening the mouth. Thus, thread inser-
lidocaine alone is recommended. Motor dysfunc- tion is recommended in the SMAS area near the
tion occurs at the ipsilateral face. When the fron- premassteric space.
tal branch of the facial nerve is involved, the In thread lifting at the neck area for double
eyebrows cannot move and eye opening could be chin deformities, pulling the bilateral thread
impacted. When the zygomatic or buccal branch tightly can tighten the center of the neck area,
is involved, an unnatural facial appearance could resulting in a tight sensation [7]. Precaution
occur during smile or opening the mouth. should be exercised around the great auricular
nerve, located in the sternocleidomastoid muscle
fascia (Fig. 17.9) [8].
17.2.5 Pain Pain killer prescriptions and refraining from
opening the mouth too widely can help reduce
Pain can occur immediately pot-procedure but pain. Over time, the thread tends to harmonize
also persist afterward. Pain is more likely in the with tissue and reduce pain symptoms.
17 Complications of Thread Lifting and Treatments 219
b
17.3.2 Thread Protrusion
a b
Fig. 17.10 Thread protrusion. (a) Protrusion is noticeable when smiling (blue circle). (b) Partially removed threads
a b c
Fig. 17.11 Thread protrusion. (a) Protrusion when expressed. (b) Minimal stab incision for removal. (c) Removed
threads
a b c
Fig. 17.12 Patient with thread insertions. (a) Wide dorsum after thread insertion. (b) Thread removal during rhino-
plasty. (c) Removed threads
17.3.3 Penetration of Glands These glands are covered with deep fascia,
making them difficult to penetrate. Sharp needles
The penetration of glands is one of the most seri- or cannulas can effectively penetrate the glands.
ous complications associated with thread lifting. Additionally, when the patient feels pain, they are
The parotid gland can be perforated during face likely to clench the masticatory muscle, causing
lifting, and the submandibular gland can be per- gland penetration (Fig. 17.15).
forated during double chin correction using Swelling occurs for 2–7 days in addition to
thread insertion (Figs. 17.13 and 17.14). localized infections. Symptoms are likely to
17 Complications of Thread Lifting and Treatments 221
Body contouring is an important field of plastic A beautiful buttock should fulfill the
surgery. Thread lifting is commonly used for following criteria (Fig. 18.1) [3]
facial lifting but also can be used for body con- 1. Bilateral prominent dimples, one on each
touring. In this chapter, we will discuss hip lifting side of the medial crest, which is a part of
using threads and fat grafts. We will also discuss the posterior superior iliac spine.
the anatomy and esthetic unit of the gluteal area. 2. A V-shaped sacral triangle starting from the
end of the gluteal crease toward the dimples.
3. Infragluteal fold not exceeding two-thirds
18.1 Introduction of the medial posterior thigh.
4. Two shallow depressions caused by the
The criteria defining beauty have changed over the great trochanter.
decades. It also varies across countries, cultures,
race, and so on. However, the buttock is one of the Furthermore, the “ideal” waist-to-hip ratio for
most important contributors to a person’s overall women is considered 0.67–0.7%. The waist-to-
beauty, and gluteal surgery is one of the most rap- hip ratio and lumbosacral curvature also contrib-
idly growing fields of plastic surgery. A total of ute to the overall esthetics for beauty.
17,245 surgeries were performed in the United
States alone in 2015, which were a 29% increase
compared to 2014 [1]. The International Society of
Aesthetic Plastic Surgery reported more than
30,000 cases were performed in 2018 [2].
What is an esthetically beautiful buttock?
Y. C. Jung
Hershe Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea Fig. 18.1 Criteria for a beautiful buttock
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 223
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_18
224 Y. C. Jung and W. Lee
Fig. 18.2 The
important ligaments of
buttock lifting
18.4 Thread Lifting Technique During deep insertion, the thread may involve the
gluteus maximus muscle. In such instances,
The entry point for thread perforation should be patients will experience muscle pain, and the sur-
located at the sacrocutaneous ligament geon may notice muscle twitching. When this
(Fig. 18.2), 1 cm above the sacrocutaneous liga- happens, the cannula should be retracted slightly
ment. A total of four to five entry points are made, and reinserted into the deep subcutaneous plane,
and 20–30 mL of tumescent solution is inserted parallel to the muscle. Because the buttock area
at each entry point, totaling 100–150 mL in the comprises large and heavy soft tissues, a single
ipsilateral buttock. Mild massage is recom- thread may be inadequate for soft tissue gather-
mended to ensure even distribution. ing. While maintaining the tension in the left
The lifting vector should be superomedial to hand, another thread is inserted through the same
gather gluteal soft tissue (Fig. 18.4) and three to entry point in a different direction. Similarly,
four threads are inserted at each entry point. three to four additional threads are inserted
When inserting a thread, the tissue was through the same entry point but in different
grasped with the left hand 1 cm below the entry directions. This procedure is repeated for the
point at the ischium (already marked before sur- remaining entry points along the sacral triangle.
gery). The thread was inserted while maintaining To avoid pain in the sitting position, the thread
tension in the left hand, such that it penetrated the should not be inserted below the ischial line. Skin
deep fat layer and superficial fascial system. The dimpling that cannot be immediately released
cannula tip should not be located near the skin may occur (Fig. 18.5). However, it will subse-
area because of skin dimpling. Furthermore, the quently relax with the overall contouring of the
lifting vector must be considered while gathering buttocks after all the threads have been inserted.
the soft tissue in the superomedial direction. After surgery, immediate results can be observed.
Previously lifting was performed to lift the
gluteal soft tissue, against gravity (Fig. 18.6)
using three to four thread insertions.
More effective posterior projection is needed
to gather the upper medial area. The entry points
are made at the lateral margin of the sacral trian-
gle (Fig. 18.7). Natural lateral depression also
occurs.
The thread lifting strategy is designed such
that four divisions can be made at the buttock
Fig. 18.5 Dimple formation during the procedure Fig. 18.6 Gluteal thread lifting strategy
226 Y. C. Jung and W. Lee
18.6 Thread Lifting and Fat Graft The patient’s pain feel is controversial, as
reported previously [6].
Tumescent solution with 1% lidocaine and What are the advantages of fat graft and thread
1:100,000 epinephrine is injected in the prone lifting performed together (Fig. 18.11)? First,
position. The donor site is also injected with the those who want buttock lifts tend to have less fat,
tumescent solution. The entry point for fat injec- so fat graft is performed, usually first, followed
tion is near the infragluteal fold and around the by thread lifting. Threads are structural supports.
sacral triangle, which is the same as that for Second, relatively small quantities of fat can be
thread insertion. The fat graft is placed in the harvested to reduce donor site morbidity. Third,
upper medial side for projection. After the fat the relatively small amount of fat can create an
graft, thread lifting is performed considering the effective posterior projection.
vector. Gluteal fat injection mortality is approxi- Since the SNS was developed, patients desire
mately 1/3000 patients. The causes of fat embo- a reduced flank and big, round buttocks
lisms are explained by two theories. First is the (Fig. 18.12).
direct cannulation theory wherein bolus fat is Fat graft can be performed in the upper but-
injected into a valveless vein. Second is the lac- tock area using threads. The esthetic aspects must
eration siphon theory. be considered in addition to the patient’s desires.
Large volumes of fat have been typically In the esthetic unit, the zone 5 outer leg and zone
injected into the gluteus muscle. Therefore, pre- 9 inferior gluteal/posterior leg junction are
vious research describes local anesthesia per- esthetically superior when shallow.
formed for fat grafts in the subcutaneous layer The posterior projections should be performed
and that patients feel pain when the cannula in the upper medial direction of thread insertion
passes the gluteus maximus fascia. Therefore, a (Fig. 18.13). Fat grafts are performed for
more superficial approach can be performed [5]. augmentation.
228 Y. C. Jung and W. Lee
18.7 Cases
Case 1
See Fig. 18.14
The danger zone should be considered. Fat
injections are not recommended in this area
(Fig. 18.15).
Case 2
See Fig. 18.16
Case 4
See Fig. 18.18
Case 5
See Fig. 18.19
230 Y. C. Jung and W. Lee
Fig. 18.14 A 46-year-old woman underwent a fat graft and thread lifting
Fig. 18.16 Thread lifting and fat graft, pre-op (Lt), at 2 weeks post-op (middle), at 3 months post-op (Rt)
232 Y. C. Jung and W. Lee
Fig. 18.17 A 400 mL fat graft and thread lifting. Pre-op (Lt), at 1 week post-op (middle), at 3 months post-op (Rt)
18 Body Contouring Using Threads and Fat Graft 233
Fig. 18.18 A 300 mL fat graft and thread lifting. Pre-op (Lt), at 2 weeks post-op (middle), at 3 months post-op (Rt)
234 Y. C. Jung and W. Lee
Fig. 18.19 A 300 mL fat graft and thread lifting. Pre-op (Lt), at 1 week post-op (middle), at 1 month post-op (Rt)
18 Body Contouring Using Threads and Fat Graft 235