Nghệ Thuật Và Khoa Học Căng Da Bằng Chỉ: Dựa Trên Giải Phẫu Pinch (The Art and Science of Thread Lifting)

13/10/2026 • by Bs CKI Phẫu thuật tạo hình, tái tạo và thẩm mỹ Trương Hoài Anh •

Tài liệu đỉnh cao về kỹ thuật căng da bằng chỉ (Thread Lifting) từ các chuyên gia Hàn Quốc. Cuốn sách kết hợp giữa nguyên lý giải phẫu cơ mặt ứng dụng (Pinch Anatomy) và nghệ thuật thẩm mỹ để tối ưu hóa hiệu quả nâng cơ, giảm nếp nhăn và hạn chế tối đa rủi ro biến chứng.

📂 Chuyên mục: Tài liệu thẩm mỹ, Thẩm mỹ nội khoa, Trẻ hóa da

🏷️ Từ khóa: căng da bằng chỉ, thread lifting, trẻ hóa khuôn mặt, nâng cơ, giải phẫu vùng mặt

📖 Xem bản dịch / Nội dung văn bản

123
Based on Pinch Anatomy
Bongcheol Kim
Seungmin Oh
Wonsug Jung
The Art and Science
of Thread Lifting

The Art and Science of Thread Lifting

Bongcheol Kim • Seungmin Oh
Wonsug Jung
The Art and Science
of Thread Lifting
Based on Pinch Anatomy

ISBN 978-981-13-0613-6 ISBN 978-981-13-0614-3 (eBook)

Library of Congress Control Number: 2018960879
© Springer Nature Singapore Pte Ltd. 2019
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Bongcheol Kim
Lamar Clinic Isu Branch
Seoul
South Korea
Wonsug Jung
Department of Anatomy
Gachon University College of Medicine
Incheon
South Korea
Seungmin Oh
ON Clinic
Seoul
South Korea

v
Looking back to when I first started thread lifting, it was at a point in my career
when I was deeply engrossed in looking for different methods to help patients
look younger. Of course, the surgical approach would be most ideal and effective,
but these surgical techniques are not realistically possible to do in an aesthetic
clinic. Therefore, I naturally became interested in lifting using absorbable threads.
Date:
Name:
Thread:
Age:
Temporal muscle hypertrophy (
)
Temporal hollowness (
)
Zygomatic bone prominence (
)
Zygomatic bone op scar (
)
Jaw surgery

(
)
Sunken cheek

(
)
Liposuction

(
)
Acnescar

(
)
Thread lifting / HIFU
(
)
Masseter muscle hypertrophy (
)
Marionette line

(
)
Cheek fat

(
)
Submental fat

(
)
Lat. Canthus elevation
(
)
Asymmetry

(
)
Zygomaticus muscle action (
)
Simulation vector
(
)
Patient’s demand:
Effect:

Starting with simple absorbable mono-thread procedures, I passed through
many stages of research and experience finally bringing me to this point now
where I feel the need to share my journey and knowledge with the medical
community.
The above figure is a chart I developed from the accumulation of my clini-
cal and anatomical experience and knowledge which can be used to plan
thread lifting procedures. Many discussions and sharing with other medical
doctors have also contributed to the completion of this chart.
Foreword

vi

In my early years of using threads, I would attend numerous thread lifting
seminars and spend the whole night pondering and working out endless ques-
tions and problems in my head. However, since threads were new and there
were very little published information on them, it was very difficult to find
clear evidence-based explanations to my questions. Most doctors would just
say that you need to try it for yourself to find the answer.
I decided that the only choice was to experiment myself and continue to
research with other colleagues to find the principles I was looking for. The
above figure shows schematically the lifting mechanism of bidirectional cog
threads. It depicts very simply how bidirectional cog threads can create a lift-
ing effect.

The photograph shows the lifting effects created by bidirectional cog
threads in porcine tissue. As seen in the experimental porcine tissue, I tried to
prove what only existed in my mind through actual experimentation. I still
remember the joy of being able to physically prove the hypothetical reality
and theory which existed in my mind.
Foreword

vii

As my research accumulated one by one, the answers to ‘what are the
more effective and safe thread lifting methods’ began to emerge.
One of them was to know how to pull the skin effectively to minimizing
damage to blood vessels and nerves.
Skin layer
Subcutaneous Fat
Fascia layer

The process of compiling results and knowledge through research and
experimentation studies was very difficult and challenging. However, as time
passed by, these results started to form into a more organized system.
Foreword

viii
Skin (Derma)
Subcutaneous
Fat
Show changes afterwards. Dimpling

It took numerous hours to write this book for the purpose of introducing
safe and effective methodology to perform thread lifting. We hope that this
book will serve to assist many doctors who are currently experiencing difficul-
ties with thread lifting and who would like to perform these procedures after
understanding the underlying mechanisms of thread lifting. We also sincerely
hope that all doctors who read my book do not have to experience the difficul-
ties which I had to go through to learn safe and effective thread procedures.

I would like to note that this book also contains experimental results of the
authors and their hypotheses. These will be areas requiring further research in
various fields in the future.
Foreword

ix
Through publishing this book, we also hope to make a meaningful rela-
tionship with many other doctors around the world who are interested in fur-
thering the expertise in this field of aesthetic medicine. We also look forward
to seeing more future publications which can build upon and surpass the con-
tent we have set forth here.
Seoul, South Korea
Bongcheol Kim
Seoul, South Korea
Seungmin Oh
Incheon, South Korea
Wonsug Jung
Foreword

xi
Since we gathered with mutual desire of pursuing a goal of writing a book on
thread lifting, several seasons have passed. Time to time, when the progress
was slow and resolution could not be made, we encouraged each other to
reach this place. To complete writing within a set period, we often become
very tired of working restlessly. However now, we are at our final destination.
Without the mutual trust in each other, we do not think we could have arrived
here.
The biggest gift from writing this book may be the mutual trust in each
other. Although there are remaining areas yet to be completed and to be fur-
ther researched, we think that this would be helpful to those doctors who are
interested in thread lifting. We would like to first thank our families who sup-
ported and encouraged us and stayed by our side as we wrote this book. Also,
we are grateful to various doctors who helped us in obtaining knowledge in
threads. Dr. Jihyun Lee helped us in dissection of cadavers and tissue pro-
cessing. Especially, we would like to give many thanks here to Dr. Kwan
Hyun Youn who completed the excellent anatomy illustrations with much
effort. We promise to ourselves through this book we will continue to try with
the attitude of studying continuously in the future, and we hope to contribute
to brightening the bigger world for the cosmetic medicine of Korea.
Co-authors:
Seoul, South Korea
Seungmin Oh
Seoul, South Korea
Bongcheol Kim
Incheon, South Korea
Wonsug Jung
Note of Appreciation

xiii
There has been inadequate high quality studies conducted on absorbable
thread lifting. It is difficult to find studies that clarify the mechanism and
studies regarding its effect are still in progress. Physicians inevitably have no
choice but to refer to studies on non-absorbable thread lifting. Nevertheless,
knowledge of facial anatomy can be applied to lifting threads regardless of its
bio-absorbability.
According to Mendelson, the face is divided into the mobile frontal and
the fixed lateral regions, which are separated by the vertical line from the
lateral canthus. To ensure successful non-absorbable thread lifting outcomes,
it is important to have a solid understanding of the distinctive characteristics
of each region.
Recently, interesting results have been published from research conducted
in Korea. In this study, cog and twin threads were placed and the patients
were followed over a period of 24 weeks. Clinical improvement in both lift-
ing and quality of skin texture was observed but satisfaction was higher for
quality of skin texture than for lifting. The authors of the study attribute the
lower satisfaction in lifting to the lack of anchoring.
Lifting effect is contingent upon anchoring. Inserting mono-threads or
inserting cog threads in the subcutaneous layer and simply tugging will not
yield sufficient lifting effects. For effective lifting results, a thorough under-
standing of fixation points is necessary. Therefore, the authors focus first and
foremost on fixation points in this book.
On the other hand, there is a study that states that regardless of the plane
of thread insertion, deeper tissue repositioning and augmentation is necessary
to induce lifting. This is a very important point.
Analysis of structural changes with aging show that reduction in volume is
a major factor in aging. Therefore, antiaging/rejuvenation treatments such as
filler injections that replenish lost volume yield good clinical outcomes.
These procedures are generally called “volumizing-lifting”. Adding lost vol-
ume with fillers or autologous fat has the effect of shifting the deeper tissues
via augmentation.
Volumizing using fillers and other materials is definitely an effective pro-
cedure. However, in patients with ptosis of skin and fat tissue due to lack of
elasticity associated with aging, volumization procedures alone may not be
effective. In such cases, performing volumizing procedures in conjunction
with lifting procedure may result in more favorable outcomes.
Prior Researches

xiv
To scientifically demonstrate the aforementioned clinical outcomes, the
authors are planning to conduct a study called “Lifting in conjunction with
volumization procedures is more effective than volumization alone.”
This book also introduces case that demonstrates tissue repositioning with
thread lifting via 3D scanning. The authors anticipate that a lot of research
will be conducted on this subject.
Prior Researches

xv
After absorbable thread treatments became widespread, the authors collected
patient feedback on thread lifting results. Both positive and negative com-
ments have been received.
Below is the list of negative responses.
Efforts to address the negative responses must be made. This book con-
tains clinical studies, experiments, and experiences that have been conducted
so far. We received help from specialists in various fields, and further research
is also planned.
This book addresses how to overcome the negative responses and explains
how to perform effective, long lasting thread lifting procedures while avoid-
ing complications such as swelling and skin dimpling. Complication manage-
ment is also discussed.
Current Status of Thread Lifting
• The limited effect.
• Short longevity of effect.
• Possibility of severe bruising and swelling.
• Possibility of skin dimpling.
• Difficulty/inconvenience in speaking.

xvii
Bongcheol Kim
Director of Lamar Isu Clinic
College of Medicine, Chonnam National University
Internship – Samsung Medical Center (Seoul)
Residency – Samsung Medical Center (Seoul)
Vice president of the Korean Association for Laser, Dermatology and
Trichology
KOL of Silhouette Soft®
KOL of QT Lift®

Author’s Profile

xviii
Seungmin Oh
Director of ON Clinic
College of Medicine, Seoul National University
Internship – Seoul National University Hospital
Residency – Seoul National University Hospital
Medical MBA, Kyung Hee University
President of OK Medi. Co., Ltd.
Executive Board Member of the Korean Association for Laser,
Dermatology and Trichology
KOL of QT Lift®
Advisory Board Member of Hugel Co., Ltd.

Author’s Profile

xix
Wonsug Jung
Assistant Professor, Department of Anatomy, Gachon University College
of Medicine
Graduated from Yonsei University College of Medicine, MD
Graduated from Yonsei University Graduate School, PhD
Member of the Korean Association of Anatomists
Member of the Korean Association of Physical Anthropologists

Author’s Profile

xxi
Part I Why Is Fixing Technique Important?
1 Definition of Terms�� 3
1.1 Fixing Point�� 3
1.2 Direction �� 3
1.3 Hanging Point �� 3
2 Importance of the Fixing Point�� 7
3 What Is a Fixing Point Formed in Lifting Procedures? �� 9
3.1 Method of Making a Fixing Point�� 9
Part II Facial Anatomy for Non-surgical Thread Lifting
4 Anatomy for Absorbable Thread Lifting�� 13
4.1 Layers of the Face�� 13
4.1.1 Skin �� 13
4.1.2 Superficial Fat�� 13
4.1.3 Musculo-aponeurotic Layer/SMAS�� 13
4.1.4 Deep Fat�� 14
4.1.5 Deep Fascia�� 15
4.2 Cadaveric Photo Series of Facial Layers�� 18
4.3 Anatomical Structures that Could Be Damaged
During Thread Lifting�� 21
4.3.1 Blood Vessels�� 21
4.3.2 Nerves �� 23
4.3.3 Parotid Duct�� 23
5 Avoiding Vessel Damages in Thread Lifting�� 31
5.1 Thread Lifting and Blood Vessels�� 31
5.2 Superficial Temporal Artery�� 31
5.3 Transverse Facial Artery �� 33
6 Avoiding Nerve Injury in Thread Lifting�� 35
6.1 Injury to Facial Nerves�� 35
6.2 Facial Nerves in the Zygomatic Arch Area�� 36
6.3 Technique to Reduce Nerve Injuries�� 36
Contents

xxii
Part III Why Pinch Anatomy?
7 What Is Pinch Anatomy?�� 41
8 Why Is Pinch Anatomy Important? �� 43
9 Method of Studying the Pinch Anatomy�� 45
9.1 Study Method�� 45
9.2 Result�� 45
10 Pinch Anatomy for Each Area�� 47
10.1 Pinch Anatomy: Temple Area Inside the Hairline�� 47
10.2 Pinch Anatomy: Temple Area �� 50
10.3 Pinch Anatomy: Zygomatic Arch Area�� 51
10.4 Pinch Anatomy: Sub-zygomatic Arch Area�� 52
10.5 Pinch Anatomy: Cheek Area�� 53
10.6 Pinch Anatomy: Lower Cheek Area�� 54
11 Pinch Anatomy Summary �� 57
11.1 Areas Where Pinch Anatomy Is Important �� 57
11.1.1 Temple Area Inside the Hairline �� 57
11.1.2 Zygomatic Arch Area�� 58
Part IV Understanding Absorbable Threads
12 Evolution of Absorbable Thread Lifting�� 65
12.1 Trend of Thread Lifting�� 65
12.1.1 Distinction of Threads�� 65
12.1.2 Current Trend�� 67
13 Understanding PDO�� 69
13.1 Physical Characteristics of PDO�� 69
13.2 Functions of PDO �� 69
13.3 Tissue Changes After Inserting PDO Threads�� 69
13.4 Histologic Findings After PDO Thread Insertion �� 69
14 Understanding of PLLA�� 71
14.1 PLLA as a Suture Material �� 71
15 Type of Absorbable Thread Products�� 73
15.1 QT Lift (= VOV Lift, = BLUE ROSEⓇ FORTE)�� 73
15.1.1 Features�� 73
15.1.2 Advantages Determined by the Authors �� 73
15.2 Silhouette Soft®�� 75
15.2.1 Features�� 75
15.2.2 Advantages Determined by the Authors �� 76
15.3 N-Cog Lift�� 76
15.3.1 Features�� 76
15.3.2 Advantages Determined by the Authors �� 76
Contents

xxiii
Part V Basic Techniques
16 Design and Patient Selection�� 81
16.1 Finding the Vector (Simulation)�� 81
16.2 Marking Reference Lines�� 81
16.3 Indicating Dangerous Areas�� 83
17 Anesthesia�� 85
17.1 Anesthesia Using Dental Lidocaine�� 85
17.1.1 Anesthesia Using the Dental Lidocaine�� 85
17.2 Anesthesia Using Cannulas�� 85
17.2.1 Anesthesia Using Cannulas
(Tumescent Solutions or Lidocaine)�� 85
18 Entry Point�� 89
18.1 Location of Entry Point�� 89
18.2 Number of Entry Points�� 90
18.3 Selection of Entry Point Tools�� 90
18.4 Cautions to Be Taken While Making Entry Point:
Bleeding (Superficial Temporal Artery and Vein)�� 90
18.5 Sterile Draping of Hairline�� 93
19 Insertion Technique �� 95
19.1 Various Techniques and Inserting Tools�� 95
19.1.1 Disposable Cannula (Blunt/Sharp Cannula)�� 95
19.2 Thread Insertion After Cannula Insertion �� 96
19.3 Temporal Anchoring (41 cm Long) U Pattern�� 96
19.4 Insertion Using a Thread with Needles at Both Ends�� 96
20 Cutting and Finishing�� 99
20.1 Removing Cannula�� 99
20.2 Cutting�� 99
20.2.1 Cutting While Pulling the Thread�� 99
20.2.2 Cutting While Pushing the Skin�� 99
Part VI Techniques for Various Types of Thread
21 Technique Using a Mono-thread�� 103
21.1 Mono-thread Insertion��103
21.2 Difference in Changes from the Mono-thread Technique��104
21.3 Explanations About the Mechanism ��105
21.3.1 Method of the Mono-thread Technique: Neckline��105
21.3.2 Mono-thread Technique: Inner Cheek��106
21.3.3 Mono-thread Technique: Frontal Cheek
and Nasolabial��106
21.3.4 Mono-thread Technique: Temples��107
Contents

xxiv
22 Technique Using Cog Threads�� 109
22.1 Unidirectional Cog Thread��109
22.2 Spike ��109
22.3 Zigzag Method��110
22.4 Bi-directional Cog��111
22.4.1 Understanding Bi-directional Cogs��111
22.4.2 Experiment on Actual Bi-directional Cogs��111
23 Temporal Anchoring Technique�� 115
23.1 Mechanisms��115
23.2 Insertion Method��120
23.2.1 Design ��120
23.2.2 Anesthesia Method��120
23.3 Entry Point and Anchoring��121
23.3.1 Tools for Entry Points ��121
23.3.2 Anchoring Tools��121
23.3.3 Depth and Direction of Anchoring Point��121
23.3.4 Side Effects: Prevention and Treatments
for Headache��123
23.4 Adequate Cannula for Long-Thread Insertion (17G) ��124
23.4.1 Method of Using Inner Guide Needle
(Blunt) + Sharp Outer Sheath (One Pair) ��124
23.4.2 Method of Using Inner Guide Needle
(Blunt) + Blunt Outer Sheath (One Pair)
and Sharp Inner Puncture Needle ��124
23.5 Cutting and Finishing��125
23.5.1 Finishing (Pulling)��125
23.5.2 Cutting��125
23.5.3 Changes in the Skin Around
the Entry Point (Dimple)��130
23.5.4 Fine Wrinkles Around the Eyes
and (Distortion of the Skin)��130
24 Insertion Method of Bi-directional Needle Thread
(Silhouette Soft®)�� 139
24.1 Mechanisms (Concept) ��139
24.1.1 Effect of Silhouette Soft®��139
24.1.2 Exclusive Advantages of Silhouette Soft®��139
24.2 Characteristics��139
24.2.1 Structure��139
24.2.2 Ingredients��140
24.2.3 Preparations for the Procedure��140
24.3 Method of the Procedure��140
24.3.1 Designing��140
24.3.2 Anesthesia��141
24.3.3 Entry point��141
24.3.4 Insertion��144
24.3.5 Cutting and Finishing
(Traction, Pulling Threads)��149
Contents

xxv
24.4 Various Techniques ��152
24.4.1 Basic Technique 1: Straight Technique��152
24.4.2 Basic Technique 2: Angle Technique��152
24.4.3 Basic Technique 3: U Technique��153
24.4.4 Post-mandibular Anchoring (PMA) Technique��155
24.4.5 Various Combinations Using Two Threads��157
24.4.6 Eyebrow Lifting��160
24.5 Useful Tips��161
25 Considerations to Be a Thread Lifting Expert�� 165
25.1 Temporal Muscle Hypertrophy (or Trigonocephaly)��165
25.2 Temporal Hollowness ��165
25.3 Zygomatic Bone Prominence��165
25.4 Sunken Cheek ��166
25.5 Operation Scar: Zygomatic Bone Reduction Surgery,
Double-Jaw Surgery, and Lifting Surgery��166
25.6 Liposuction ��167
25.7 Acne Scars��167
25.8 History of Lifting Procedure: Thread Lifting and HIFU��167
Part VII Procedures for Each Area
26 Forehead (Eyebrows)�� 173
26.1 Simple Fixing Method��175
26.2 X-Cross Method��175
26.3 Anchoring Method��176
27 Wrinkles Around the Eyes�� 179
27.1 Summary of the Eye Area Lifting��179
27.1.1 Lifting of the Eye Area ��179
27.2 Anatomy of the Eye Area��179
27.2.1 Anatomy��179
27.3 Techniques Which Can Be Used in the Eye Area��181
27.3.1 Preconditioning by Dissection with Tumescent
Technique��181
27.3.2 Method of Forming a Fixing Point
in the Eye Area��181
27.3.3 Tying Method or Simple Cog Insertion Method��181
27.3.4 X-Cross Method��181
27.4 Cautions��183
28 V-Line (Lower Face)�� 185
28.1 Fascia Anchoring Method��185
28.2 Tying Method��186
28.3 X-Cross Method��186
29 Nasolabial Folds �� 189
29.1 Anchoring Method��189
29.2 Method of Fixing with Bi-Directional Cogs��189
Contents

xxvi
30 Marionette Line�� 191
30.1 Angle Technique ��192
30.2 L Shape Technique (Kim’s Technique)��192
30.3 Anchoring Technique: Pulling Method Behind
the Jaw Line��193
30.3.1 Designing��194
30.4 Tornado (Twister Thread) Supplementary Method��194
31 Jaw Line (Double Chins)�� 197
31.1 Necklace Technique��198
31.1.1 Designing��198
31.1.2 Making an Entry Point��198
31.1.3 Insertion��198
31.1.4 Traction and Cutting ��198
31.1.5 Side Effects: Pain and Dimples��199
31.1.6 Cautions in Choosing Patients��200
31.1.7 Factors Which Affect the Outcome
of the Procedure��200
31.2 Method of Anchoring Below the Ear
(Conventional Technique)��203
31.3 Method of Combining the Neck: Marionette��203
31.4 Method of Tying or Simple Burying��203
32 Neck Wrinkles�� 207
32.1 Method of Filling Wrinkles��207
Part VIII Evaluation of Procedure Outcome
33 Method of Evaluating the Effect of Thread Lifting�� 211
34 Evaluation of the Outcomes Using Morpheus® System�� 213
34.1 Simulation Using Morpheus®��213
34.1.1 Evaluation of Outcomes��213
34.1.2 Judging Outcomes��213
34.1.3 Interpretation of the Result ��214
34.2 Evaluation of Before and After Photos
Using Morpheus®��217
34.3 Potential and Future of the Morpheus® System��217
34.3.1 Use��217
35 Utilization of Morpheus®�� 219
Part IX Side Effects and Treatments
36 Dissatisfaction�� 223
36.1 Unrealistic Expectation of Patients��223
36.2 Patients for Whom the Procedure Itself Is Difficult��223
36.3 Structural Limitation of Thread Lifting Products ��224
36.4 Technique Issues of the Physician��224
Contents

xxvii
37 Stiffness and Pain�� 225
37.1 Points to Verify��225
37.2 Cause of Pain��225
37.2.1 Suspected Infection��225
37.2.2 Pain Resulting from Hematoma��225
37.2.3 Cog Hanging in a Specific Area��225
37.2.4 Skin Stimulated by Thread End��226
37.3 Treatment According to Cause of Pain ��226
38 Bruise and Hematoma�� 227
38.1 Damage of the Dermal Plexus by Needle-Type Thread��227
38.1.1 Prevention Method��228
38.2 Bleeding at the Entry Point��228
38.2.1 Prevention Method��228
38.3 Bleeding on the Route of Cannula Insertion��229
38.3.1 Prevention Method��229
39 Skin Fold�� 231
39.1 Things to Be Checked Through Examination��231
39.2 Causes and Solutions��231
40 Protrusion of Threads�� 233
40.1 Protrusion Outside the Skin��234
40.2 Protrusion Within the Mouth (Intraoral)��235
40.3 Thread Near Protrusion (Impending Protrusion)��236
41 Migration of Threads�� 237
41.1 Threads Without Cog��237
41.2 Incorrect Cutting of Bi-directional Cog Threads��238
41.3 Breakage of PDO Threads Due to Long-Term Storage��239
42 Bulging at Entry Points �� 241
42.1 Area of Occurrence��241
42.2 Solution��241
42.3 Prevention ��241
43 Dimple (a Dent in the Skin)�� 243
43.1 Mechanism of Dimples Formation ��243
43.1.1 Inconstant Insertion Depth of Cogs��244
43.1.2 Sinking of Cutting Parts��246
43.1.3 When Some Cogs Are Not Hung Consistently
in the Dermal Layer��247
43.2 Type of Dimples Depending on Area��248
43.2.1 Dimples in the Route of Thread Insertion��248
43.2.2 Dimple at Exit Point (U Technique:
Anchoring Method)��250
43.2.3 Dimple at Entry Point (U Technique:
Anchoring Method)��251
Contents

xxviii
44 Sunken Cheek�� 253
44.1 Anatomical Structure��253
44.2 Clinical Importance��255
44.3 Cautions��255
45 Temporary Paralysis of the Facial Nerves �� 257
45.1 Cause��257
45.2 Clinical Features ��257
45.3 Solution��257
46 Lateral Canthus Elevation�� 259
46.1 Cause��259
46.2 Solution��259
46.3 Prevention ��259
47 Infection�� 261
47.1 Thread Lifting and Infection��261
47.2 Prevention of Infections��261
47.3 Treatment��262
Appendices��263
1.1 Appendix 1: Summary�� 263
1.2 Appendix 2: Procedure Records �� 266
Further Readings�� 266
Contents

Part I
Why Is Fixing Technique Important?

3
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Definition of Terms
A successful and effective lifting treatment must
be based on a thorough understanding of changes
to the face due to aging. In addition, learning
clear meaning of various terms used in explain-
ing lifting is necessary.
Among the key contents used in the book, the
authors obtained some of them through experi-
encing lifting actually. As such, if we start with-
out clarifying the meaning of words, confusion or
curiosity may occur. Accordingly, we think it is
necessary to start our story after clarifying the
definition and the meaning of some important
terms.
1.1
Fixing Point
There are three important terms in absorbable
thread lifting. The first one is the fixing point, the
second one is the direction, and the third one is
the hanging point.
As mentioned above, the concept of the fix-
ing point is important while performing thread
lifting procedure. Previous studies on the effect
of thread lifting have been made without proper
anchoring. This tells the reason for the poor lift-
ing effect. A fixing point means the point which
receives the pulling force when a certain part of
the face is being pulled. Taking bungee jumping
as an example would help to understand.
Provided that jumping is done after connecting
the jumping stand and the body with the rope for
jumping, the jumping stand to which the rope is
tied would be the fixing point.
1.2
Direction
Direction in lifting procedure means the vector
from the hanging point to the fixing point.
Direction must exist to call lifting real and a
desired shape can be made. Simple thread insert-
ing procedures without direction do not make the
desired shape, whereas a lifting procedure can
create a lifting effect and desired face shape with
a suitable direction from the hanging point to the
fixing point.
1.3
Hanging Point
The hanging point refers to the point at the end of
the thread when the thread was inserted from the
fixing point to the direction of the facial part to be
pulled. In the example of pulling a sagged cheek
upward, the hanging point exists at a point
between the fixing point and the sagged cheek to
be pulled (Fig. 1.1).
In some cases, the hanging point does not pre-
cisely coincide with the part to be lifted
(Fig. 1.2). Lifting still can be possible. This is
because facial tissues are intricately connected to
each other by fibrotic tissues in the subcutaneous
fat layer or various ligaments, etc. Especially,
1

4
Fixing point
Hanging Point
Part to be pulled
Fig. 1.2 If the hanging
point and the part to be
pulled do not coincide,
the actual part to be
pulled is either the lower
cheek or the hanging
point of the thread
which is the lower
cheekbone. The hanging
point and the part to be
pulled are different
Fixing point
Direction
Hanging point
Fig. 1.1 Definition of
fixing point, hanging
point, and direction.
Pulling the hanging
point to the direction of
the fixing point is facial
lifting
1 Definition of Terms

5
certain areas on the face such as the lower cheek-
bone area and the fibrotic tissue in the
subcutaneous layer are very tough and dense. If a
thread is inserted into such fibrotic tissues and
pulled, these dense tissues will be pulled effec-
tively, and tissues which are located away from
the hanging point also pulled. For example, to lift
the lower cheek part to the direction of the head,
the thread does not necessarily have to be inserted
in the lower cheek area to create a lifting effect.
However, in a certain patient group, inserting
and pulling a thread only to the hard fibrotic tis-
sue in the lower cheekbone area can bring a good
effect. Therefore, patients and procedure tech-
nique selection should be well considered before
treatment.
1.3 Hanging Point

7
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Importance of the Fixing Point
The difference between the lifting technique
which can make a fixing point and the lifting
technique which cannot make a fixing point is
that the former clearly has direction. Various pro-
cedures which contract the skin or reduce the fat
layer can make the face to appear pulled. Namely,
even if there is no direction, the face can look
lifted and tightened. This is related to the changes
to the face as a result of aging.
As aging progresses, each plane of the face
goes through changes. Various changes such as
sagging of fat due to gravity, stretching of fibrotic
tissues surrounding the fat, and stretching of the
skin together make the aging appearance of the
face.
If the skin is contracted or the fat layer is
reduced, as they have effects of tightening
stretched tissues, they are thought to be able to
bring the similar effect of lifting. Also, through
various procedures, various fibrotic tissues exist-
ing in the face can be settled and newly formed.
However, this is thought to have weaker
effects than the lifting procedure which strongly
forms a fixing point. The concept of the fixing
point has been passed down from the past.
Sulamanidze M. et al. said that thread lifting pro-
cedures consist of floating method and fixing
method. Mendelson et al. classified the face into
the frontal part which moves and the lateral part
which is fixed.
In this regard, Hyeonho Han et al. announced
that the performance of thread lifting with fixing
type in the lateral part of the face and floating
type in the frontal part of the face together showed
good results.
The fixed type discussed here means forming
a strong fixing point on the temporal fascia area.
This is an important thesis discussing about the
importance of the fixing point (Fig. 2.1).
To optimize lifting effects, pulling must be
done with direction, and a strong fixing point
must exist from the pulling direction. This is
because force must support in the opposing direc-
tion from the movement of the tissues resulting
from aging and gravity.
Although there is relative amount of differ-
ence in strength, each thread lifting techniques
have the mechanisms of making a fixing point or
roles which function the same as the fixing point.
In some cases, the basis was uncovered through
animal testing, and in some cases basis is not
made clear. Fixing a thread in the fascia area is
thought to be the strongest technique. However,
this technique is not easy, and also when bleed-
ing, the duration of the procedure takes longer,
and side effects such as hematoma can possibly
occur.
If knowledge can minimize the possibility of
bleeding while making the fixing point strong
and procedural skills are clearly made, we think
2

8
that safe and effective thread lifting can be
performed.
This is also the reason for talking about the
fixing point first in this book. The authors
performed several experiments to understand
thread lifting mechanisms in the body. They will
be helpful in understanding the mechanisms of
thread lifting.
STF
DTF superficial layer
DTF deep layer
Fig. 2.1 Temporal
fascia. Showing the
superficial temporal
fascia and the deep
temporal fascia. The
deep temporal fascia has
a part which divides into
the deep layer and the
superficial layer. STF
Superficial Temporal
Fascia, DTF Deep
Temporal Fascia
(Published with kind
permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)
2 Importance of the Fixing Point

9
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
What Is a Fixing Point Formed
in Lifting Procedures?
3.1
Method of Making a Fixing
Point
The mechanism of mono-thread used in the first-
generation absorbable thread lifting is expressed
through this (Fig. 3.1).
Physicians expected lifting effects by insert-
ing more threads in the direction that the face was
desired to be pulled. It will be explained in the
later part of this book that when the absorbable
ingredient, PDO, enters into the tissue, various
changes occur. Especially, changes such as con-
traction of tissues and proliferation of fibrotic tis-
sues prove to some extent the theoretical basis for
the thread lifting using mono-threads (Yoon JH,
et al. Tissue changes over time after polydioxa-
none thread insertion: An animal study with pigs.
J Cosmet Dermatol. 2018;00:1–7).
The fixing point forming mechanism is as var-
ied as the thread lifting type. In this regard, there
are not many cases which adequately explain such
mechanisms. For example, they are not able to
accurately explain why bi-directional cog thread
or mono-thread technique causes facial lifting.
But lifting is obviously possible if the thread
is hanging in a relatively firm fascia region, runs
in the subcutaneous fat layer, and is then pulled.
Of course, discussions about the lasting time and
whether the thread really hangs in the fascia, etc.
will be dealt with later. However, the lifting pro-
cedure using the method of hanging the thread in
the hard fascia area and pulling is not easy to fol-
3
Relatively high conglutination occurs
Relatively low conglutination occurs
Fig. 3.1 Forming a
fixing point of
monofilament threads.
Formation of fibrotic
tissues occurs more in
the area where relatively
many threads were
inserted. No clear fixing
point exists

10
low due to its level of difficulty. Based on the
recent trend, if there is any lifting method which
can make a hard fixing point with short and sim-
ple procedure without any side effect, it would be
the most ideal.
Recently, lifting is performed in the form of
gathering tissues in the middle part of the thread
using a bi-directional cog thread. This will be
explained in the following figure, and a point
which serves the similar function as a fixing point
occurs in the middle part of the thread. Such
method is more accurately explained as soft tis-
sue repositioning rather than lifting.
After inserting a bi-directional cog thread and
tying the threads to each other in the insertion
area, the role of the fixing point can be strength-
ened. This is a case where the knot formed by the
tie serves as a weak fixing point.
There is also a method of forming a fixing point
using the hard ligament tissue in the inner side of
the face. By causing the cog thread to be hung in
the area of the true ligament, a hard fixing point
can be formed. Places to which such special tech-
nique can be applied exist, and it can make results
better than the mono-thread insertion method.
3 What Is a Fixing Point Formed in Lifting Procedures?

Part II
Facial Anatomy for Non-surgical Thread
Lifting

13
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Anatomy for Absorbable
Thread Lifting
4.1
Layers of the Face
Like the scalp, the facial tissue can be divided into
five layers. And the face and the scalp are con-
nected to each other layer by layer. There is an
exception in the fifth layer where masticatory
muscles have different embryological origins from
facial expression muscles (Table 4.1 and Fig. 4.1).
4.1.1
Skin
In general, the skin of the male is slightly thicker
than the female. And the thickness of the dermis
of Koreans does not differ largely from that of
Caucasians. However, the epidermis of Koreans
tends to be thicker than that of Caucasians.
Table 4.2 lists the skin thickness by area based
on a Korean study. It is noteworthy that the neck
being the thickest among all the area measured is
not a common finding in other studies. These
inter-study variations probably result from the
differences in the population of study and meth-
ods of measurement.
4.1.2
Superficial Fat
It is a layer corresponding to the hypodermis. It is
located superficial to the facial expression mus-
cles and consists of several compartments.
Superficial fat sags downward by aging (Fig. 4.2).
4.1.3
Musculo-aponeurotic Layer/
SMAS
This layer consists of facial expression muscles
and aponeurosis. And the layer is connected to
the galea aponeurotica of the scalp.
Aponeurosis interconnects the platysma mus-
cle and frontalis muscle. The aponeurosis is
named differently by its relative location to the
zygomatic arch; the aponeurosis upper to the
zygomatic arch is being called the temporopari-
etal fascia or superficial temporal fascia and the
part lower to the zygomatic arch the SMAS
(superficial musculo-aponeurotic system).
The branches of the facial nerve innervating
the facial expression muscles travel deeper than
this layer, and some blood vessels (e.g., superfi-
cial temporal artery) travel within the temporopa-
rietal fascia.
4
Table 4.1 Layers of the face
Facial layer
Scalp layer
First
layer
Skin
Skin
Second
layer
Superficial fat
Connective
tissue
Third
layer
Facial expression muscle/
SMAS (musculo-
aponeurotic layer)
Aponeurosis
Fourth
layer
Deep fat
Loose areolar
tissue
Fifth
layer
Deep fascia
Periosteum

14
4.1.4
Deep Fat
In the fourth layer of the face, there are several
spaces, and the retaining ligaments traverse
between them connecting the periosteum/deep
fascia to the skin. Deep fat is located deep to the
facial expression muscles and divided into several
Frontalis
Skin
Subcutaneous fat
Temporoparietal fascia
Innominate fascia
Deep temporal fascia
Temporalis
Masseter
SMAS
Parotidomasseteric
fascia
Platysma
Fig. 4.1 Facial layers.
The coronal section of
the face is represented
schematically.
(Published with kind
permission of ©
Kwan-Hyun Youn 2018.
All rights reserved)
Table 4.2 Skin thickness of Koreans
Male
Female
Forehead
0.90 mm
0.84 mm
Eyelid
0.57 mm
0.47 mm
Cheek
1.24 mm
1.04 mm
Chin
0.89 mm
0.75 mm
Neck
1.56 mm
1.26 mm
4 Anatomy for Absorbable Thread Lifting

15
compartments (Fig. 4.3). In the temporal area,
the connective tissue beneath the temporoparietal
fascia is called the innominate fascia.
4.1.5
Deep Fascia
There are masticatory muscles like temporalis m.
and masseter m. in the temporal fossa and the
mandible. The periosteum of the skull proceeds
as the deep fascia covering muscles of mastica-
tion (Figs. 4.1 and 4.4).
The deep fascia over the temporalis m. is
called the temporalis muscle fascia or the deep
temporal fascia, and it attaches to the zygomatic
arch after being split into a superficial and a
deep layer. There is a superficial temporal fat
pad in between the two layers of the deep tem-
poral fascia and a deep temporal fat pad which
is an extension of the buccal fat pad lying
Central forehead fat
Middle forehead fat
Superior orbital fat
Inferior orbital fat
Medial cheek fat
Nasolabial fat
Lateral orbital fat
Middle cheek fat
Superior jowl fat
Lateral temporal-cheek fat
Inferior jowl fat
Submandibular jowl fat
Fig. 4.2 Superficial fat compartments. (Published with kind permission of © Kwan- Hyun Youn 2018. All rights
reserved)
4.1 Layers of the Face

16
between the temporalis m. and the deep tempo-
ral fascia.
In the mandible, the deep fascia surrounds not
only the masseter m. but also the parotid gland;
hence, it is called as the parotidomasseteric fas-
cia, and it also attaches to the zygomatic arch.
The musculo-aponeurotic layer/SMAS is a con-
tinuous layer, crossing over the zygomatic arch,
while the deep fasciae attach to the upper and
lower borders of the zygomatic arch and are not
one continuous layer.
The temporal branch of the facial nerve exits
the parotid gland by penetrating the parotidomas-
seteric fascia, and after crossing the zygomatic
arch, it traverses the innominate fascia to inner-
vate the orbicularis oculi m. and frontalis m.
Retro-orbicularis
oculi fat (ROOF)
Deep medial cheek fat
(lateral part)
Deep medial cheek fat
(medial part)
Sub-orbicularis
oculi fat (SOOF)
Buccal fat pad
Fig. 4.3 Deep fat compartments. (Published with kind permission of © Kwan- Hyun Youn 2018. All rights reserved)
4 Anatomy for Absorbable Thread Lifting

17
Galea aponeurotica
SOOF
Periosteum
Superior temporal septum
Temporoparietal
fascia
Deep temporal
fascia
Inferior temporal
septum
Parotidomasseteric
fascia
SMAS
Buccal fat pad
Fig. 4.4 Layers of the face. (Published with kind permission of © Kwan- Hyun Youn 2018. All rights reserved)
4.1 Layers of the Face

18
• After removing the skin and the subcutaneous
fat
tissues,
the
third
layer,
musculo-
aponeurotic layer/SMAS, is exposed.
• Platysma, orbicularis oculi, and frontalis mus-
cles and the interconnecting aponeurosis.
• The part of aponeurosis below the zygomatic
arch is called SMAS; the part above the zygo-
matic arch is called the superficial temporal
fascia (STF) or temporoparietal fascia.
• The musculo-aponeurotic layer/SMAS is the
most important layer in the surgical lifting
procedure.
• By lifting the SMAS layer, the parotidomasse-
teric fascia which is the deep fascia covering the
parotid gland and the fourth layer in the tempo-
ral area, the innominate fascia, are exposed.
(Published with kind permission of © Wonsug Jung 2018. All rights reserved)
Innominate
fascia
Parotidomasseteric
fascia

Orbicularis oculi
platysma
Frontalis
SMAS
STF

(Published with kind permission of © Wonsug Jung 2018. All rights reserved)
4.2
Cadaveric Photo Series
of Facial Layers
4 Anatomy for Absorbable Thread Lifting

19
• The part of parotidomasseteric fascia cover-
ing the parotid gland is thicker than the part
covering the masseter area.
(Published with kind permission of © Wonsug Jung 2018. All rights reserved)

(Published with kind permission of © Wonsug Jung 2018. All rights reserved)
Parotid gland

• By lifting up the parotidomasseteric fascia,
the parotid gland was exposed.
4.2 Cadaveric Photo Series of Facial Layers

20
The branches of the facial nerve coming out of
the borders of the parotid gland are clearly visible.
• The branches of the facial nerve travel within
the parenchyma of the parotid gland.
(Published with kind permission of © Wonsug Jung 2018. All rights reserved)
Subcutaneous fat
STV
STF
DTF
superficial layer
Superficial
temporal fat pad
DTF deep layer
STA
Middle temporal vein

(Published with kind permission of © Wonsug Jung 2018. All rights reserved)

4 Anatomy for Absorbable Thread Lifting

21
• Note the presence of the temporoparietalis m.
in the same layer as the superficial temporal
fascia.
4.3
Anatomical Structures that
Could Be Damaged During
Thread Lifting
Although nonsurgical thread lifting is considered to
be a minimally invasive procedure, some anatomical
structures may be at risk of being damaged during
treatment. Since thread lifting is performed mainly
from the top to the bottom in a perpendicular direc-
tion, there is risk of injury in structures which course
obliquely or horizontally in the lateral face (Fig. 4.5).
Such structures are summarized in Table 4.3.
4.3.1
Blood Vessels
1. Frontal branch of the superficial temporal
artery.
• The superficial temporary artery bifurcates
into frontal and parietal branches at 18 mm
anterior and 37 mm superior to the tragus.
• The frontal branch travels anterosuperiorly
in the temple. It meets the lateral border of
the frontalis muscle at 16 mm lateral to the
lateral canthus and 15 mm above the eye-
brow and then travels on the surface of the
frontalis m. afterward (Fig. 4.6).
2. Zygomatico-orbital artery
• As a branch of the superficial temporal artery,
the zygomatico-orbital artery exists at 80–90%
and runs parallel to the upper border of zygo-
matic arch toward the outer corner of the eye.
3. Transverse facial artery.
• The transverse facial artery originates from
the superficial temporal artery within the
parotid gland and travels in the same depth
as the facial nerves.
• It travels in between the zygomatic arch
and the parotid gland and runs approxi-
mately 14 mm (5–26 mm) below the lower
border of the zygomatic arch.
• This is a cadaveric photo showing the layers
of the temple.
• The superficial temporal artery (STA) is enclosed
by the superficial temporal fascia (STF).
• The middle temporal vein is embedded in the
superficial temporal fat between the superfi-
cial and deep layers of the deep temporal
fascia.
(Published with kind permission of © Wonsug Jung 2018. All rights reserved)
Temporoparietalis

4.3 Anatomical Structures that Could Be Damaged During Thread Lifting

22
4. Middle temporal vein.
• Middle temporal vein runs approximately
2 cm above the zygomatic arch and drains
into the superficial temporal vein.
• It runs between the superficial and deep
layers of the deep temporal fascia and is
embedded in the superficial temporal fat
pad.
Superficial temporal a.
Zygomatico-orbital a.
Middle temporal v.
Temporal br.
Zygomatic br.
Transverse facial a.
Parotid duct
Buccal br.
Marginal
mandibular br.
Fig. 4.5 Anatomical structures running the lateral face horizontally or obliquely. (Published with kind permission of ©
Kwan- Hyun Youn 2018. All rights reserved)
Table 4.3 Anatomical structures that could be damaged
during thread lifting
Blood
vessels
Frontal branch of superficial temporal
artery
Zygomatico-orbital artery
Transverse facial artery
Middle temporal vein
Nerves
Temporal, zygomatic, buccal, and
marginal mandibular branches of the
facial nerves
Other
structure
Parotid duct
4 Anatomy for Absorbable Thread Lifting

23
4.3.2
Nerves
• The temporal, zygomatic, buccal, and mar-
ginal mandibular branches of the facial nerve
emerge from the parotid gland and run anteri-
orly beneath the SMAS.
• The temporal branch of the facial nerve exits
the parotid gland by penetrating the paroti-
domasseteric fascia and travels up across the
zygomatic arch covered by the innominate
fascia. The temporal branch penetrates the
innominate fascia at 1.5–3 cm above the zygo-
matic arch and runs just beneath the superfi-
cial temporal fascia.
• There are several temporal branches of the
facial nerve, and they are located approxi-
mately within the triangle created by the ear-
lobe, the hairline, and the lateral eyebrow.
• The temporal branch of the facial nerve
courses along the Pitanguy’s line which
runs from a point 0.5 cm below the tragus
to a point 1.5 cm above the lateral
eyebrow.
• The temporal branch of the facial nerve
crosses the middle third of the zygomatic arch
which is 1.8 cm from the posterior end of the
zygomatic arch and 2 cm from the anterior
end of the arch (Fig. 4.7).
4.3.3
Parotid Duct
• Parotid duct generally runs above the line
connecting the tragus and angle of the
mouth.
• Parotid duct follows a curved trajectory from
the 1/3 point and 2/3 point along the line con-
necting the tragus and the angle of the mouth,
with the peak of curve being 1.5 cm above the
line (Fig. 4.8).
Fig. 4.6 The course of
the superficial temporal
artery. (Published with
kind permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)
4.3 Anatomical Structures that Could Be Damaged During Thread Lifting

25
The photographs of the above structures are composed on a model’s face (Figs. 4.9, 4.10 and 4.11)
and the histologic sections containing those structures are illustrated for reference (Fig. 4.12).
Fig. 4.8 The course of the parotid duct. (Published with kind permission of © Kwan- Hyun Youn 2018. All rights
reserved)
4.3 Anatomical Structures that Could Be Damaged During Thread Lifting

26
Zygomaticus
major
SMAS
Risorius
Depressor
anguli oris
Fig. 4.9 Musculo-aponeurotic layer/SMAS. (Published with kind permission of © Wonsug Jung and Kwan- Hyun
Youn 2018. All rights reserved)
4 Anatomy for Absorbable Thread Lifting

27
Parotid gland
Masseter
Buccal fat pad
Fig. 4.10 After removal of the SMAS and parotidomas-
seteric fascia, the parotid gland and branches of facial
nerves exiting it can be seen. (Published with kind permis-
sion of © Wonsug Jung and Kwan- Hyun Youn 2018. All
rights reserved)
4.3 Anatomical Structures that Could Be Damaged During Thread Lifting

28
Branches of facial nerve
Fig. 4.11 After removal of the superficial part of the parotid gland, the branching pattern of the facial nerve can be
observed. (Published with kind permission of © Wonsug Jung and Kwan- Hyun Youn 2018. All rights reserved)
4 Anatomy for Absorbable Thread Lifting

29
Superficial temporal artery
Superficial temporal fascia
Deep temporal fascia
Temporalis
Facial nerve temporal branch
Temporoparietalis
Deep temporal fascia
Superficial
temporal fascia
Facial nerve
temporal branch
Parotidomasseteric
fascia
SMAS
SMAS
Masseter Facial nerve
buccal branch
Parotid duct Orbicularis
oris
Parotid gland
Parotidomasseteric
fascia
Fig. 4.12 Schematic drawing of the tissue specimen of each area of the face. (Published with kind permission of ©
Wonsug Jung and Kwan- Hyun Youn 2018. All rights reserved)
4.3 Anatomical Structures that Could Be Damaged During Thread Lifting