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

32
Superficial temporal a.
Zygomatico–orbital a.
Transverse facial a.
Fig. 5.1  Important
arteries in thread lifting.
The thread must cross
these arteries when
midface thread lifting is
performed. (Published
with kind permission of
© Kwan- Hyun Youn
2018. All rights
reserved)
Skin
Subcutaneous fat
Superficial
temporal fascia
Deep
temporal fascia
Temporalis
Fig. 5.2  Depth of the
superficial temporal
artery. (Published with
kind permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)
5  Avoiding Vessel Damages in Thread Lifting

33
procedure, resulting in discomfort and low satis-
faction of the patients.
5.3
Transverse Facial Artery
Transverse facial artery is branched from the
superficial temporal artery within the parotid
gland and runs embedded in it. Therefore, when
the thread passes over the parotid gland, it must
be through the subcutaneous fat layer. If any
damage occurs in the parotid gland, the trans-
verse facial artery is also in danger, resulting in
sialocele and even hematoma.
After emerging from the parotid gland, the
transverse facial artery still travels beneath the
SMAS and facial expression muscles. If the thread
is inserted into the subcutaneous fat layer after
clearly recognizing it, vascular injury can be
avoided.
5.3  Transverse Facial Artery

35
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Avoiding Nerve Injury in Thread
Lifting
6.1
Injury to Facial Nerves
When performing midface lifting, precaution
must be taken not to damage facial nerves
(Fig. 6.1).
When the main temporal branch of the facial
nerves is damaged, complications such as eyelid
sagging and drooping eyebrows can occur
(Fig. 6.2).
In case of thread lifting, the incidence rate of
side effects seems to be lower than surgery. This
is because thread lifting procedure is minimally
invasive and facial nerve ramifies into numerous
branches and anastomosis exists between them.
6
Fig. 6.1  Dangerous
zone. (Published with
kind permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)

36
6.2
Facial Nerves
in the Zygomatic Arch Area
To be able to perform thread lifting safely with-
out nerve damages, the thread needs to be inserted
through the safe facial plane. The zygomatic arch
is the most likely place for nerve damage because
the thickness of the soft tissues is relatively thin
at this area.
When the facial nerve passes the zygomatic
arch, it runs below the SMAS, and it travels very
close to the bone (Figs. 6.3 and 6.4).
From the perspective of the pinch anatomy,
when pinched softly, the facial nerve cannot be
pulled upward from the zygomatic arch area. If
progression of thread in the zygomatic arch area
is made with this knowledge in mind, the possi-
bility of nerve damage can be reduced during the
procedure.
6.3
Technique to Reduce Nerve
Injuries
When performing thread lift, we have to be cau-
tious not to damage the facial nerve with sharp
needle or careless cannula movement. It is pos-
sible to perform safe procedure by reducing the
pressure on the soft tissues with pinch technique
and passing threads over the zygomatic arch area
carefully through gentle operation.
Fig. 6.2  If temporal branches of the facial nerve are damaged in this area, the eyebrows may droop due to the weakness
of the frontalis muscle. (Published with kind permission of © Kwan- Hyun Youn 2018. All rights reserved)
6  Avoiding Nerve Injury in Thread Lifting

37
Skin
Subcutaneous fat
Zygoma
Parotid gland
Masseter
Deep temporal fascia
Superficial temporal fascia
Superficial layer of
deep temporal fascia
Deep layer of
deep temporal fascia
Facial nerve
Fig. 6.3  Course of the temporal
branch of the facial nerve. (Published
with kind permission of © Kwan-
Hyun Youn 2018. All rights reserved)
Temporoparietal fascia
Innominate fascia
Facial nerve temporal branch
Zygomatic arch
SMAS
Fig. 6.4  Course of the temporal
branch of the facial nerve. (Published
with kind permission of © Kwan-
Hyun Youn 2018. All rights reserved)
6.3  Technique to Reduce Nerve Injuries

Part III
Why Pinch Anatomy?

41
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
What Is Pinch Anatomy?
The facial structures displayed in medical illus-
trations or revealed by cadaver dissection are
their natural appearance. These are in their natu-
ral condition without exerting manipulation such
as pinching or pulling on them. On the contrary,
the tissue status being pulled or pinched during
procedures is different from their original appear-
ance. As well as the difference in the appearance,
changes occur in the internal tissues.
In general, clinicians tend to perform aesthetic
procedures while pinching the skin for the ease of
the procedure. However, what happens below the
skin at that time is not clearly known.
Therefore, we named the anatomy in the new
status changed through pinching or pulling the
tissues upward as “pinch anatomy” and studied
tissue changes therefrom (Fig. 7.1).
7
Fig. 7.1  Logo of pinch anatomy

43
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Why Is Pinch Anatomy Important?
While performing thread lifting procedures, pre-
cautions must be taken against damaging the
nerves and blood vessels. Especially, if the can-
nula containing the tread is a sharp needle type,
there is higher possibility of bleeding or nerve
damage.
Thread lifting is not a surgery, but a minimally
invasive procedure. The advantages of minimally
invasive procedures are low occurrence of com-
plications, fast recovery, and the short procedure
time. Therefore, maximizing the value of the
thread lifting would be to minimize the possibil-
ity of bleeding and nerve damage.
The knowledge of the depth of major nerves
and blood vessels based on facial anatomy is a
prerequisite for thread lifting. In addition to this,
we think that knowledge about the pinch anatomy
will make the procedure to be safer and more
effective. We expect that additional studies will be
carried out on pinch anatomy in the future.
In summary, clinicians generally tend to pinch
or pull the tissues for the ease of procedure. In
such case, anatomical structure changes occur. If
thread lifting is carried out in the safe layer with
clear knowledge of the anatomical changes in the
pinched status, damages to the blood vessels and
nerves can be avoided.
Considering the depth and course of main
blood vessels and nerves, in manipulating a
pinch, which layer of face is pulled upward
and whether blood vessels and nerves are
pulled upward are very important. If they are
assumed to be pulled, passing the thread in
deeper layer would be safer, and if they are not
pulled, inserting the thread superficially would
be safer.
8

45
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Method of Studying the Pinch
Anatomy
9.1
Study Method
After marking the hairline from fresh cadaver
which has not been frozen or fixed and shaving
the hair, several points were marked at important
sites for thread lifting procedure (Fig. 9.1).
After performing a gentle pinch in each area,
the pulled up skin was cut at the bottom with scis-
sors (Fig. 9.2).
While the tissue is being pulled, the skin is
thought to be cut at a slightly deeper than the
layer where the cannula is inserted. The exposed
area was observed with the naked eye, and at the
border of the cut area, tissue specimens were col-
lected to be examined microscopically to deter-
mine which layer of face was pulled up and cut.
9.2
Result
In the temple area inside the hairline, the sub-
cutaneous fat layer was cleanly removed, and
the superficial temporal artery and the superfi-
cial temporal fascia enclosing it were not
damaged.
9
Fig. 9.1  Sites where pinch and cut were performed.
(Published with kind permission of © Wonsug Jung 2018.
All rights reserved)
Fig. 9.2  The method of gentle pinch and cutting of pulled
up skin. (Published with kind permission of © Wonsug
Jung 2018. All rights reserved)

46
In all other areas, some amount of subcutane-
ous fat was not removed, and facial expression
muscles were observed to be intact where mus-
cles could be seen through barely remaining sub-
cutaneous fat (Fig. 9.3).
Fig. 9.3  Result of pinch and cut. (Published with kind
permission of © Wonsug Jung 2018. All rights reserved)
9  Method of Studying the Pinch Anatomy

47
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Pinch Anatomy for Each Area
10.1
Pinch Anatomy: Temple Area
Inside the Hairline
While performing long thread lifting, how deep
anchoring will be done is very important. This is
because the temporal fascia creates much stron-
ger fixing point than the subcutaneous fat layer.
At the time of pinch, it is necessary to know
which fascia in the temporal area is being pulled.
The anchoring itself is a blind procedure; there-
fore the layer that thread hangs cannot be con-
firmed visually.
During performing anchoring in the temporal
fascia area, there must be no damage to the super-
ficial temporal artery which is enclosed in the
superficial temporal fascia. Finding out how
blood vessels and fascia move around these areas
when performing a pinch helps to reduce injury
of blood vessels (Figs. 10.1 and 10.2).
Gross Finding  Temple areas inside the hairline
Temple areas inside the hairline

10
Skin
Subcutaneous fat
Superficial
temporal fascia
Deep
temporal fascia
Temporalis
Fig. 10.1  Location of
the superficial temporal
artery in the temporal
area. (Published with
kind permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)

48
• Through cutting after pinching, the subcutane-
ous fat layer was removed, and the superficial
temporal fascia was exposed. Damage to the
superficial temporal fascia was not visible.
• Only the subcutaneous fat layer was presumed
to be pulled upward by the pinch.
• This shows that the superficial temporal fascia
was not pulled upward easily by a gentle pinch.
• Based on the lack of difference in the border
of cut skin and the subcutaneous fat layer, it
can be assumed that the pinch separated the
subcutaneous fat layer from the fascia beneath.
• The superficial temporal artery is surrounded
by the superficial temporal fascia, but it
sticks out to the subcutaneous fat layer. The
entire fat layer was removed without damage
to the artery, which supports that the pinch
caused separation of the subcutaneous fat
layer and the superficial temporal fascia.
Histologic Finding  The temple area inside the
hairline

• The red square indicates the orientation of the
tissue specimen.
• There is almost no subcutaneous fat layer in
the temple area inside the hairline.
• The superficial temporal fascia (STF) splits to
surround the superficial temporal artery
(STA), and it is not damaged from cutting
after pinching.
• The temporal branches (black arrows) of the
facial nerve travel in between the STF and the
deep temporal fascia (DTF).
Fig. 10.2 
Recommended area for
anchoring. Anchoring is
done between the frontal
and parietal branches of
the superficial temporal
artery. (Published with
kind permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)
10  Pinch Anatomy for Each Area

49
STF
Epidermis
STA
DTF
Temporalis
Temporalis tendon

• In another cadaver, the skin was pinched deeply
and cut at one point to determine whether there is
difference in movement of tissue layers accord-
ing to the strength of pinch method (Fig. 10.3).
• When the cutting was done after gentle pinch-
ing using the ordinary method, only the sub-
cutaneous fat layer was cut, and there was no
damage to the STF and the STA. When the
pinch was manipulated deeply, however, the
STF was cut, and the deep temporal fascia
(DTF) was exposed. The exposed deep tem-
poral fascia (DTF) was not damaged at all.
• Depending on the strength of the pinch
method, the pulled up layer can be different.

STF
STA
Border of the cut STF
DTF
Fig. 10.3  The temporal
area where two different
pinch methods were
applied. On the left side,
the skin was pinched
gently; on the right side,
the skin was pinched
deeply. (Published with
kind permission of ©
Wonsug Jung 2018. All
rights reserved)
10.1  Pinch Anatomy: Temple Area Inside the Hairline

50
• The red square indicates the orientation of the
tissue specimen.
• The left side of the tissue specimen is the
area where a gentle pinch was performed,
and the right side is where a deep pinch was
applied.
• Only the subcutaneous fat layer was cut, and
there was no damage to the STA and STF in the
left, but it can be seen that the STF was removed,
and the DTF was exposed in the right.
• Thin temporoparietalis muscle was observed
in the same layer as the STF.
STA
DTF
DTF
STF
Epidermis
Temporoparietalis
Temporalis

10.2
Pinch Anatomy: Temple Area
• This is an area which is bounded by the orbital
rim, the zygomatic arch, and the hairline.
• Important anatomical structures such as the
temporal branch of the facial nerve and the
frontal branch of the superficial temporal
artery traverse this area.
• The temporal branches of the facial nerve pass
deep to the superficial temporal fascia, and when
the skin was cut after being pinched, there was
no damage to the superficial temporal fascia.

Gross Finding  Temple area
Temple area

• In the area where the subcutaneous fat exists
to a certain extent, only part of the subcutane-
ous fat layer is removed together with the skin
when pinched and cut.
• Part of the subcutaneous fat layer remains,
and there is no damage to the superficial tem-
poral fascia which is located deep to it.
• Therefore, the superficial temporal artery
which is enclosed in the superficial temporal
fascia and the temporal branch of the facial
nerve which travels deep to the STF are not
damaged.
10  Pinch Anatomy for Each Area

51
10.3
Pinch Anatomy: Zygomatic
Arch Area
Due to the possibility of injury to the facial nerve,
the tissue change from pinch in this area raises
the most curiosity. As the temporal branch of the
facial nerve runs beneath the superficial temporal
fascia in this area, whether the superficial tempo-
ral fascia is pulled is important. Especially, as it
is before the temporal branch of the facial nerve
makes many branches, a nerve damage in this
area can potentially cause a relatively serious
complication.

• As it can be seen in Fig. 10.4, the facial nerve
crosses the zygomatic arch and traverses the
innominate fascia to reach just beneath the
SMAS in the temporal area.
• When thread lifting is performed using the
temporal anchoring method, the cannula pro-
ceeds toward the lower cheek after passing the
zygomatic arch. The facial nerve crosses the
zygomatic arch deep to the SMAS and super-
ficial temporal fascia. Therefore, when the
cannula proceeds within the subcutaneous
layer after separating the subcutaneous fat
layer from the SMAS through pinching, there
is less chance to cause injury to the facial
nerve.
Gross Finding  Zygomatic arch area
Zygoma

• In the area where the subcutaneous fat layer
exists to a certain extent, only some of the subcu-
taneous fat layer is removed together with the
skin when cutting is performed after pinching.
• Some remaining subcutaneous fat is observed
with the naked eye, and the SMAS which is
located more deeply is not damaged.
• Accordingly, the temporal branch of the facial
nerve which travels deep to the SMAS is not
damaged.
• Muscles are seen through the area where large
amount of the subcutaneous fat layer is removed.
Histologic Finding  Zygomatic arch area

10.3  Pinch Anatomy: Zygomatic Arch Area

52
• The red square indicates the orientation of the
tissue specimen.
• After pinching, some of the subcutaneous fat
layer is removed through cutting.
• In the area where the muscles are seen through
thin subcutaneous fat, there is no damage to
the muscle.
• The temporal branch of the facial nerve travels
deep to the SMAS.
Deep temporal fascia
Superficial temporal fascia
Superficial layer of
deep temporal fascia
Deep layer of
deep temporal fascia
Skin
Subcutaneous fat
Zygoma
Parotid gland
Masseter
Fascial nerve
Fig. 10.4  Course of the temporal
branch of the facial nerve.
(Published with kind permission
of © Kwan- Hyun Youn 2018. All
rights reserved)
Epidermis
Cutaneous nerve
Facial nerve
SMAS
Zygomaticus major
Orbicularis oculi

10.4
Pinch Anatomy: Sub-­
zygomatic Arch Area
The sub-zygomatic arch area is usually
depressed creating a sunken cheek. This is an
area with relatively severe adhesion due to
abundant fibrotic tissues. Therefore, when cog
threads are hung in this area, it can tolerate pull-
ing force fairly well, and a good lifting outcome
can be expected.
On the other hand, if the process of the
thread lifting is carried out without clear
knowledge of the characteristics of this area,
10  Pinch Anatomy for Each Area

53
side effects such as sinking can easily occur for
the same reason. Therefore, an optimal proce-
dure must be performed based on various skills
such as the pinch manipulation and design
know-how.

Gross Finding  Sub-zygomatic arch
Sub-zygomatic arch

• In the right top side of the cut surface, the dermis
and subcutaneous fat tissues are cut obliquely.
This is the result of this area not being pulled
upward as much as the other areas at the time of
pinching due to the dense fibrotic tissues.
• In the area where the subcutaneous fat layer
exists to a certain extent, only some of the
subcutaneous fat layer is removed together
with the skin when cutting is performed after
pinching.
• Some remaining subcutaneous fat is observed
with the naked eye, and the SMAS which is
located more deeply is not damaged.
• Therefore, the parotid gland which is located
deep to the SMAS is not damaged.
10.5
Pinch Anatomy: Cheek Area

For the cheek area, it is advisable to keep in mind
the location and the depth of the masseter muscle
and the parotid gland.
As illustrated in Fig. 4.5, the parotid duct, the
facial nerve branches, etc. travel embedded in the
parotid gland; therefore inserting and proceeding
thread through the subcutaneous layer can be safe.
When this area is pinched, it can be seen that
only the subcutaneous fat layer is pulled, but in
case of those patients with thin subcutaneous fat
layer, the depth for the procedure needs careful
adjustment to suit the individual. It is advised to
proceed the thread with sense of penetration
through the tissue area which is lifted after gentle
pinching.
In this area, caution must be exercised not to
damage the parotid glands, the parotid duct, the
facial nerve, the transverse facial artery, etc. The
above structures travel inside the parotid gland,
and after they emerge from the gland, they run
covered by the SMAS
The layers pulled up with pinch manipulation
must be kept in mind, and a thread should be
inserted into the proper plane during the thread
lift procedure.
10.5  Pinch Anatomy: Cheek Area

54
Histologic Finding  Cheek

• The red square indicates the orientation of the
tissue specimen.
• In the bottom of the cutout surface, the dermis
and subcutaneous fat tissues are cut obliquely.
This is the result of this area not being pulled
upward as much as other areas at the time of
pinching due to the dense fibrotic tissues.
• In the area where the subcutaneous fat layer
exists to a certain extent, only some of the
­subcutaneous fat layer is removed together
with the skin when pinched and cut.
• Some remaining subcutaneous fat is observed
with the naked eye, and the SMAS which is
located more deeply is not damaged.
• Both the SMAS and the parotidomasseteric
fascia are thick over the parotid gland, but
they become thin over the masseter.
• The buccal branches of the facial nerve which
travel with the parotid duct can be observed.
Parotid duct
Facial nerve SMAS
SMAS
Epidermis
Masseter
Parotid gland
Parotidomasseteric fascia

10.6
Pinch Anatomy: Lower
Cheek Area
In this area, caution must be taken not to damage
the buccal and marginal mandibular branches of
the facial nerve. The branches of the facial nerve
travel inside the parotid gland, and after they
come out of the gland, they run beneath the
SMAS.
The layers pulled up with pinch manipulation
must be kept in mind, and a thread should be
inserted into proper plane during the thread lift
procedure
Gross Finding
• In the area where the subcutaneous fat layer
exists to a certain extent, only some of the sub-
cutaneous fat layer is removed together with the
skin when cutting is performed after pinching.
• Some remaining subcutaneous fat is observed
with the naked eye, and the SMAS which is
located more deeply is not damaged.
10  Pinch Anatomy for Each Area

55
• Therefore, the buccal and marginal mandibu-
lar branch of the facial nerve which travel
deep to the SMAS is not damaged.
Lower
cheek

10.6  Pinch Anatomy: Lower Cheek Area

57
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Pinch Anatomy Summary
11.1
Areas Where Pinch Anatomy
Is Important
Pinch anatomy is meaningful in that it can assist
with safe procedures. Especially, it helps to prevent
blood vessel damage in the temporal area and nerve
damage in the zygomatic arch area. It is related to
the movement of blood vessels and nerves in the
facial layer when pinch is applied to those areas.
11.1.1 Temple Area Inside
the Hairline
Pinch anatomy in the temporal area shows vari-
ous key facts. The result of cutting after pinching
is shown in Fig. 10.3. Note that fat around the
superficial temporal artery is removed almost
completely. In other words, the fat layer located
at the same depth as the blood vessel is damaged,
while the blood vessel itself is intact (Figs. 11.1,
11.2, and 11.3).
When deep pinch was applied to the temporal
area, interesting result was observed. The super-
ficial temporal fascia was also removed along
with the skin and subcutaneous fat (Fig. 11.4).
Figure 11.4 provides a lot of information.
Although the method of fixing a thread in the fascia
in the temporal area is the most effective, it is not
technically easy. Also, as it is a blind technique,
when anchoring is done, whether the thread actually
hangs in the superficial temporal fascia or the thread
reaches up to the deep temporal fascia cannot be
directly confirmed visually. It is clear that the thread
must be hung in the fascia to make a harder fixing
point. However, whether the thread is actually hung
in the fascia is difficult to know even during the
procedure.
Based on the overall pinch anatomy findings
in the temporal area, the following conclusions
can be drawn.
11
1. When a pinch is done, a certain area of
the temporal tissue loosens and this area
is pulled up.
–– When the pinch is gently applied, the
interface between the subcutaneous
fat and the superficial temporal fas-
cia becomes loose, and the gap is
created between them.
–– When the pinch is deeply applied, the
superficial temporal fascia is sepa-
rated from the deep temporal fascia.
2. When the gentle pinch is applied, the
superficial temporal vessel encased by
the superficial temporal fascia remains
at the bottom, while subcutaneous fat is
pulled upward with the skin.
3. With the knowledge of pulled up layers
with different pinch methods, clinicians
can be confident in targeting the tempo-
ral fascia for anchoring a thread.

58
11.1.2 Zygomatic Arch Area
The facial nerve passes across the zygomatic
arch. When a surgical facial lifting is per-
formed, the facial nerve can be injured causing
frontalis muscle weakness and eyebrows
sagging.
Also in case of performing absorbable thread
lifting, caution must be taken when the cannula is
crossing the zygomatic arch. The facial nerve runs
beneath the superficial temporal fascia, and it
does not get lifted with gentle pinching (Fig. 11.5).
Therefore, the cannula can cross the zygomatic
arch without damaging the facial nerve if it is
advanced in the subcutaneous fat layer.
Skin
Superficial temporal a.v.
Subcutaneous fat
Superficial
temporal fascia
Deep
temporal fascia
Temporalis
Fig. 11.1  Location of the superficial temporal artery in the temporal area. (Published with kind permission of © Kwan-
Hyun Youn 2018. All rights reserved)
Skin
Subcutaneous fat
Superficial
temporal fascia
Superficial temporal a.v.
Deep
temporal fascia
Temporalis
Fig. 11.2  The result of cutting after pinching. (Published with kind permission of © Kwan- Hyun Youn 2018. All rights
reserved)
11  Pinch Anatomy Summary

59
Separation of subcutaneous
fat from the superficial
temporal fascia creating gap
between them
Fig. 11.3  The proposed mechanism of intact superficial temporal artery with surrounding fat completely removed.
(Published with kind permission of © Kwan- Hyun Youn 2018. All rights reserved)
11.1  Areas Where Pinch Anatomy Is Important

60
Fig. 11.4  The proposed mechanism of removal of the superficial temporal fascia. (Published with kind permission of
© Kwan- Hyun Youn 2018. All rights reserved)
11  Pinch Anatomy Summary

61
Fig. 11.5  Pinch on the
zygomatic arch area
(Published with kind
permission of ©
Kwan- Hyun Youn 2018.
All rights reserved)
Summary
Area where manipulation of pinching is
useful
• Temple area inside the hairline
–– Pinching may reduce the likelihood of
damaging the superficial temporal ves-
sel when making a puncture and anchor-
ing a thread.
–– Pinching may help the thread to proceed
at an appropriate depth without damag-
ing blood vessels.
• Zygomatic arch area
–– When gentle pinch is applied, the facial
nerve located deep to the SMAS is not
pulled upward.
–– Pinching may reduce the possibility of
facial nerve injury.
11.1  Areas Where Pinch Anatomy Is Important

Part IV
Understanding Absorbable Threads

65
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Evolution of Absorbable Thread
Lifting
12.1
Trend of Thread Lifting
First-generation
lifting thread
Second-generation
lifting thread
Third-generation lifting
thread
Fourth-generation lifting
thread
Shape
Feature
Thin mono-thread
Thread in a twister
shape
Cutting thread with cog
Bi-directional molding
cog
Key
effects
Improve fine wrinkles
Skin regeneration
Lifting
Lifting
Skin elasticity
Skin elasticity
Improve fine wrinkles
Improve deep wrinkles
V-line
V-line
Skin regeneration
Skin regeneration
Skin elasticity
Skin elasticity
12
The present day can be called the golden days of
the PDO threads. As there are various types and
product groups, even selecting is not easy.
Therefore, to select the adequate PDO lifting
products, clear understanding of the characteris-
tics of various threads is required. Threads can be
classified by several standards, and threads can
be selected based on the purpose of the
procedure.
Standards for classifying the PDO threads are
in Table 12.1.
12.1.1 Distinction of Threads
The top picture in Fig. 12.1 means mono-thread.
By inserting into the subcutaneous or SMAS
layer and causing tissue reactions, lifting or tight-
ening effects can be obtained.
The bottom picture in Fig.  12.1 is a cog
thread. A cog which looks like a thorn is pro-
duced by a cutting or molding method in accor-
dance with the direction to pull. If it is pulled
after inserting the thread in the facial tissue, tis-
sues will be hanged to the threads due to the
function of cogs.
The top picture in Fig. 12.2 shows a unidirec-
tional cog thread in which the direction of the
cogs is consistent from the beginning to the end.
This was largely used in the initial cog thread lift-
ing procedures. The function of making a fixing
point was weak, and there was insufficient expla-
nation about mechanisms. This is not used much
currently.

66
The bottom figure in Fig.  12.2 shows a bi-­
directional cog thread. This product is used
mostly in cog thread lifting. Cogs in different
directions are made on one thread, and they have
a function of gathering tissues to the middle area
of the bi-directional cogs.
Figure 12.3 shows various bi-directional cogs.
The top picture is the ordinary bi-directional
cogs. The bottom picture is in the similar form to
the bi-directional cogs but is made in the form of
continuously changing directions. It is often
called a zigzag type thread. Rather than serving
the lifting function of pulling tissues, it is largely
used for the purpose of fixing the lifting effect
made by bi-directional cog threads and prevent-
ing sinking of the skin.
The top picture in Fig.  12.4 shows a
mono-thread.
The bottom picture shows a PDO thread in a
twisted form. Products with various names exist.
With internal structure of twisting type, it is
expected to form collagen better, and it has a
slight volumizing effect. Therefore, by inserting
many of them in one area simultaneously, it
sometimes has an effect which is similar to fill-
ers, and it sometimes shows effect of pressing the
sagged cheek area by using the feature that is
harder than ordinary mono-threads. It is pro-
duced to be thicker and harder than ordinary
PDO threads.
The top picture in Fig. 12.5 shows cutting type
thread among production forms of cogs. As the
cogs are labile, when they are inserted into tis-
sues and pulled, they hang on tissues well. On the
other hand, as the thickness of the thread body is
Table 12.1  Classification of absorbable threads
Classifying standards
1. Existence of
cog
Mono-thread
Cog thread
2. Direction of
cog
Uni-directional
cog thread
Bi-directional
cog thread
3. Diversity of
cog directions
Zigzag type cog
thread
Bi-directional
cog thread
4. Twisting of
thread
Simple type
Twister type
5. Manufacturing
method of cog
Cutting method
Molding
method
6. Length
Long thread for
anchoring
Short thread
7. Shape of
needle
Cannula type
Needle type
8. Ingredient and
duration
PDO
PLLA
Fig. 12.1  Mono-thread and cog thread
Fig. 12.2  Uni-directional cog thread vs bi-directional
cog thread
Fig. 12.3  Bi-directional cog thread and zigzag type
thread
Fig. 12.4  Simple type (mono-thread) and twister type
12  Evolution of Absorbable Thread Lifting

67
becoming thin due to cutting, tensile strength is
reduced.
The bottom figure is a molding thread which
has been positioned to be a key thread among cog
threads. It is manufactured in the method of
molding while simultaneously pressing the body
and cogs of the thread. It shows better effects
than the cutting thread in terms of tensile strength
and retentivity.
The top picture in Fig.  12.6 is a PDO bi-­
directional cog thread called a long thread. However,
it does not use the functions of the bi-­directional
cogs and actually uses the functions of unidirec-
tional cogs by fixing the area without cog in the
middle of the thread to the fascia in the temporal
area. This is a thread used in fixed type lifting.
The bottom picture is a PDO bi-directional
cog threads ordinarily referred as short threads.
Using the mechanisms of the bi-directional cogs,
lifting effects are created by causing the tissues to
gather at the middle area of the thread.
The top picture in Fig. 12.7 shows a sharp nee-
dle type cog contained in a cannula. As it is a nee-
dle type, it easily passes tissues during procedures.
However, the chance of bleeding is relatively high
compared to the thread contained in a cannula.
The bottom picture shows a cog thread con-
tained in a blunt cannula. This is harder for
­passing tissues during procedures, but it has
advantage of causing less bleeding.
12.1.2 Current Trend
Based on the current trend of absorbable threads,
cog threads are used mainly. Mono-threads are
still advertised as being used for lifting purpose;
based on the prior use, it is thought to be more
accurate to say that it is used for the purpose of
tightening to contract inner tissues.
For strong and sustained lifting effects, a
molding type PDO thread which is stronger and
longer lasting is developed and used. Based on
such development from technical and material
engineering perspectives, various indications and
procedure methods are being made. For example,
recently, absorbable threads are being used for
other purposes, not simply lifting but reducing
the nostrils and raising the nose, etc. For such
contents used in advertisements, our clinicians
should have attitudes of attempting to study and
verify the effects of the new techniques and
durations.
On one hand, ingredients which can last lon-
ger are being paid attention as materials for
absorbable thread lifting. As the existing fillers or
medical devices, materials which are verified for
safety are largely used. Cosmetic medicine in
Korea is developing at a rapid rate. This is not an
outcome
achieved
not
only
by
medical
practitioners.
This is an outcome achieved through conver-
gence of complicated intermix of power of engi-
neers who plan and develop products and
marketing-related people who commercialize
them, etc.
Fig. 12.5  Cutting thread and molding thread
Fig. 12.6  Long thread and short thread
Fig. 12.7  Needle type thread and cannula type thread
12.1  Trend of Thread Lifting

69
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Understanding PDO
13.1
Physical Characteristics
of PDO
The thread of PDO ingredient has been used as a
suture for a long period and it is proved to be
safe. It lasts longer compared to Dexon and
Vicryl and completely absorbs after 6  months
and disappears from the body. Therefore, it has
been used for closing the area which requires
long tension.
Moreover, as PDO threads can be manufac-
tured in a surface which is soft and monofila-
ment in form, the risk of latent infection which
can occur by settling of germs on the surface of
the thread is low. Accordingly, it has been
accepted for its safety and sustainability as a
suture.
13.2
Functions of PDO
In general, a PDO is known to cause changes to
the dermis. As discovered in several studies, it
has effects of improving pores or fine
wrinkles.
Especially, it is known to increase thickness
of the papillary dermis, which is done through
the method of fostering collagen formation in
the dermal matrix.
13.3
Tissue Changes After
Inserting PDO Threads
In the journal, the authors explain tissue changes
after inserting the PDO thread into the subcutane-
ous layer.
This is an excellent study which can explain
the changes to the skin and the subcutaneous
layer after submitting the PDO thread. Based on
this, significant portion of thread lifting mecha-
nisms could be explained.
The changes after inserting the PDO can be
summarized as follows.
13.4
Histologic Findings After
PDO Thread Insertion
1. Many PMN cells, including eosinophile, are
gathered making granulation tissues around
the thread which is inserted. In the granulation
tissues, newly made collagenous connective
tissues are abundantly observed.
13

70
2. The newly made collagenous connective tis-
sues converge into the pre-existing fibrous
connective tissues nearby (merging effect).
Through merging effect, an inflammatory
reaction is in progress to the surrounding
area where the thread is inserted, and mecha-
notransduction (=cell signal delivery hap-
pens when granulation tissues are formed)
starts and spreads as waves to surrounding
tissues.
3. Inside the granulation tissues which are newly
made near the inserted thread, fibroblasts and
myofibroblasts show. Myofibroblast is mostly
clearly related to a wound contracture in the
wound healing process, and it is a cell which
serves a key role of causing elasticity in the
area of the procedure and tight skin after the
skin regeneration procedure.
4. The cross-sectional area size of capillaries is
larger in experimental group where the PDO
thread was inserted than control group. Also,
many eosinophils were observed which shows
effects for inducing fibrosis in the wound
healing process.
5. There was fat cell denaturation by granulation tis-
sue only in the area where the thread was inserted,
and there was no change to fat cells away from
granulation tissues (Fig. 13.1, Table 13.1).
Fig. 13.1  Schematic
diagram of change after
mono-thread insertion.
(Five tissue changes
mentioned above are
shown)
Table 13.1  Summary of histologic changes after insert-
ing PDO
Newly developed fibrous connective tissue
Merging with existing fibrous connective tissue
Tissue contraction by myofibroblast
Increased capillary vessel size
Fat cell denaturation
13  Understanding PDO

71
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Understanding of PLLA
14.1
PLLA as a Suture Material
Once it is discovered that volume loss is the most
crucial element of aging, various materials were
used to create volume in the face.
PLLA (poly-L-lactic acid: Sculptra®) is used
as a material for volumizing. PLLA can be biode-
graded and it is an adequate material for the liv-
ing body. In general, after being inserted into the
body, it forms collagen, and it is known to be sus-
tained for 2 years. After being inserted into the
body, PLLA forms type 1 collagen and type 3
collagen, and it is known to cause almost no or
very small amount of inflammatory reaction to
the surrounding tissues.
Kulkarni and colleagues also have stated that
when PLLA was injected into the subcutaneous
tissue, there is a very weak inflammatory response
initially, but it disappears as time goes on.
Gogolewski et  al. also observed changes after
injecting PLLA. It was stated that as PLLA was
decomposed, collagen settlement increased but
that no acute inflammatory response was observed.
Hyaluronic acid ingredient can also make
some collagen around the injected area, but this
differs from what is made by the PLLA ingredi-
ent. Volume formation using a hyaluronic acid
filler is mostly by the hyaluronic acid itself and
partially by newly formed collagen. On the other
hand, PLLA ingredients differ in that they are
decomposed slowly over a period of 2 years and
collagens mostly fill the space.
14

73
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Type of Absorbable Thread
Products
15.1
QT Lift (= VOV Lift, = BLUE
ROSEⓇ FORTE)
15.1.1 Features
QT lift or QTL (=VOV lift, = BLUE ROSEⓇ
FORTE) is a molding type PDO thread. In this
product, the sustained duration and tensile
strength, which were weak features in the exist-
ing cutting type threads, are significantly improv-
ing. Through a pressure molding method, while
constantly maintaining the thickness of the body
of the thread, cogs are strong and durable
(Fig.  15.1). As cogs are many in number and
close together, they hang the tissues evenly in
many areas.
Through in vitro study, it was discovered that
it has stronger tensile strength (Fig.  15.2) and
longer duration than cutting type cog threads
(Table 15.1).
A long thread to fix the temporal fascia and a
short thread for simple insertion and tying, etc.
are commercialized (Table 15.2).
15.1.2 Advantages Determined
by the Authors
There are several problems with absorbable
thread lifting.
① Insufficient effect
② Short duration
③ Side effects such as dimpling
④ Bruising and swelling
Among these, molding type thread achieved
improvement from perspectives of effects and
duration. As seen Fig. 15.2, not only the ten-
sile strength is five times the existing cutting
15
Fig. 15.1  QT
lift = VOV lift = BLUE
ROSEⓇ FORTE. (Close
shot. A strong thread
body and a cog shape
made by pressure
molding method can be
seen)

74
type thread, but also the duration of cog is
relatively long.
In case of QT lift (=VOV lift, = BLUE
ROSEⓇ FORTE), which is a PDO thread in pres-
sure molding method, the important advantages
are that it is strong and has a long duration. And
it is relatively thin compared to other threads
which have the same strength. Therefore, it is
possible to do the procedure using a smaller
cannula. Also, as the cog is strong, a procedure
using the tying method mentioned later is pos-
sible. When performing a procedure using a
short thread, as a way to strengthen the function
of the fixing point, the tying method is often
used. Both the complex skill in the form of fix-
ing at the deep temporal fascia using a long
thread and a skill of simply inserting into fat and
pulling can be used. Namely, this is a thread
40.8 N
8 N
VOV lift = BLUE ROSE® FORTE=QT lift
Cutting thread
Fig. 15.2  Tensile
strength. Ref. R&D
dept. of Feel tech Co.,
Ltd., 2015. (Source:
2015 research materials
of Blue Rose Porte
manufacturer)
Table 15.1  Long lasting
Initial shape
After 30 days
After 90 days
VOV lift
Long-lasting, durable sculpted cogs
VOV lift stays in perfect shape and improving its duration
Source: Esthetics Co., Ltd.
Table 15.2  Characteristics of QT lift = VOV lift = BLUE ROSEⓇ FORTE
Thread and Cannula
Characteristics of QT lift = VOV lift = BLUE
ROSEⓇ FORTE [18G/19G]
Characteristics of QT lift = VOV lift = BLUE
ROSEⓇ FORTE [410 mm]
Source: 2015 research materials of Blue Rose Porte manufacturer
15  Type of Absorbable Thread Products

75
which is useful for both beginners and experi-
enced practitioners.

15.2
Silhouette Soft®
15.2.1 Features
Silhouette Soft® is made of PLLA ingredients. It
is the same ingredient as a collagen stimulator
which was sold under the name Sculptra® in the
past, and it has a longer duration than the PDO.
It has cogs in unique form which is different
from ordinary cogs (Fig. 15.3). These cogs are
called cones and are not fixed in their positions.
Each cone drives freely between knots in the
middle of the thread. As 12 cm needle is attached
in both ends, procedures can be done without the
help of supplementary cannulas or needles.
Rather than a true lifting, it brings lifting effects
by gathering tissues based on the soft tissue repo-
sitioning concept (Fig. 15.4).
0.5 cm length for 8 cone suture
0.8 cm for 12 and 16 cone sutures
2 cm length
23G needle
12 cm
0.5 cm length for 8 cone suture
0.8 cm for 12 and 16 cone sutures
Fig. 15.3  Exterior and structure of Silhouette Soft®. (Source: Silhouette Soft® /SINCLAIR)
Volume
a
b
Fig. 15.4  Mechanisms of Silhouette Soft®. (a) It is a method of pulling after inserting the cog thread. (b) Silhouette
Soft® procedure is a method of repositioning by pulling tissues at both sides)
15.2  Silhouette Soft®

76
From a perspective of materials, PLLA threads
are harder than PDO threads. Also, due to lower
elasticity, if PLLA are bended or pulled hard, the
risk of being broken is higher than the PDO. On
the contrary, duration is longer than the PDO
threads. It is well known for the function of col-
lagen formation through stimulating surrounding
tissues.
15.2.2 Advantages Determined
by the Authors
The biggest advantage is that the procedures
using the Silhouette Soft® are simple and allow
diverse designs. As needles are attached at the
both ends of the thread, procedures can be done
simply without additional devices. Since the ends
are sharp, there is no problem with proceeding
through the subcutaneous layer. When the proce-
dure is performed adequately, there is less pain
and bleeding due to the needle size is fine.
It is more suitable for patients that require tis-
sue repositioning rather than lifting procedures
with fixing points. For example, it is useful for
treatments like gathering under eye tissues and
pulling sagged lower cheeks upward by pushing
upward. Complicated designs which are difficult
to achieve with other types of threads can be
achieved more easily by using Silhouette Soft®.
This is due to the advantage of the soft and flexible
needles come with the Silhouette Soft® which
makes it relatively easy to proceed in curved areas.
Also, it is advantageous for procedures such as
nose tip reshaping procedure, sagged neck lifting,
etc. Apart from the above pros, as it is a needle type,
it should be noted that severe bleeding can occur
during procedure if the adjustment of depth fails.

15.3
N-Cog Lift
15.3.1 Features
This is the first-generation PDO threads in the coun-
try. It is manufactured by cutting method. It has
various product groups, and there are many areas in
which procedures can be performed. It can also be
used for lifting sensitive areas which are difficult to
do with other threads such as periorbital area.
Bi-directional cogs and zigzag type cogs are
widely used (Figs.  15.5 and 15.6), and proce-
dures are simple.
15.3.2 Advantages Determined
by the Authors
The procedure is simple and convenient. N-cog
threads have a versatile range of products designed
to treat different area of concerns. Various tech-
niques are systematically established; it is suitable
for those who just start cog threads procedure.
Although the holding power of cutting cog
threads is relatively weaker than that of molding
cog threads, a good result can be obtained by
using suitable techniques and a sufficient volume
of threads.

15  Type of Absorbable Thread Products

77
Fig. 15.5  N-cog lift. (Source: N-Finders Co, Ltd.)
Cog which receives the
most power
4.5 cm
Cogs which receive the most power
9 cm
Point where stress gathers
Cogs which receive the most power
4.5 cm
1.5 cm
1.5 cm
Power dispersion
1.5 cm
9 cm
1.5 cm
Stress dispersion
1.5 cm
1.5 cm
stress
Cogs which receives the
most power
Cogs which receives the
most power
stress
Cogs which receives the
most power
Cogs which receives the
most power
stress
Cogs which receives the
most power
Cogs which receives the
most power
stress
Cogs which receives the
most power
Cogs which receives the
most power
stress
Cogs which receives the
most power
Cogs which receives the
most power
stress
Cogs which receives the
most power
Fig. 15.6  N-cog lift. (Source: N-Finders Co, Ltd.)
15.3  N-Cog Lift

Part V
Basic Techniques
Depending on the type of threads and the physician, there are various tech-
niques. In this part, we deal with design, anesthesia, entry point, thread inser-
tion, and cutting and finishing, which are the basics of thread lifting
procedures. This chapter consists of useful techniques which are done most
frequently in general and focuses on the methods for procedures using cog
threads.
Depending on the physicians or conditions of patients, it is necessary to
choose different techniques. Detailed techniques based on the types of the
threads are dealt in 「Part VI.  Techniques for Each Type」 and 「Part
VII. Procedures for Each Part」.

81
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Design and Patient Selection
Design is the most fundamental and crucial stage
of thread lifting which determines the result of
the procedures. As the direction and degree of
sagging differ among people, it is recommend-
able to design accordingly. However, in practice,
patients choose the type and number of the
thread before procedures. In such case, it is dif-
ficult to achieve a good result. Through detailed
designing, the best outcome can be achieved
based on variable conditions. It is recommended
that physicians try to pull the skin with various
directions on patients’ faces, and the key vector
must be selected therefrom. To achieve a mutu-
ally satisfying result, sufficient communication
is vital during the process. There are largely
three common vectors used by the authors in
cheek lifting.
16.1
Finding the Vector
(Simulation) (Fig. 16.1)
Using one or both hands, we can predict the out-
come of the procedure by pushing the skin in the
direction you want to lift it. (The authors called
this process as simulation.)
• (During consultation) Lifting simulation
works better when the skin is lifted using two
or three fingers or the palm rather than one fin-
ger. The patient should be educated that out-
come varies depending on the type and the
amount of threads. It can be explained to the
patient that the difference between the simula-
tion result of a finger and a palm is related to
the number of threads used.
• Show expected outcome to the patient using
the mirror.
• (During procedures) Once the type and the num-
ber of threads are chosen, find out a key vector
that creates the best result through simulation.
• Draw horizontal lines/vertical lines/oblique
lines which serve as reference lines.
• Mark the starting point and the ending point on
the key vector line based on the length of threads.
16.2
Marking Reference Lines
(Fig. 16.2)
1. Draw a horizontal line from the lateral
canthus – ⓐ.
16
• Vector which goes from the marionette
line to the ear lobule.
–– This is called as the oblique vector in
this chapter.
• Vector which passes the mandible-­
zygomatic arch-temple.
–– This is called as the vertical vector in
this chapter.
• Vector which passes the nasolabial fold-­
zygomatic bone-hairline.
–– This is called as the nasolabial vector
in this chapter.

82
Fig. 16.2  Reference lines and
basic vectors of design
:
locations of entry points at the
time of inserting threads
Fig. 16.1  Simulation using fingers (finding adequate vectors)
16  Design and Patient Selection

83
2. Draw a vertical line from the lateral
canthus – ⓑ.
3. Draw a line which connects from the oral
commissure to the lobule – ⓒ.
4. Draw a horizontal line from the end of the
eyebrow – ⓓ.
• Meaning of ⓐ: At the point where this line
and the hairline meet, entry point can be
marked for the nasolabial vector.
• Meaning of ⓑ: When performing nasola-
bial lifting or marionette lifting, the hang-
ing point does not need to be the desired
area of pulling. Sufficient effect can be
achieved even if the hanging point is not
located medially to the line ⓑ.
• Meaning of ⓒ: In lifting sagged cheeks
using the vertical vector, the hanging point
doesn’t need to reach to the desired area of
pulling (as explained above, the desired
area of pulling and the hanging point of the
thread
do
not
necessary
coincide).
Sufficient lifting can be achieved even if
the ending point is not more below than the
line ⓒ. This does not mean that the thread
should never be inserted below this line.
Moving approximately 1FB below the line
ⓒ would be okay.
• Meaning of ⓓ: When an entry point is made
at the point where this reference line and
the hairline meet (d’), precaution must be
taken to avoid damage of the superficial
temporal artery (STA). The STA runs more
laterally to the hairline between a’ and d’ in
most cases and drives more medially to the
hairline after it passes d’. However, in some
cases, it runs more medially to the hairline
between a’ and d’. Therefore, it’s crucial to
avoid STA damage by checking its pulse
around the hairline while marking entry
point prior to procedure.
16.3
Indicating Dangerous Areas
Indicate routes of the STA.
Summary
Importance of Thread Selection and Patient
Selection
• Prior to designing, the type and amount
of threads should be discussed with
patients during consultation.
• If the patients have excessively high
expectation or are not good candi-
dates  for thread lifting, it is not
recommended.
• Therefore, it is advisable to select proper
patients who will get a good level of
results.
Tip!
The reason that you don’t need to make the
hanging point medially over the line ⓑ.
• In case of threads with strong cogs, pos-
sibility of dimple is increased (see 「Part
9. Side Effects and Measures」).
• As the subcutaneous fat layer is very
dense in this area, progressing a cannula
requires much more force.
• As the subcutaneous fat layer is very
dense in this area, the likelihood of tis-
sue damage and blood vessel damage is
higher.
Tip!
The reason that it is not good to have the
ending point much more below the line ⓒ.
• If the hanging point is placed near the
jaw bone, threads with weak tensile
strength may be cut, or the patient may
experience pain when the mouth is
opened widely.
16.3  Indicating Dangerous Areas

84
Importance of Design and Vectors
• Among all the process of thread lifting
procedure, authors believe that designing
process is the one which decisively influ-
ences the treatment outcome. Once
patients are selected and the type of
threads is chosen, the result of the proce-
dure is expected to a certain extent. In
general, the number of threads is deter-
mined during designing.
• During thread lifting training, designing of
both sides is usually done by the trainer
(the author). Thereafter, the author inserts
the threads on the right side, and the trainee
performs procedures on the other side.
• What do you think the outcome of the pro-
cedure would be? In conclusion, there is
not much difference in the results from the
right side and the left side. Of course, there
is some difference in the occurrence of
bleeding during procedures or dimples
after procedures. However, if procedures
are done after finding the key vector and
designing, the results from both sides tend
to be satisfactory.
• However, if designing is not done by the
trainer but done directly by the trainee and
procedures are performed (if the designing
is not done with the key vector, but with an
inappropriate vector), in most cases, they
do not achieve the satisfactory result.
Therefore, designing by finding the appro-
priate vector can be considered as a key
step during the process.
16  Design and Patient Selection

85
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Anesthesia
17.1
Anesthesia Using Dental
Lidocaine
17.1.1 Anesthesia Using the Dental
Lidocaine (Figs. 17.1 and 17.2)
Inject locally in multiple areas.
Advantages
• It can be easily done by beginners.
• It can be done in much shorter time than anes-
thesia using cannulas.
Disadvantages
• As needles are injected in multiple areas,
bruising may occur.
• More painful than anesthesia using cannulas.
17.2
Anesthesia Using Cannulas
17.2.1 Anesthesia Using Cannulas
(Tumescent Solutions or
Lidocaine) (Figs. 17.3 and 17.4)
Advantages
• If anesthesia is performed using a dental lido-
caine needle, dissatisfaction is sometimes expe-
rienced due to unexpected occurrence of bruising
in anesthetic sites. However, if tumescent solu-
tion is injected through entry points using can-
nulas, bruising can be prevented nearly 100%.
• Less pain is experienced than in the anesthesia
using the dental lidocaine.
Disadvantages
• It takes longer time than the anesthesia using
the dental lidocaine.
17
Fig. 17.1  Anesthesia using the dental lidocaine

86
Fig. 17.2  Anesthetic
sites using the dental
lidocaine
Fig. 17.3  Anesthesia
using cannulas
17  Anesthesia

87
Fig. 17.4  Route for
anesthesia using
cannulas
17.2  Anesthesia Using Cannulas

89
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Entry Point
18.1
Location of Entry Point
Location of entry points varies depending on
the direction of thread insertion (vector). In
case of ⓐ and ⓑ vectors in Fig. 18.1, which are
the most common vectors in lifting, the loca-
tions of entry points can be placed largely in
three points.
1. To match the hairline
2. More inferomedial than the hairline
3. More superolateral than the hairline
18
Fig. 18.1  Location of
entry points.
: entry
point

90
18.2
Number of Entry Points
Once the vector and number of threads are
decided, entry points should be made. There are
two types.
1. Inserting one thread into one hole
2. Inserting multiple threads into one hole (most
cases)
18.3
Selection of Entry Point
Tools
There are two types of tools used in making entry
points.
1. Disposable needle
2. Awl (Figs.18.2 and 18.3)
Advantages in using awl
• Low risk of bleeding (blunt)
• It creates large size entry point
–– If the hole is made too small due to the
concern of bleeding, friction could
occur while a cannula enters.
While making an entry point using the above
tools, the correct layer it should penetrate is SQ
layer. It is not necessary to penetrate the SMAS
and muscles by deep puncture.
18.4
Cautions to Be Taken While
Making Entry Point:
Bleeding (Superficial
Temporal Artery and Vein)
(Figs.18.4 and 18.5)
Fig. 18.3  Tools used in making entry points
Fig. 18.2  Method of making entry points using awl
18  Entry Point

91
Sentinel vein
Superficial
temporal
artery
Entry points
Path for
thread insertion
Fig. 18.4  Routes of
vein (sentinel vein) and
artery (superficial
temporal artery) near the
hairline – two vessels to
be cautious of when
making entry points
18.4  Cautions to Be Taken While Making Entry Point: Bleeding (Superficial Temporal Artery and Vein)

92
a
b
Fig. 18.5  Route and
depth of the superficial
temporal artery near the
hairline. Black arrow:
After pinching and
cutting the skin. STA is
surrounded by the
superficial temporal
fascia. Red arrow: STA
can be observed where
the skin is intact. Blue
dots: Original hairline.
(Published with kind
permission of © Wonsug
Jung 2018. All rights
reserved)
18  Entry Point

93
18.5
Sterile Draping of Hairline
• Aseptic technique must be applied while
making entry point along the hairline (see
Fig. 23.7).
• Caution must be taken not to have the patient
hair caught in the thread or entered into the
entry point during procedures to avoid
contamination.
• After the procedure ends, in general, skin tape
is affixed on the entry point and removed after
2–3 days.
Summary
Solutions of Entry Point Bleeding
• Bleeding at entry point – In case of eas-
ily hemostasis (a few seconds ~ within
1 min)
–– Small-sized vessel injury.
–– Continue inserting the thread.
• Bleeding at entry point  – In case that
immediate hemostasis is not possible
(2–3 min or longer)
–– This is a case of medium-sized vessel
or branch of STA/STV damage. In such
case, a new entry point must be made.
–– Generally, there is less blood vessel
route in the medial side to the hairline.
Try to make a new entry point by mov-
ing about 5 mm to the medial side.
• Bleeding after thread insertion
–– This is case of bleeding in the inser-
tion route. This can occur if a blunt
cannula is handled too roughly or a
sharp needle is used.
–– Control bleeding and leave the thread
as it is.
• Swelling from bleeding during cannula
insertion
–– Sometimes swelling can occur due to
bleeding in the cheek area during
insertion of cannula (blunt/sharp). In
such case, remove the cannula and do
not insert the thread. Hemostasis
must be applied for a long period.
18.5  Sterile Draping of Hairline