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

96
after going forward. Once the cog thread is
inserted into the tissues, the thread is
immediately anchored, so that only the
cannula can be pulled back. (Problems may
occur if insertion depth is not well
adjusted.) However, reversing is possible if
only the proximal head of the cannula and
thread is pressed by the thumb. While with-
drawing the cannula, if any one of the cogs
is inserted into tissue, further reversing is
impossible. In such case, the cog would be
anchored at inappropriate location, and
then the thread and cannula must be
removed.
Surgical cannula (reusable cannula)
• Each of the thread needs insertion of surgical
cannula and subsequent insertion of thread into
a sheath. So it requires longer treatment time.
• In proceeding with a cannula, going forward
and reversing can be repeated. If the cannula is
inserted at a depth that is not desired, it can be
pulled back and be proceeded forward again.
19.2
Thread Insertion After
Cannula Insertion (Figs. 19.3
and 19.4)
19.3
Temporal Anchoring (41 cm
Long) U Pattern (Fig. 19.5)
19.4
Insertion Using a Thread
with Needles at Both Ends.
(Fig. 19.6)
Fig. 19.3  Surgical cannula (reusable cannula). A guide
needle with a blunt end is connected to the handle and the
sheath which surrounds the outer surface covers the guide
needle
Fig. 19.4  Surgical cannula. As for the method of using a
surgical cannula, insert the entire cannula first (guide nee-
dle + sheath), remove the guide needle, and then insert the
thread into the sheath (In the figure, the long thread has
already been inserted in a “U” shape)
Fig. 19.2  Disposable cannula
19  Insertion Technique

97
5 mm length
20 mm length
23G needle
120 mm
5 mm length
Fig. 19.6  Thread for lifting which has needles attached to
both ends. Although it is a long thread, a simple procedure can
be performed without additional tools. Instead of cogs, cones
exist between knots and they are bi-­directional. For insertion,
needles are attached to both ends of the thread (details are
dealt with in 「Part 6–4 Technique of Inserting Bi-Directional
Needle Threads」). (Source: Silhouette Soft®/SINCLAIR,
)
a
b
Fig. 19.5  Method of
anchoring temporal
fascia using long
cannulas. (a) This is a
process anchoring the
temporal area using a
curved needle for
inserting long threads
(details of this procedure
are dealt with in 「Part
6–3 Technique of Fixing
a Thread in the
Temple」). (b) Tools
needed for the
procedure. From the left,
sterile scissors, a long
cannula set (17G), a
temporal ring, an awl,
cannula for anesthesia,
and a design ruler
19.4  Insertion Using a Thread with Needles at Both Ends

99
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Cutting and Finishing
20.1
Removing Cannula
After a thread is inserted and its cannula is being
removed, the skin is to be pressed upward using the
opposite fingers. (Press upward the skin surface of
thread insertion area in a desired direction.)
20.2
Cutting
20.2.1 Cutting While Pulling
the Thread
1. Precaution
If pulling of the threads is not consistent
that just one thread is pulled strongly, the mid-
dle of the bi-directional thread which is
strongly pulled is elevated, and the remaining
threads inserted in the area are not elevated.
Finally focal protrusion/depression can occur.
This can cause patient’s dissatisfaction.
It is important for the physician to keep in
mind that all threads need to be pulled evenly.
2. Prevention of focal bulging/depression
–– When a thread is pulled, an assistant should
press approximately 2–3  cm below the
entry point and then cut with sterile scis-
sors while pushing the skin.
–– If it occurs in the zygomatic arch level, the
likelihood of dissatisfaction increases due
to the widening of the cheekbones. So
design must be done in a way that the mid-
dle point of the bi-directional thread does
not coincide with the zygomatic arch level.
20.2.2 Cutting While Pushing
the Skin
Cut while slightly pushing the skin and then
embed the tip of the thread in the SQ.
20

Part VI
Techniques for Various Types of Thread

103
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Technique Using a Mono-thread
21.1
Mono-thread Insertion
From a theoretical perspective, it is difficult to
see mono-threads having good lifting effects.
Basically, as the concept of the fixing point is not
clear and the theoretical basis for the creation of
direction is thought to result from contraction of
the subcutaneous fat tissues, the effect would be
weak. The authors will talk about their thoughts
more in detail later. In such case, there is some
difference in effect, consistency, and duration of
the procedures depending on the physicians.
However, based on author’s experience, it is
possible to make good outcomes when a suffi-
cient number of threads are inserted using ade-
quate methods. This technique has been used for
a long time and is still being used widely.
Theoretical explanations about the above
technique are expressed in Figs. 21.1 and 21.2.
When threads are inserted into two sites, tissues
are pulled to more thread inserted side. We will
review about such outcome results later in detail.
The theoretical basis is deduced from the
mono-thread insertion based on the tissue experi-
mental results shown in the article changes over time after polydioxanone thread
insertion: An animal study with pigs> by Jung
Hyun Yoon et al. Histological changes from PDO
thread
insertion
are
summarized
in
the
following.
21
Skin
Subcutaneous fat
Muscle
Fig. 21.1  Changes after
inserting a mono-thread.
The past theory explains
that direction is created
from less insertion point
to more insertion point
Summary of histologic changes after PDO thread
insertion
• Newly developed fibrous connective tissue
• Merging with existing fibrous connective tissue
• Tissue contraction by myofibroblast
• Increased capillary vessel size
• Fat cell denaturation

104
Namely, the effect of the mono-thread inser-
tion is attaching the sagged tissues inward rather
than pulling the tissue with direction.
Considering the aging change at the level of
fat, fibrous tissue, and skin with the histologic
change from thread insertion, it can be deduced
that the following results can be obtained:
• Due to the effects of fat denaturation from
insertion of mono-threads and effects of pro-
liferation and contraction of fibrotic tissues,
the size of the bulging fat decreases. As a
result, there is a tightening effect in which the
face sticks inward.
• New fibrotic tissues are created and connected
to the pre-existing surrounding fibrotic tis-
sues. In conclusion, the structure of the subcu-
taneous fibrous connective tissues becomes
dense and strong.
• Through the myofibroblast formed around
inserted threads, contraction effects of tissues
occur. This can explain the effect of pulling
the sagged face skin inward.
• It can be expected that the skin environment
will be improved by the findings that the size
of the capillaries increase.
In the end, effect of mono-thread insertion can
be expected to be caused by contraction of fat tis-
sue, strengthening of fibrous connective tissue,
and improvement of the dermal environment.
Based on the tissue slide opinion of the study
done by Jung Hyun Yoon et al., only in the tis-
sues which are nearby the threads are seen to
denature fat. However, as the amount of the sub-
cutaneous fat in the face itself is not much and
due to additional effects (proliferation and merg-
ing effect of fibrotic tissues), some beneficial
effects may be made from fat denaturation and
contraction of fibrotic tissues through the PDO
insertion. Based on objective index on the lifting
effects, we plan to conduct researches which
evaluate the results quantitatively using such
index.
21.2
Difference in Changes
from the Mono-thread
Technique
The outcome of discussions with various doctors
about how deep threads are inserted in clinical
practices and why they are performed in such
way is as follows.
Fig. 21.2  Changes after inserting a mono-thread. The
past theory explains that direction is created from less
insertion point to more insertion point
PDO mono threads
fibrous connective
tissue develop
Skin
Subcutaneous fat
Muscle
Fig. 21.3  Method of
inserting a mono-thread.
Method of inserting
threads: wave form
insertion in order to
increase the contact area
with the subcutaneous
fat layer
21  Technique Using a Mono-thread

105
Fig. 21.4  Mono-thread
procedure technique.
Method of inserting
threads above and below
along the jawline
In general, the opinion is that to shrink the
sagged fat layer, a thread is to be inserted into the
subcutaneous fat, and to pull the sagged skin, a
thread is to be inserted closely attached to the
subdermis area. Considering the changes after
inserting the PDO, we think this is an adequate
technique for procedures. To reduce the fat layer,
it seems that inserting deeply while increasing
contacts with the fat layer as much as possible
would be effective, and to cause changes to the
dermis, we think it would be useful to locate the
thread closely to the dermal layer.
The study which discovers the difference in
the relative histologic changes based on the depth
of the PDO insertion is thought to be able to bring
an important result in establishing a theoretical
background for the thread lifting techniques in
the future. It is also necessary to study the pattern
of tissue change according to the shape and thick-
ness of thread.
21.3
Explanations About
the Mechanism
21.3.1 Method of the Mono-thread
Technique: Neckline (Fig. 21.4)
• For more definition of the jawline, insert the
PDO mono-threads above and below the jawline
making sure they are also parallel to the jawline.
• Create a jawline by causing contraction of the
fat layer and conglutination of fibrotic tissues.
• If the PDO is inserted like a wave passing in
and out of the subcutaneous fat layer and the
SMAS layer, tissue contraction may be
expected in a wider area as the threads go
through the process of fibrosis while they
melt. In clinical practice, the method of insert-
ing the threads by moving the top and bottom
parts of the fat layer rather than simply insert-
ing was once popular.
21.2  Difference in Changes from the Mono-thread Technique

106
21.3.2 Mono-thread Technique: Jowl
(Fig. 21.5)
• The anatomical explanations about the reason
for bulging of the inner cheek area are as
follows:
–– Due to an empty space between the risorius
m. and zygomaticus major, the SMAS is
not continuous, and an empty space is cre-
ated. Deep fat tissues which are stretched
from aging push and come out mainly
through this area.
• The mechanism of procedures on the inner
cheek using the PDO mono-threads is using
the effect of fat denaturation, fibrosis effect,
and tissue contraction effect of the PDO.
• On one hand, in case of using a hard PDO
twister-type thread in a spring form, an effect
of pressing fat which sticks out like by causing
the muscles to cover fat in this area may be
expected. In reality, the twister-type PDO in a
spring form is expected to have an effect of
pressing tissues and volumizing effects and is
used in various areas.
21.3.3 Mono-thread Technique:
Frontal Cheek and Nasolabial
Fold (Fig. 21.7)
• Drooping frontal cheek areas are elements
which
aggravate
the
nasolabial
folds.
Through inserting mono-threads in the area
where the frontal cheek droops above the
nasolabial fold, conglutination of fibrotic tis-
sues and contraction of fat cells may be
expected.
• As a result, there is an effect of pushing the
bulging frontal cheek in slightly.
• If a slightly thicker and harder spring-type
monofilament is inserted from the cheek to
over the nasolabial fold area, there is an effect
Fig. 21.5  Mono-thread
technique. Method of
performing procedures
to cause shrinking of the
jowl area
21  Technique Using a Mono-thread

107
of reducing the frontal cheek by pressing with
force the hard PDO thread.
21.3.4 Mono-thread Technique:
Temples (Fig. 21.8)
Due to aging, wrinkles and sagging are formed
around the eye area. The fundamental treat-
ment would be the forehead lifting surgery or
eyelid surgery, but a simple procedure using
mono-­thread lifting is also possible. Of course,
the effect does not reach that of surgical
treatment.
If hard PDO threads in a spring form are
inserted in a radial shape in the temple area, it can
be seen that the eyebrows are slightly lifted.
As the PDO in a spring form is hard as well as
having small volume, it plays a role of volumiz-
ing and lifting the sagged eye areas and the tem-
ple areas. However, the effect and duration are
questionable. Comparative clinical experiments
seem necessary.
The most advanced thread lifting technique is
anchoring the threads in the temple area using
long various tools. This requires a technique
(know-how) of pulling with long threads with
fixing points making around the temples.
Classification of thread lifting techniques:
Zygomaticus minor
Zygomaticus major
Risorius
Fig. 21.6  Anatomical
mechanism of the fat
bulging inner cheek.
(Published with kind
permission of ©
Kwan-Hyun Youn 2018.
All rights reserved)
1. Short-thread technique (QT lift) – dis-
posable cannula/needle
2. Long-thread technique(QT lift)  – long
cannula
3. Technique using a thread with needles
attached in both sides (Silhouette Soft®)
21.3  Explanations About the Mechanism

108
Fig. 21.8  Techniques
for the mono-thread of
the spring-type temples.
Insert threads into the
subcutaneous fat layer in
a radial shape. A
volumizing effect with
lifting effect can be
expected
Fig. 21.7  Mono-thread
technique – frontal
cheek and nasolabial
21  Technique Using a Mono-thread

109
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Technique Using Cog Threads
22.1
Unidirectional Cog Thread
After inserting the cogs to be hung on tissues,
pull them in one direction. The lifting effect is
maintained only if the fixing point of thread is
made in anyway.
However, based on the structure and mecha-
nism of the thread, it is difficult to maintain the
lifting effect (Fig. 22.1). Nowadays, this type of
thread is used for limited cases.
22.2
Spike
Threads in a spike form are used for fixing after
performing lifting using bi-directional cog threads,
etc. first. Among various techniques of thread lift-
ing, after dissecting the layer to which the thread
is to be inserted, if the thread in a spike form is
inserted into such layer after adjusting the up-and-
down direction well (Fig. 22.2), it plays the func-
tion of fixing the dissected and dislocated plane.
When lifting through plane dissection is performed,
spike-form thread is useful rather than cog thread.
The following matters need to be considered
in performing a spike thread procedure:
• It is advisable to insert for fixing in the area
where
tissues
are
dislocated
through
dissection.
• It is advisable to insert accurately on the sur-
face where the upper board and the lower
board are separated through dissection, and
the direction of cogs is very important. After
accurately finding out the direction of lifting,
the spike thread must be inserted. The pulled
direction and the lying direction of cogs in the
upper side of the thread must coincide
(Fig. 22.3).
• If it is inserted into an opposite direction, fix-
ing does not occur and it slips, not stabilizing
the pulled tissues. Surely, this will not be able
to maintain the lifting effect.
Through Fig. 22.3, it can be seen well which
side the top and bottom of spike cogs must be.
Lifting can be maintained only if the spike cog is
inserted in the direction which prevents driving
22
Pulling direction
Fig. 22.1  Unidirectional cog. It can be fixed after pulling tissues in one direction

110
which returns in the direction that is opposite
from the pulled direction.
On the other hand, based on Fig. 22.4, if the
direction of cogs can’t prevent the movement of
the tissue to return to the original position,
pulled tissue would be slipped. Therefore, when
spike threads are used, direction is very
important.
22.3
Zigzag Method
The mechanism of the bi-directional zigzag cog
method is as follows (Fig. 22.5):
• The cog thread of zigzag method is largely
used for fixing pulled tissues after performing
lifting rather than for lifting itself.
Pulling direction
Fig. 22.3  Right
insertion direction;
pulled tissues can be
stabilized
Pulling direction
Fig. 22.4  Wrong
insertion direction; this
cannot stabilize the
pulled tissues
Pulling direction
Fig. 22.2  Spike thread. Rather than the function of pulling tissues, it stabilizes already pulled tissues, and the up-and-­
down direction is important
22  Technique Using Cog Threads

111
• After lifting procedure using bi-directional
cog threads, to prevent side effects like sink-
ing, zigzag threads are sometimes inserted
supplementary.
22.4
Bi-directional Cog
22.4.1 Understanding Bi-directional
Cogs
Bi-directional cogs consist of forward cogs which
play the role of pulling and reverse cogs which
play the role of fixing the pulled tissues not to go
down (Fig. 22.6). In the end, it has effects of lift-
ing the tissues in both sides to the middle part
without any cog.
It has better effect than unidirectional cogs.
As seen in the figure, the accurate func-
tion of bi-directional cog threads is not to pull
in one direction but to gather in the middle part
(Figs. 22.7 and 22.8). Namely, it can be under-
stood as a method of pulling both sides to the
middle area. If design and procedures are per-
formed with well understanding of this mecha-
nism, a good result can be expected.
By using such characteristics of the bi-­
directional cogs, the sunken facial area can be
adjusted (Fig. 22.9). If there are adequate design
and technical support for the facial shape, lifting
in any form is possible.
22.4.2 Experiment on Actual
Bi-directional Cogs
1. After preparing a wide area in the subcutane-
ous fat layer of pork, areas below the muscle
layer were removed.
2. After inserting a 19 G bi-directional cog thread
to the skin perpendicularly, progress was made
in a consistent depth through the subcutaneous
layer by changing the direction horizontally.
3. After removing the cannula, the cog thread
was pulled.
4. Changes were observed thereafter (Fig. 22.10).
Pulling direction
Fig. 22.5  Zigzag
method (multi-bi-­
directional cog). It
stabilizes pulled tissues
in the middle
Forward cog
Reverse cog
Pulling direction
Fig. 22.6  Bi-directional
cog
Fig. 22.7  After simple
insertion
22.4  Bi-directional Cog

112
Fig. 22.10  Traction test of bi-directional cogs. The appear-
ance after inserting the bi-directional cog thread into the sub-
cutaneous layer and pulling in one direction can be seen.
Although it is slightly distant from the thread entry site,
when it is seen through a cutting surface, it can be seen that
the subcutaneous fat layer that coincides with the middle
area of the cogs is gathered and inflated. If the procedures
are performed after understanding the mechanism well, it
has the effect of gathering tissues as well as the effect of lift-
ing, namely, the effect of volumizing through redisposition
Fig. 22.9  Actual practice with bi-directional cogs. By
causing the tissues in the middle part to be gathered, the
bi-directional cogs show lifting effects. In actual practice,
it is also important to understand the function of the area
where the cog thread enters subcutaneously. The entry
point area of the thread inevitably passes beneath the der-
mis; the cog thread tends to be hung hard at that point.
Lifting effects can be maximized by using the effect of
gathering tissues to the middle area and the effect of cogs
in the opposite direction of the cog thread hanging in the
bottom of the dermis well
Fig. 22.8  Pulled after
insertion. If this is used
wrongly, it can be a
cause of side effects
22  Technique Using Cog Threads

113
22.4.2.1
Angle Technique Using
Bi-directional Cogs
The angle technique can be understood as an
expansion of bi-directional cogs. As mentioned
previously, bi-directional cogs create lifting
effects by repositioning tissues to the middle
where there is no cog. In case of the angle tech-
nique, by causing the angle to be slightly bent,
rather than in straight line, it is a method of
causing the tissues inside the bent angle to
gather (Fig. 22.11).
It has effects of adjusting sinking, together with
lifting effects, and various designs are possible.
Insert the cannula with threads and proceed
(Fig. 22.12), then deflect the direction at angle
point, and insert to the end.
Remove the cannula from the skin and pull the
thread to make the tissue inflated.
22.4.2.2
V Technique (Bending
and Fixing)
22.4.2.3
Methods of Tying Cog
Threads
Tying method means tying of the cog thread at
the fixing point. A thickened tie enters inside the
skin thereafter and acts as a stronger fixing point
than simple cog thread insertion using uni- or bi-­
directional cogs.
22.4.2.4
X-Cross Technique
To strengthen and maintain the lifting effect, it is
important to utilize reverse directional cogs. In
general, remaining cogs are removed after the
desired length of insertion. In some case, a signifi-
cant amount of reverse directional cogs is cut out.
To optimize the lifting effect, it is important to
vitalize the function of reverse cogs. In such case,
without removing the remaining cogs, the method
of pushing them toward the opposite direction
can be used (Fig. 22.13). In addition, by tying the
middle part of the cog thread, it can be combined
with the method of making one more area which
can act as a fixing point (Fig. 22.14). By using the
two skills together, it is a method of strengthen-
ing the function of the fixing points (Fig. 22.15).
Direction of
fixing function
Pulling
direction
Pulling direction
Inflated part
Entry point
Fig. 22.11 
Bi-directional cog thread
technique – concept of
angle technique
Fig. 22.12  Techniques of bi-directional cog thread  –
insertion of angle technique
22.4  Bi-directional Cog

114
After tightly pulling the tie
Appearance of tangling of
cogs in the tied site
Fig. 22.14  Method of
tying cog threads
Pulling direction
Direction of
fixing function
Fig. 22.15  Bi-directional cog thread technique  – the
X-cross technique concept has the advantage of using the
remaining opposite directional cogs without having to
throw them out
Pulling direction
insertion point
For strengthening the
fixing point, bend and
insert the remaining
cog thread to other
direction
Fig. 22.13  Mimetic
diagram of fixing
technique by bending.
Remaining cogs are not
cut and thrown out but
are used for fixing
function
22  Technique Using Cog Threads

115
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Temporal Anchoring Technique
23.1
Mechanisms
The difference between lifting of the anchor-
ing method and others using a mono-thread or
cog thread is that it can make a strong fixing point.
It is ideal to anchor a thread in the fascia of the
anchoring site (Fig.  23.1). If the thread is
anchored in the subcutaneous fat layer, the fixing
force is weak. Understanding the changes in tis-
sues that occur when pinch manipulation is per-
formed at the temple area, the thread can be
reliably anchored to the fascia layer. The thread
should be appropriately anchored to the temple
area fascia by pinch manipulation where there is
no large vessels. After the anchoring is done
properly, the remaining thread is inserted to the
subcutaneous layer and exits out to perform the
lifting procedure.
The pulled skin is placed in a folded state at
the anchored area (Fig.  23.2). And it is main-
tained by cogs of thread. The instant result is
stronger than the mono-thread method and the
simple cog thread lifting procedures. The longev-
ity is determined by the strength of the cogs, effi-
ciency of the cogs, sustainability of threads, and
expertise of the physician.
23
Summary
Design Method (Fig. 23.3)
1. Facial landmarks and reference line
ⓐ  Horizontal line at the lateral canthus
ⓑ  Perpendicular line at the lateral
canthus
ⓒ  Line connecting from the oral com-
missure to the lobule
ⓓ  Horizontal line from the end of the
eyebrow
2. Mark a reference line inside the
hairline
ⓔ  Perpendicular line at the center of the
tragus
ⓕ  Temporal crest: it appears simultane-
ously with masseter muscle contraction

116
Thread inserting direction
Thread inserting direction
Pulling direction
Pulling direction
Skin
Skin
Subcutaneous fat
Subcutaneous fat
fascia
fascia
Muscle
Muscle
Fig. 23.1  Fascia anchoring method. This shows the mechanism of hanging the thread in the fascia and making
a fixing point
Showing the movement of subcutaneous fat
Skin
Subcutaneous fat
fascia
Fig. 23.2  Understanding of lifting mechanisms about fascia anchoring method; pulled tissues gather in at some point
between the fixing point and the exit
23  Temporal Anchoring Technique

117
Fig. 23.3  Design of the
fascia anchoring method
3. Entry point
Assuming that the semicircle located
from approximately two finger breadth
from the crossing point of ⓔ and ⓕ is ⓗ,
it is convenient to set an entry point
therein. If you make an entry point higher
than this, it is difficult to handle the can-
nula because of the curved surface of the
skull. If lower than this, you may cause
damage to the anterior branch of the STA
(superficial temporal artery. see Fig.
23.4) resulting in massive bleeding.
Summary
Cautions
to
be
Considered
during
Designing
1. Prevention of “slanted eyes” and senti-
nel vein rupture
If the innermost thread is near the lateral
canthus, the lateral canthus may be
lifted after the procedure. In some cases
with young patients, they desire lifting
the lateral canthus, but patients in their
mid- to elder ages generally consider
lifting of the lateral canthus to be unnat-
ural. Therefore, it is necessary to explain
about the lateral canthus rising, and if
that is not desired, the design of thread
pathway should not be done so close to
the lateral canthus. It is advisable to dis-
tance at least two finger breadths away
from the lateral canthus (arrows in Fig.
23.5). When designing as above, it will
not overlap the running of sentinel vein).
2. Prevention of aggravation of fine wrin-
kles under the eyes
With the rising of the lateral canthus,
when the infraorbital skin is pulled, the
fine wrinkles below the eyes may appear
deeper. This can be prevented to a certain
extent by designing the thread to pass
through two finger breadths away from
the lateral canthus. During designing, by
23.1  Mechanisms

118
actually pulling the skin with the finger,
check whether the under-eye wrinkles
become deeper together with whether the
lateral canthus lifts or not.
3. Passing the sunken cheek must be
prevented
4. Cautions to be taken at the area of fre-
quent dimples
When the exit of the thread is located
medially, it is advisable to stay within
the crossing points of the blue-dotted
line (limit line) as shown in Fig. 23.6 ③
and ④. If the exit is medial passing the
crossing point, the lifting effect of mouth
sagging may become better, but due to
the occurrence of dimples, patient’s sat-
isfaction level is more likely to decrease.
5. STA point to be cautious of −1
When designing the pathway of the out-
ermost thread, do not design in the space
between the tragus and inner one finger
breadth where the pulse of STA is most
strong. It is advisable to design at least
1.5 -2 finger breadth away from center of
the tragus (arrow of Fig. 23.5 ). If the dis-
tance is closer than this, the likelihood of
STA damage becomes high, and also,
there may be claim of “Łwrinkling of the
skin in front of the ear”Ł after the proce-
dure (patients with skin laxity).
6. STA point to be cautious of −2
The entry point should be within range
ⓗ. In some cases, an anterior or parietal
branch of STA may run within that
range. Before you make entry points,
you must check whether you feel a pulse.
Summary
Hairline preparation and draping.
1. Hairline preparation
Either cut few pieces of hair with scis-
sors or shave using a shaver. In preparing
the hairline, all hair in the opposite area
to the progression direction as well as the
progression direction must be prepared.
Preparing the hair pieces to the mini-
mum extent is necessary for the easy
posttreatment management. Unexpected
bleeding can occur severely in some
cases in anchoring threads in the tem-
poral areas. In such case, we must
change the anchoring location inevi-
tably. Considering this, it is advisable
to prepare the hairline enough to allow
anchoring twice.
2. Fixing (Fig. 23.7)
Prepare the nearby hairline using the
Fixomer, TegadermⓇ, hairpins, rubber
bands, 3M, etc. If procedures are per-
formed without this step completely, it
would interfere with thread insertion a
lot. Moreover, if hair gets into the entry
point, it can cause folliculitis. Therefore,
it is advisable to clean and prepare the
hairline prior to the procedure.
3. Disinfecting
In order to prevent foreign substances
from getting into the cannula during
insertion, areas which touch the cannula
or all areas which can touch the cannula,
including the hair, must be strictly
disinfected.
23  Temporal Anchoring Technique

119
Fig. 23.5  Cautions to
be taken in designing the
fascia anchoring
method – “slanted eyes”
Fig. 23.4  Blood vessels
to be cautious in
designing the fascia
anchoring method –
STA (superficial
temporal artery)
23.1  Mechanisms

120
23.2
Insertion Method
23.2.1 Design
23.2.2 Anesthesia Method
1. Anesthesia of entry and exit points – needle
• It is advisable to anesthetize the entry and
exit points using lidocaine (1: 100,000)
which includes epinephrine. If the exit is
not anesthetized, bruising can occur due to
the dermal plexus bleeding.
2. Anesthesia of thread progression route
1. Injection of tumescent solution or lower-­
concentration lidocaine using a cannula
• Proper anesthesia allows smooth can-
nula insertion during thread lifting.
Using very long and thin one can reduce
pain, but it is difficult to maintain con-
sistent driving depth and easy bends
during progression; an adequate thick-
ness is recommended (diameter of
0.9–1.0 mm).
a
b
Fig. 23.7  Preparations for the fascia anchoring method – draping and preparing the hairline. (a) Showing of attaching
a sterile TegadermⓇ. (b) Tools needed to prepare the hairline
Fig. 23.6  Cautions to
be taken in designing the
fascia anchoring
method – area of
frequent dimples
23  Temporal Anchoring Technique

121
• In lieu of a cannula, there is also a
method of injecting anesthetic agents
conveniently into various points of
thread pathway using needle and dental
lidocaine,
but
it
has
some
disadvantages.
–– As anesthesia does not occur as
desired, it may require additional
anesthesia during thread insertion.
–– If needles are inserted in various places,
due to dermal plexus bleeding, a likeli-
hood of bruising increases.
2. Lidocaine local anesthesia using needles
• In the long-thread lifting procedure, the
thread passes through the subcutaneous fat
layer. However, as the subcutaneous fat
layer is not an area where pain senses are
well developed, pain is minimal in general
when driving the subcutaneous fat layer
except some specific area (mainly vessel
crossing area).
• Using this, a small amount of lidocaine
is sometimes injected using a needle
into the driving route to anesthetize.
–– Advantages are that less swelling
occurs after the procedure, the proce-
dure becomes simple, and the depth of
driving can be learned through finding
out patient’s pain.
–– On the other hand, compared to
anesthetizing the driving route using
a cannula, patients can feel pain in
the interim and become anxious.
23.3
Entry Point and Anchoring
23.3.1 Tools for Entry Points
1. Awl
• It is suggested to use an awl than a needle.
• Advantages
1. Risk of bleeding is low (blunt).
2. If the hole is made small as a result of
concern for bleeding, the friction causes
difficulty in advancing the cannula. By
using an awl, a hole with a sufficient
size can be procured. Progressing a can-
nula becomes convenient.
23.3.2 Anchoring Tools
1. Needle
2. Temporal ring (Fig. 23.8)
• Advantages over a needle
1. Likelihood
of
bleeding
decreases
significantly.
2. Less chance to develop a dimple at
entry point
23.3.3 Depth and Direction
of Anchoring Point
There are various opinions as follows:
• Fixing at the periosteum
• Fixing
at
the
deep
temporal
fascia:
theoretically
• Fixing at the superficial temporal fascia
• Fixing at the deep SQ
An entry point can be located in the line of the
temporal crest (viz., much more above than the ⓗ
area in Fig. 23.3). In such case, there are advan-
tages of reducing bleeding which can occur dur-
ing temporal fascia anchoring and anchoring to
more solid tissues (periosteum). However, differ-
ently from the structure of the skull of Westerners,
as in many cases, Asians have triangular skull (not
trigonocephaly, but the skull is more developed
than the size of the face), it is not easy for a can-
nula to drive along the curve at a consistent depth.
Tip!
In some cases where SQ tissues at the
anchoring point are too loose
In the process of pulling the thread after
the insertion, in some cases, loose SQ tis-
sues cannot attach and hold to the thread,
and the thread is dragged down from the
anchoring point. Even if the SQ tissues are
relatively dense, if the physician pulls the
thread too strongly, the same can occur.
Therefore, an assistant must press the
anchoring point with the fingers when the
thread is pulled.
23.3  Entry Point and Anchoring

122
a
b
c
e
d
Fig. 23.8  Tools for the fascia anchoring method (tempo-
ral ring). (a) Taking a temporal ring of which the end
looks semicircular. (b) Between the two entry points,
insert one side first (in this case, the two entry points can
be made in advance using an awl or a needle). (c) After
anchoring by revolving the temporal ring, exit to the
opposite entry point (causes the ring to come out partially
to the extent of exposing the hole in the temporal ring). (d)
Put the thread in the hole at the end of the ring. (e) Take
out the temporal ring by revolving again in the direction
opposite from the insertion
Tip!
Direction of Anchoring
Based on Michael A. Carron et al., when
anchoring is performed in the fascia area of
the temporalis muscle, it has been discov-
ered that the resistance against the pulling
power is stronger in the horizontal method
than in the vertical method (1.9 vs 5.01,
tearing force kg/cm).
Summary
Measures for Bleeding While Anchoring:
Long Threads
1. Bleeding after anchoring with a needle
• Injury to small blood vessels
Bleeding may show due to damage
of small blood vessels from a sharp
needle, after the passing of the nee-
dle or the thread, but if it stopped by
pressuring, the inserted thread may
continue to proceed.
23  Temporal Anchoring Technique

123
Horizontal anchoring
Vertical anchoring

23.3.4 Side Effects: Prevention
and Treatments for Headache
Headaches may occur when fixing is done on the
fascia.
1. There is no need to prescribe NSAID or
Tylenol as a routine, but through listening to
the medical history prior to the procedure, if a
medical history of temporal area headache is
present, it is advisable to prescribe this as a
preventive measure.
2. If a headache occurs after the procedure, in
some cases, a painkiller would not solve it, but
the headache is cured through injecting botuli-
num toxin. Currently, botulinum toxin has
obtained an FDA approval as having preventive
effects for chronic recurrent migraine. However,
based on the meta-analysis by Jeffrey L. Jackson
et  al., it is known not to have an effect on
chronic tension-type headaches. The patho-
• When
vessel
penetration
is
suspected
In some cases, almost no bleeding
occurs after a needle pass, but signifi-
cant bleeding occurs after the thread
is put on the needle and then
anchored, resulting in swelling in the
entry point area. This may be caused
by passing of a sharp needle through
the middle of a thick blood vessel. As
it was fine when the needle passes
initially, physician believes that it
will stop bleeding soon. But, despite
the long pressure, hemostasis is not
easy. This is because vessel damage
is aggravated when a thread pene-
trates a blood vessel. In such case, it
is advisable to cut the middle of the
bi-directional thread and remove it.
Thereafter, pressure for a sufficient
period to stop bleeding and perform
the procedure again with another
entry point elsewhere.
2. Bleeding after anchoring with a tempo-
ral ring
As the ring is thicker than a needle, even
an injury occurs during anchoring pro-
cess and blood will not emerge at the
entry point immediately. After putting
the thread and passing, bleeding shows.
If bleeding does not easily stop, in such
case also, the thread needs to be removed
and discarded.
→ Differently from a needle, a tempo-
ral ring is thicker, forming a tunnel
through anchoring. After anchoring,
rather than putting the thread right
away, take out the temporal ring, and
check whether there is any bleeding
in the place where it passed. If there
is no bleeding, put the thread back
after inserting the temporal ring again
to the preformed tunnel. If there is
bleeding, anchor to another point
after hemostasis. If such method is
used, the cases of removing threads
due to bleeding after anchoring with
a temporal ring can be reduced.
3. Blood vessel damage from cogs
As a thread drives, blood vessel dam-
ages may occur also from cogs.
However, in such case, bleeding can be
stopped easily and the inserted thread
may continue to proceed.
23.3  Entry Point and Anchoring

124
physiology of headaches which occur from
temporal anchoring procedures is not known.
• Among headaches occurring after the tem-
poral anchoring procedure, there are some
cases that do not respond to analgesics but
respond effectively to botulinum toxin. We
think that there is a vascular factor associ-
ated with the headache. Further research
and establishing clear treatment standards
for this would be necessary.
3. To treat headaches of patients with temporal
muscle hypertrophy, if botulinum toxin is
injected, an additional slimming effect of
wide head shape can be obtained.
23.4
Adequate Cannula for Long-­
Thread Insertion (17G)
It consists of two components, internal needle
and external sheath, and is approximately
15–20 cm in length.
23.4.1 Method of Using Inner Guide
Needle (Blunt) + Sharp Outer
Sheath (One Pair) (Figs. 23.9b,
23.10, and 23.11)
Disadvantages
• Much force is needed when it penetrates the skin.
• Sharp outer sheath gets resistance when pass-
ing through tissues. Sometimes a hair follicle
gets caught at the end of the bevel.
23.4.2 Method of Using Inner Guide
Needle (Blunt) + Blunt Outer
Sheath (One Pair) and Sharp
Inner Puncture Needle
(Fig. 23.9a, Fig. 23.12, Fig. 23.17)
Advantages
• Inserting a thread into the outer sheath is con-
venient as the entrance of outer sheath is cut in
oblique shape.
a
b
Fig. 23.9  Tools for the fascia anchoring method – two types of cannula sets. (a) Two needles + one sheath method. (b)
one needle + one sheath method
Tip!
Tips for Proceeding a Cannula
• It is advisable to insert a cannula at a
consistent depth (if it passes superfi-
cially, the likelihood of bumps or dim-
ples after thread insertion increases).
• Entry point, zygomatic arch: There are
not much fat between the SMAS and
dermis in this area. If a cannula is
inserted with a feeling of right below the
subdermis rather than close to the
SMAS, it proceeds smoothly at an ade-
quate depth within the subcutaneous
layer.
23  Temporal Anchoring Technique

125
Inner guide needle (blunt) + Outer sheath (sharp)
Inner guide needle (blunt)
Outer sheath (sharp)
Inner Guide needle (blunt)
Outer Sheath (sharp)
a
b
c
d
Inner Guide needle (blunt)
+ outer Sheath (sharp)
Fig. 23.10  Tools for the fascia anchoring method – one
needle + one sheath method. (a) Inner guide needle
(blunt) combined with outer sheath (sharp). (b) Inner
guide needle (blunt) separated from outer sheath (sharp).
(c) (Magnification of the end part of a/arrow indicates end
of the sheath) As the guide needle is longer than the bevel
of the sheath, when it enters in the combined status, dam-
ages within the tissues are minimized. Sometimes, tissues
get caught at the end of the bevel. (d) (Magnification of
the end part of b) As there is a bevel at the end of the
sheath in the opposite direction from the handle, it is
sharp. It penetrates the skin at the exit point by using the
sheath with itself separated from the guide needle
23.5
Cutting and Finishing
Cutting is not done right after inserting threads
but after pulling the procedure part more.
23.5.1 Finishing (Pulling)
With one hand hold both ends of the thread at the
exit, and fix the skin at the cog/cone after mov-
ing the skin to the direction from the original
location to the entry point using the other hand
with the feeling that the cog is caught in the
skin(viz., while the thread stays in the original
location, push and lift the skin toward the entry
point). Repeat this process twice or thrice. While
this process takes place, an assistance must be
pressing the anchoring point using his/her hand.
If the physician pulls the thread too strongly
without this, tearing of the anchoring point can
happen (see Fig. 23.11m temporal fixation).
23.5.2 Cutting
While holding the thread, push the skin upward
by approximately 4–5 mm at the exit point, and
cut the thread using scissors in the other hand.
23.5  Cutting and Finishing

126
Fig. 23.11  Temporal fixation (41 cm long) – U pattern.
(a) To insert a long thread, firstly use a long needle to
perform anchoring in the temporal area. (b) Insert the
thread into the hole at the end of the needle. (c) Using the
needle holder, pull out the entire needle from the entry
point in the other side. (d) Once the entire needle passes
through, separate the thread from the needle. (e) Pull so
that each half of the thread hangs in the two entry points
in a “U” shape. (f) Insert a long cannula at the first entry
point (Fig. 23.12a blunt guide needle + sheath) and pass-
ing through the subcutaneous layer. (g) Penetrate and pass
toward the exit (first separate the blunt guide needle out of
the sheath, and insert the puncture needle in Fig. 23.12a
into the sheath. Then, using the other hand, grab the for-
ceps, support the exit, and come through the skin with
force in the right hand) (see Fig.  23.17g–h). (h) If the
puncture needle is separated from the sheath, only the
sheath stays in between the entry point and the exit. (i)
Insert the thread through the sheath from the entry point to
the exit. (j) Pull and remove the sheath from the other
side. (k) After the sheath is being removed, only the cog
thread is left underneath the skin. (l) If the remaining half
of the thread is inserted using the same method, one long
thread hangs in a “U” shape. (m) While gently lifting the
skin upward with the other hand, fix the cog on the skin.
(n) Finally, cut the thread (press the skin upward with dis-
infected scissor and cut with one to two cogs out), and
then gently pull the skin by snapping with the finger
a
b
c
23  Temporal Anchoring Technique

127
d
e
f
Fig. 23.11  (continued)
23.5  Cutting and Finishing

128
g
h
i
Fig. 23.11  (continued)
23  Temporal Anchoring Technique

129
j
k
l
Fig. 23.11  (continued)
23.5  Cutting and Finishing

130
Immediately after cutting, a dimple may show at
the cutting point. It can be easily resolved by gen-
tly pulling the skin downward by snapping the
tissue using the thumb or index finger below the
exit (see Fig. 23.11n temporal fixation).
23.5.3 Changes in the Skin Around
the Entry Point (Dimple)
After completing the procedure, it is normal to
have the skin around the entry point to be slightly
folded upward.
23.5.4 Fine Wrinkles Around the Eyes
and (Distortion of the Skin)
If there is severe skin laxity (mid to elder ages),
fine wrinkles may show around the eye and tem-
Entry
point

m
n
Fig. 23.11  (continued)
poral areas after procedure (Fig. 23.14). This
occurs in perpendicular to the direction of the
lifting direction.
In general, it disappears within few days
due to gravity. Therefore, there is no need to
push down the skin to restore its original
form.
23  Temporal Anchoring Technique

131
Inner puncture needle (sharp)
Inner guide needle (blunt) + Outer Sheath
Inner puncture needle (sharp)
Inner guide needle (blunt)
Outer sheath
Inner puncture needle (sharp)
Inner guide needle (blunt)
Outer sheath
a
b
c
d
Fig. 23.12  Tools for the
fascia anchoring
method – two needles +
one sheath method. (a)
Inner guide needle (blunt)
combined with outer
sheath. (b) Inner guide
needle (blunt) separated
from outer sheath. (c)
(Magnification of the
handle part) There is a
bevel at the end of the
sheath which connects to
the handle. (d)
(Magnification of the end
of the opposite side) The
guide needle is inserted
combined with the sheath,
and tissue damages are
minimized when
proceeding. Penetration
of the skin at the exit
point is performed, while
the sheath and the inner
puncture needle are
combined
Tip!
How to Distinguish Procedures Which Are
Within a Normal Range from Abnormal Ones
After inserting a thread in a U shape and
both ends of the thread are pulled:
• If there is no sinking in the skin near the
two entry point holes, it is normal.
• If the skin near one or two entry points
are concaved inward:
→ Cause (Fig. 43.9; see causes and pre-
ventions of entry point dimples).
→ Treatment: Dissection must be per-
formed using scissors or other
tools.
→ Prevention: Form a tunnel using an
awl or use a temporal ring instead of
a needle.
23.5  Cutting and Finishing

132

x 1ea
/ each side
QT lift
long thread
41cm
Fig. 23.13  An example
of design using the
fascia anchoring method
(one thread per each
side)
Fig. 23.14  Areas where
fine wrinkles may occur
after the fascia
anchoring method. If the
fascia anchoring method
is performed on an
elderly person with thin
skin, it is likely to cause
barrow-shaped wrinkles
in the temporal area next
to the eyes. Normally it
is self-healed in 2 to
3 days in general
23  Temporal Anchoring Technique

133
Before
After
Fig. 23.15  Photos
before and after the fascia
anchoring method: QT
lift long thread (41 cm) ×
2ea + QT lift 18 cm
(L Shape Technique) ×
2ea / each side

QT lift
long thread
41 cm
x 2ea
/ each side
Fig. 23.16  An example of
design using the fascia anchoring
method (two threads per each
side)
23.5  Cutting and Finishing

134
Fig. 23.17  Temporal fixation (41 cm long) – U pattern:
two threads per side using the temporal ring. (a) Hold the
temporal ring which looks like a half ring at the end. (b)
Insert one through one entry point first, and exit from the
other entry point again after anchoring the temporal ring
while it is being revolved. (c) Insert each thread in the two
holes at the end of the ring (for a tool with two holes, the
procedure time can be saved by inserting two threads at
once). (d) Remove the temporal ring from the other side
again while revolving it. (e) Remove the ring and pull the
thread in a “U” shape so that each half of the thread hangs
in the two entry points. (f) Insert a long cannula in the first
entry point (Fig. 23.12a blunt guide needle + sheath), pass
the thread at the same depth in the subcutaneous layer, and
go up to the front of the exit. (g) Separate and remove the
blunt guide needle from the sheath. (h) Only the sheath
remains. Insert the puncture needle in Fig. 23.12a into the
sheath. (i) Using the other hand, grab the forceps, support
the exit, and prepare to pass the puncture needle from exit
with force in the right hand. (j) If the puncture needle is
separated from the sheath, only the sheath hangs in between
the entry point and the exit. (k) Insert the thread into one
entry point of the sheath, and cause it to come out of the
exit. The following process is identical to j–n in Fig. 23.11
a
b
c
23  Temporal Anchoring Technique

135
e
d
f
g
Fig. 23.17  (continued)
23.5  Cutting and Finishing

136
i
h
j
k
Fig. 23.17  (continued)
23  Temporal Anchoring Technique

137
a
Before
After
b
Before
After
Fig. 23.18  Temporal
fixation (41 cm
long) – U pattern: two
lines per side using a
temporal ring. (a) QT
lift 41 cm × 4 ea. (b) QT
lift 41 cm × 4ea (face
lifting), QT lift
41 cm × 2ea (submental
lifting)
23.5  Cutting and Finishing

139
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Insertion Method of Bi-directional
Needle Thread (Silhouette Soft®)
24.1
Mechanisms (Concept)
We dealt with bi-directional cog threads in the
previous chapter. In this chapter, we introduce bi-­
directional threads with cones rather than cogs.
This method is convenient for performing with-
out a cannula as the two ends of the thread are
connected to a needle. This type of thread is
called as a thread with a bi-directional needle.
Silhouette Soft® is a representative one.
Silhouette Soft® threads consist of poly-L-­
lactic acid (PLLA) ingredient. This ingredient
decomposes and absorbs in the body. This is one
of absorbable threads.
24.1.1 Effect of Silhouette Soft®
1. Its cones bind well with the subcutaneous tis-
sues immediately after the procedure and dis-
play immediate lifting effects.
2. As time passes, new collagen is formed around
the cones and the thread. It provides additional
elasticity by supporting nearby soft tissues.
24.1.2 Exclusive Advantages
of Silhouette Soft®
Instead of cogs, there are cones, which are not
fixed and capable of moving in the space between
knots (approximately 0.5–0.8  mm), thereby
almost no dimple is created from hanging of cogs
(Fig. 24.1). This is a new lifting in a concept of
fat redispositioning.
24.2
Characteristics
24.2.1 Structure
It has a structure of connecting a bi-directional
thread with cones and needles in both ends of the
thread. Depending on the number of cones, there
are three types of threads (8 cones, 12 cones, and
16 cones). For each type of the thread, the same
number of cones is spread in half in each side. The
two ends of the thread are connected to a needle
of 12 cm in length and 23G in thickness (Fig. 24.2).
24
Fig. 24.1  Several knots and cones exist in both directions
(bi-directional). (Source: Silhouette Soft®/SINCLAIR),

140
5 mm length
20 mm length
23G needle
120 mm
5 mm length
Fig. 24.2  Example of
bi-directional needle +
bi-directional cones.
(Source: Silhouette
Soft®/SINCLAIR),

sinclairpharma.com/
silhouette-soft
There is a knot between the cones. Namely,
cones drive freely between the knots. The space
between the knots is 0.5 cm in case of 8 cones
and 0.8 cm in case of 12 cones and 16 cones. The
length of the space between the knots at the cen-
ter of the thread where a cone does not exist is
2 cm.
24.2.2 Ingredients
The thread is composed of poly-L-lactic acid
(PLLA) ingredient. Cones consisted of poly-L-­
lactic acid (82%) and glycolic polymer (18%).
These ingredients decompose and are absorbed.
PLLA is absorbed within 30 months.
24.2.3 Preparations
for the Procedure
Preparations are simple compared to lifting with
other threads. It is similar to thread lifting using
disposable cannulas. Simple configuration and
standardized techniques allow consistent proce-
dures anywhere in the world.
24.3
Method of the Procedure
24.3.1 Designing
1. Exit
In designing, the length from an entry point
to an exit must be made with extra room (viz.,
it should not be shorter than the minimum
required distance) (see Fig. 24.3). The minimum
required distance is longer than the distance
between the center of thread and the outermost
knot. When designing, we must consider the
movement of the soft tissue by lifting. If there is
severe sagging, it can be designed 1 cm ­longer
• Design rule: Mandatory item as distance
measurement is essential for designing
• Anesthetic solution: Dental lidocaine
(lidocaine 1% with epinephrine 1:100,000)
• 18G needle: entry point puncture
Table 24.1  Composition of bi-directional needle + bi-­
directional cones (Silhouette Soft®)
Product
Soft 8
cones
Soft 12
cones
Soft 16
cones
USP
designation
3.0
Length
30 cm
27.5 cm
26.8 cm
Number of
cones
8
12
16
Direction of the
cones
Bi-directional
Space between
cones
5 mm
8 mm
8 mm
Material
PLA
Needle
2 needles (23G) of 12 cm each
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

141
than the minimum required distance shown in
the table below for more traction.
In case of asymmetry, it is advisable to make
an exit point 0.5–1 cm farther than usual at the
time of designing (if you make a traction more
than the standard, a knot or cone can tag along
through the exit).
2. Route of the thread (vector)
It is advisable that beginners should avoid the
curve vector in designing passage in a “U”
pattern.
3. Entry point
4. Summary of draping and hairline
24.3.2 Anesthesia
• Anesthetic solution: Dental lidocaine (lido-
caine 1% with epinephrine 1:100,000)
• Area: entry point and exit are enough (Fig. 24.4).
There is no need to anesthetize the entire
route.
If additional anesthesia is necessary in areas
other than the entry point and the exit:
–– Patients who are largely worried about
pain.
–– When patients claim pain during the
procedure.
–– If the exit is near to the mouth (as the
subcutaneous tissues near the mouth are
dense, needles do not pass through eas-
ily, thereby more pain occurs and likeli-
hood of bleeding increases). A dimple is
easily formed at this area. But cones of
Silhouette Soft® are not fixed and they
can move between knots. Therefore, no
dimple occurs even when procedures
are done in this area (see Fig. 23.6).
24.3.3 Entry point (Fig. 24.5)
1. Entry point puncture tool
18G needle

Table 24.2  Design length for each number of cones
(minimum required distance)
Minimum required distance between the entry point and
each exit point for all patterns
8 cones suture
6 cm
12 cones suture
9 cm
16 cones suture
11 cm
Fig. 24.3  Prior to performing procedure of bi-directional
needle + bi-directional cones (Silhouette soft®), the mini-
mum required distance between the entry point to the exit
must be kept (©Medbook Co., Ltd. All rights reserved)
Fig. 24.4  Procedures of bi-directional needle + bi-­
directional cones (Silhouette Soft®)  – anesthesia with
dental lidocaine (©Medbook Co., Ltd. All rights reserved)
24.3  Method of the Procedure

142
a
b
Fig. 24.5  Procedures of bi-directional needle + bi-directional cones (Silhouette soft®) – entry point. (a) Making an
entry point using a 18G needle. (b) Showing of a Silhouette Soft® needle being inserted through an entry point
2. Puncture technique
In puncturing a hole with a 18G needle, pinch
the skin with the other hand, insert the needle
perpendicularly with a slight stir (revolving),
and dissect the subcutaneous tissues from the
dermis below the entry point. In that way,
dimples can be prevented.
Enter up to the depth of approximately 5 mm.
This depth is identical to the length of the
18 G needle bevel (Fig. 24.6).
3. Insertion of 23G Silhouette Soft® needle
through an entry point
Enter perpendicularly up to the depth of 5 mm
(Fig. 24.7). The black line at the end of the
needle is the 5 mm mark line (Fig. 24.6).
Silhouette soft®
23G needle
18G needle
5 mm
Fig. 24.6  Procedures of bi-directional needle + bi-­
directional cones (Silhouette Soft®) – bevel of 18G nee-
dle, black line at the end of the 23G Silhouette Soft®
needle
Summary
Responding to Bleeding at the Time of
Anchoring: Silhouette Soft® U Technique
1. While passing an 18G needle (puncture
needle) at an entry point
–– If blood is on the connection area of
the needle and plastic (Fig.  24.8),
continue to proceed.
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

143
–– If blood comes out continuously in the
connection area (Fig. 24.8) of the nee-
dle and the plastic, remove and per-
form hemostasis. Then, perform the
procedure through a new entry point.
2. After a Silhouette Soft® needle (23G)
passes through and an 18G needle is
removed, if bleeding occurs at the entry
point and does not stop
–– If the thread has passed the anchor-
ing point, cut the very center of the
thread, remove it, and perform hemo-
stasis. In this case, the Silhouette
Soft® cannot be reused (if the
Silhouette Soft® needle [23  g] has
passed entirely, the needle cannot be
pulled back. The connecting area of
Fig. 24.7  Procedures of
bi-directional needle +
bi-directional cones (Silhouette
Soft®) – a cross section of
inserted 23G Silhouette Soft®
needle. (Published with kind
permission of © Kwan- Hyun
Youn 2018. All rights reserved)
Fig. 24.8  Needle with blood on. Although little blood
got on at the end of the needle, as the connecting part of
the needle and the plastic does not show any blood on,
continue to proceed with the procedure. Even if there is
little blood that got on the connecting part of the needle
and the plastic, it is OK to proceed with the procedure.
However, if there is any blood coming out from the con-
necting part of the needle and the plastic, stop the proce-
dure and perform hemostasis after removing
the needle and the thread must be cut
and removed).
–– If bleeding occurs after the Silhouette
Soft® needle (23G) passes the
anchoring point partially, pull back
the needle and perform hemostasis.
Therefore, in anchoring:
1. Check how much blood got on the con-
necting part of the needle and the
plastic.
2. If you check the bleeding when only a
portion of the Silhouette Soft® needle
passes the anchoring point, there is no
need for throwing out Silhouette Soft®
unnecessarily.
24.3  Method of the Procedure

144
24.3.4 Insertion (Fig. 24.9)
1. Method of holding a needle
• Hold on to the shortest as possible closely
to the entry point (if the needle is held long,
it bends well during insertion).
• Hold with the thumb and the index finger.
• In the temporal muscle (TM) hypertro-
phy/trigonocephaly, the needle must be
held closely to the nail to insert horizon-
tally. In such case, if the needle is held
by the middle of the distal phalanx
(Fig. 24.10), the needle will insert more
deeply as it proceeds.
Fig. 24.9  Cross section of inserting the bi-directional
needle + bi-directional cones (Silhouette Soft®). (a)
Insert the end of the needle in one side of the Silhouette
Soft® perpendicularly into the subcutaneous tissues.
Insert up to the point that the black line at the end of
the needle touches the skin at the entry point so that
the depth is 5 mm. (b) To maintain the needle horizon-
tally, proceed toward the exit at a consistent depth in
the subcutaneous tissues. Then, the needle comes out
puncturing the exit. (Published with kind permission
of © Kwan- Hyun Youn 2018. All rights reserved). (c)
Pull the needle gently to outside (retract) and cause
cones to enter the subcutaneous tissues gently along
the thread. After the last cone is inserted and half of
the entire thread is inserted, stop retraction. (d) Insert
the remaining side of the needle using the same
method. After inserting the end of the needle perpen-
dicularly into the subcutaneous tissues, change the
direction and proceed toward the exit horizontally. (e)
The needle punctures the exit and comes out.
Thereafter, gently pull the needle to outside and insert
the remaining cones gently into the subcutaneous tis-
sues. (Published with kind permission of © Kwan-
Hyun Youn 2018. All rights reserved). (f, g) Once the
entire thread and cones are inserted into the subcutane-
ous tissues, cut the connecting part of the needle and
the thread first. The thread must remain long in both
exits. While holding one side of the thread with one
hand, fix the cones, pushing up the skin toward the
desired direction using the other hand (traction).
(Published with kind permission of © Kwan- Hyun
Youn 2018. All rights reserved)
a
b
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

145
c
d
e
Fig. 24.9  (continued)
24.3  Method of the Procedure

146
Fig. 24.10  Method of inserting a needle in the temporal
muscle (TM) hypertrophy/trigonocephaly. In holding a
needle, use the middle of the distal phalanx of the thumb
and the index finger in general. However, in the temporal
muscle (TM) hypertrophy/trigonocephaly, horizontal
insertion can be done at a constant depth only if the needle
is held by the end of the phalanx closely to the nails as
shown above (©Medbook Co., Ltd. All rights reserved)
Summary
Method of Inserting a Needle at a Constant
Depth Using Pinch Technique (Fig. 24.11)
• Finger pinch
–– Point pinch: useful in making an
entry point
–– Block pinch: after inserting into an
entry point and until entering up to
about the first 1/3 of the insertion route
• V pinch
–– When passing the middle part of
insertion route
–– Especially useful in the submental
area
f
g
Fig. 24.9  (continued)
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

147
Summary
Method of Checking the Depth After
Inserting a Needle
• This is a process of checking whether a
needle is inserted at a consistent depth
in the subcutaneous fat from the entry
point to the exit point.
• When a needle penetrates through the
exit, instead of pulling it out straight,
hold both ends of the needle with two
hands and bend the needle toward the
top of the skin (Fig. 24.12).
–– Check if the needle is uniformly
inserted within the subcutaneous fat.
• If the thickness of the lifted tissue
through a bent needle is not uniform, it
is advisable to withdraw the needle and
proceed again. If cones are inserted at
inconsistent depth, traction does not
work well or skin folds may occur;
therefore cautions must be taken.
–– Solution: If a needle is inserted by
proceeding straight slowly using suit-
able technique for each area, it can be
performed at a consistent depth.
• Press
–– When passing the last 1/3 of inser-
tion route.
–– Press the skin right on the insertion
route with the distal phalanges of the
second, third, and fourth fingers.
–– Useful when passing the curvy area
of the cheek or dense fibrotic area.
–– When passing the curve of the cheek,
it is easier to pass by pressing on the
skin of the end of the needle. If the
needle is bent, it would be more con-
venient to pass.
Summary
Cause and Prevention of Breakage of a
Thread When It Passes Through
1. Cause of breakage while a thread passes
through
Excessive pulling of thread
2. Prevention (technique)
The force of the hand used in pulling a
needle must be controlled. It is also
important to push the skin with opposite
hand so that the cones enter into the tis-
sues easily without being trapped.
• Hand which pulls the needle
–– Hold the needle as close as possi-
ble to the exit point while pulling.
–– If holding is done far away from
the exit point, as much force is
hung, there is a risk of the thread
being cut.
• Opposite hand
Push the skin in the opposite
direction.
–– When the first cone enters into the
entry point
–– When more than half of the cones
are inserted
Summary
Method of Gentle Retraction Without
Having the Thread Cut While It Passes
Through (Fig. 24.13)
1. First stage
When the first cone passes through the
entry point
2. Second stage
When the first cone passes in the middle
of insertion route (when the cone in the
middle part of the thread passes the
entry point)
3. Third stage
When the last cone passes through the
entry point
24.3  Method of the Procedure

148
Fig. 24.11  Procedure of Silhouette Soft®  – inserting
needle using various pinch techniques for each area. (a)
This shows the design for lower face lifting technique
using U pattern (see Fig. 24.19). Each from the left shows
the entry point (red), proximal 1/3 (blue), middle 1/3
(green), and distal 1/3 (apricot). (b) Point pinch (hard): in
making an entry point using a puncturing needle, hold the
skin around the entry point with the tip of the fingers. To
avoid injury of blood vessels and muscles, skin tissues
must be pulled upward requiring a strong grip. (c) Point
pinch (soft): when Silhouette Soft® needle enters through
an entry point, grip gently with the tip of the fingers. If
pinching too strongly, as the entry point cannot open prop-
erly, likelihood of dimple increases. Accordingly, pinch
gently so that the entry point shows slightly. (d) Block
pinch: after inserting into the entry point and passing the
proximal 1/3, grip widely with fingers to insert a needle at
a constant depth within the subcutaneous fat. (e) V pinch:
the subcutaneous fat in the middle 1/3 is very soft. Passing
this area can be easily performed by pinching in a “V”
shape using the second and the third fingers. (f) Press: the
subcutaneous fat in the distal 1/3 is very dense. Inserting a
needle while slightly pressing the tissues is useful for pass-
ing at a consistent depth within a dense layer
a
b
c
d
e
f
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)