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

150
a
b
Fig. 24.13  Procedure of
Silhouette Soft® – gentle
retraction of the thread
after needle insertion. (a)
When the first cone enters
into the entry point – push
the skin slightly, giving a
snap with one finger from
the right in front or back
of the entry point toward
the opposite direction of
insertion route. Using the
other hand, hold the
connecting part of the
needle and thread (viz.,
the closest location to the
exit) and gently pull. In
regard to the other hand,
there is no need to give a
snap like the hand
touching the skin.
(Published with kind
permission of © Kwan-
Hyun Youn 2018. All
rights reserved). (b) When
the half of cones are
inserted into the
subcutaneous tissue –
using one or two fingers,
push the skin slightly
from the right on the skin
area where the first cone
passes (approximately the
middle of the route from
the entry point to the exit)
toward the opposite
direction of insertion
route. Using the other
hand, hold the connecting
part of the needle and
thread and then gently
pull. (Published with kind
permission of
© Kwan- Hyun Youn
2018. All rights reserved)
There is not much difference in the results
from the right side and the left side.
However, in case of Silhouette Soft® train-
ing, there is some difference in the results.
Differences in traction can result in the
difference of outcome.
Many cases of differences in the two
sides are experienced in the results of lift-
ing after the traction process. Through a
proper “traction” process, good result can
be obtained and side effects like folding of
the skin can be reduced.
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

151
a
c
d
b
Fig. 24.14 
Procedure of
Silhouette
Soft® – handling of
the last cone at the
entry point (a) The
last cone is not
located perpendicu-
larly in front of the
entry point and lies
in a horizontal
position against the
skin. (b) Make the
cone place in a
vertical position
using a forcep. (c)
Pull the thread and
release a forcep. (d)
The cone is inserted
correctly
Cutting (Fig. 24.15)
• A thread is not to be pulled during cutting pro-
cess, but the thread is to be cut while pushing
the skin using curved scissors.
• If the exit and the last knot are too close and
the knot should be removed, it is advisable to
remove the last knot and the last cone
together. If the knot is removed only, the
cone next to it cannot play its role.
Furthermore, as the cone breaks away from
the thread, it can be hung in the dermis at the
exit point.
• In some cases, the end of the thread located
around the mouth corner pokes the skin in
Fig. 24.15 
Procedure of
Silhouette
Soft® – cutting
and finishing.
(a) Put a sterilized
scissors closely to
the exit point
where the thread
remains. (b) Using
a sterilized
scissors, push up
the skin and cut
closely to the last
knot. (c) Thread is
cut and buried
(©Medbook Co.,
Ltd. All rights
reserved)
a
c
b
24.3  Method of the Procedure

152
Fig. 24.16  Basic
technique of Silhouette
Soft® – straight pattern
(©Medbook Co., Ltd.
All rights reserved)
facial expression; the following cautions must
be taken:
1. If the last knot is distant from the exit, it is
advisable to cut after pushing the skin up to
the very front of the last knot.
2. Rather than cutting in an oblique angle to
the thread, cutting must be done perpen-
dicularly, thereby reducing damage to the
tissue even if it pokes the skin during facial
expressions.
24.4
Various Techniques
24.4.1 Basic Technique 1: Straight
Technique
1. Design (Fig. 24.16)
This is a useful technique for patient who has
partially sagged jowl rather than patient who
has much volume in cheek fat.
–– Exit in the bottom: The last cone (bottom)
should be fixed in the jowl.
–– Exit in the top: The last cone (top) should
be fixed around the hairline.
–– Entry point: In the middle of the two exit
points.
2. Anesthesia – dental lidocaine
–– Anesthetize one entry point and two exit
points.
3. Cutting and traction
–– Thread in the back: Pull the thread upward
first and then manipulate the thread in the
front (supporting/fixing role).
–– Thread in the front: While holding the
thread with one hand, by pushing the skin
upward with the other hand, cause the cone
in one compartment above the original
cone to hang.
24.4.2 Basic Technique 2: Angle
Technique
1. Designing (Fig. 24.17)
• Entry point: approximately 1FB inside
from the mandibular angle or right behind
• Insertion route of lower half of the thread:
If it is too close to the mandibular line, it
improves only the jawline, not the mario-
nette line. If it is located on the extension
line from oral commissure to the tragus,
the level is too high. It is advisable that
the exit point in the bottom (exit point in
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

153
lower half of the thread) is located in the
middle of above two routes. When the
angle between each half of the thread is
greater than the angle between the man-
dibular body and ramus, it can bring a bet-
ter result.
2. Anesthesia – dental lidocaine
• Anesthetize one entry point and two
exits.
3. Entry point – caution/location
• This is a technique in which a dimple fre-
quently occurs at the entry point after the
procedure.
• If the entry point is located inside from the
mandibular angle, it is likely to be exposed.
• Prior to the procedure, puncture a hole at
an entry point slightly larger than other
areas using a needle or an awl.
4. Cutting and traction
• Thread in the back (upper half of the
thread): It plays a supporting or fixing
role.
• Thread in the front (lower half of the
thread): While holding the thread with one
hand, push the skin to the entry point with
the other hand so that the skin is lifted and
fixed to the next cone.
24.4.3 Basic Technique 3: U Technique
1. Designing (Fig. 24.18)
One thread is used, but it has a similar
effect with using two cog threads in this
­technique. Twelve cones and 16 cones are
mainly used.
• Entry point: Set above the hairline but
between the lateral canthus level and zygo-
matic arch level.
• Exit points are generally set toward the
marionette line or jowl. If you want to
improve the nasolabial fold, set two exits
toward the nasolabial folds. .
2. Anesthesia – dental lidocaine
• Anesthetize two entry points and two exits.
• Anesthetize the space between the two
entry points.
3. Entry point – cautions/location
• When designing entry points, check the
sentinel vein with the naked eye, and check
the STA pulse by palpation to avoid vessel
injury.
4. Insertion
• For beginners, U pattern would be difficult
when passing a curve in zygomatic arch.
Therefore, it is advisable to avoid designing
Fig. 24.17  Basic
technique of Silhouette
Soft® – angle pattern
(©Medbook Co., Ltd.
All rights reserved)
24.4  Various Techniques

154
Fig. 24.18  Basic
technique of Silhouette
Soft® – U pattern
(©Medbook Co., Ltd.
All rights reserved)
on the curvy surface if possible. Especially,
as the curves of the zygomatic arch are more
severe in Asians, cautions must be taken.
5. Cutting and traction
• The directions of cones on both sides of the
thread are identical.
• Traction can be done with holding both
sides of the thread or each half of the thread
separately.
• Push the skin on the last cone (bottom
cone) upward so that the skin is lifted and
fixed to the next cone. Some expert groups
prefer the method of moving from the top
to the bottom.
Summary
Tips for Passing an 18G Needle (Puncture
Needle) at Entry Point
1. Tips for passing needles easily through
two entry points
• When puncturing a hole using an
18G needle, after pinching the skin
with the other hand, insert the needle
perpendicularly, and then make it lie
horizontally for passing. When it
comes out through the opposite entry
point, the result depends on the direc-
tion of the bevel.
–– If the bevel of the needle passes
facing upward: Useful to come out
through the opposite entry point.
–– If the bevel of the needle passes fac-
ing downward: It comes out punc-
turing new entry point after passing
3–4  mm further from the desired
entry point.

24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

155
2. Tips for passing the needle easily
through two entry points
• When the bevel of the 18G needle
passes facing downward around the
hairline, it is likely to anchor too
deep, and the risk of STA damage
increases from the author’s experi-
ence. If the bevel of the needle passes
facing upward, the risk of bleeding
can be reduced.
→ Therefore, when anchoring with
18G in U technique, it is advisable to
pass a needle with the bevel facing
upward.
Fig. 24.19  Applied
technique of the
Silhouette Soft® – PMA
technique (©Medbook
Co., Ltd. All rights
reserved)
24.4.4 Post-mandibular Anchoring
(PMA) Technique
1. Designing (post-mandibular anchoring using
U technique) (see Fig. 24.19):
• In performing a marionette line lifting
using L technique or U technique, it is nec-
essary to check prior to the procedure
through simulation, whether lifting works
well or not.
• In sagging of the jowl or the marionette
line, two vectors (see Fig. 24.20) should
be considered. They are a vector facing
upward (from the mandibular body
through the zygomatic bone to the tem-
ple) and a vector facing backward (from
the mentalis muscle to the mandibular
angle).
• When the angle between the mandibular
body and the horizontal line is high, as the
two vectors explained above work simi-
larly, the procedure which pulls toward the
back of the ear can make a sufficient lifting
effect. Therefore, if the lifting for jowl is
performed only by this technique, a greater
angle displays a better effect than a smaller
angle (Fig. 24.21).
24.4  Various Techniques

156
Fig. 24.20  Comparison of jawline vectors – supine posi-
tion. (a) Cadaver of the supine position (intact state not
pulled). (b) Change after pulling anteriorly  – vector
toward the mentalis muscle. (c) Change after pulling pos-
teriorly – vector toward the mandibular angle. (Published
with kind permission of © Wonsug Jung 2018. All rights
reserved). (d) Change after pulling superiorly  – vector
toward the zygomatic arch (temple). (e) Change after pull-
ing inferiorly  – vector toward the submental area.
(Published with kind permission of © Wonsug Jung 2018.
All rights reserved)
a
b
c
d
e
Summary
Factors Which Affect the Outcome of the
PMA Technique
• When the effect is good
–– When the angle between the man-
dibular body and the horizontal line
is high (30° or above)
• When the effect is poor
–– When the angle between the man-
dibular body and the horizontal line
is low (below 20°)
–– Patients with a square jaw (−> this
can make the square jaw to be more
prominent)
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

157
Fig. 24.21  Factors
which affect the
outcome of the PMA
technique
2. Anesthesia – dental lidocaine
• Anesthetize two entry points and two exits.
• Anesthetize the space between the two
entry points.
3. Entry point – cautions/location
• It is advisable to set the entry point right
behind the mandible angle, below the ear.
4. Insertion
• When a needle passes from the entry point
to the exit, the density of the fat tissues is
various depending on each area. It is more
useful to insert thread using pinch tech-
niques (see various pinch techniques for
each area in Fig. 24.22).
5. Cutting and traction
• It is the same as basic U technique.
24.4.5 Various Combinations Using
Two Threads
Tip!
Tips for Overcoming Disadvantages of the
Crisscross
Technique
and
Making
Favorable Effects
• A crossing point shall not be the bulging
area in the cheekbone (the space
between the cheekbone and the ear).
• Attempting to perform traction simulta-
neously after inserting two threads, a
desired outcome is not obtained well.
After performing insertion and traction
for one thread, it would be better to
insert the second one and then perform
traction.
• It is advisable to have the crossing point
near the entry point. This is because the
crisscross point can act as a secondary
fixing point following the entry point,
and function of the fixing point can be
enhanced. If this is utilized well, we can
expect a good result.
• If the temples are sunk, we can expect
a good volumizing effect by making a
crossing point in this area (however, in
case of sunken cheeks, the inner vector,
rather than the downward vector, reacts
together (or reacts more), and it is dif-
ficult to expect a smooth volumization
like fillers).
24.4  Various Techniques

158
Fig. 24.22  Applied techniques of the Silhouette Soft® – various combinations. (a) Straight + angle technique. (b)
Method of using two U techniques. (c) Crisscross technique. (d) Straight + angle technique
a
b
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

159
c
d
Fig. 24.22  (continued)
24.4  Various Techniques

160
Summary
Cautions in the Crisscross Technique
It can provide volumizing effects if done
on sunken areas, but there are various
considerations.
• First of all, it is difficult to pass (espe-
cially in case of thick cog thread).
• It is also difficult to insert additional
thread later even if a small thread is
selected.
• In case of those who have developed
zygomatic arch, it is advisable not to
have the crossing part in the zygomatic
arch. The zygomatic arch may appear to
be more bulging.
• When performed on the sunken cheek,
the shape might become strange due to
tangling of threads and tissues. Cautions
must be taken.
• The skin does not move much in the
process of cutting and pulling the thread
in crisscross technique case.
• The crossing point shall not be on the
zygomatic arch. It must be more to the
side of the zygomatic arch (the space
between the zygomatic bone and the ear).
Tip!
Tips for solving wide dents of the skin after
the criss-cross technique
After putting the other hand inside the
mouth and mold while pushing the skin
with the finger, the tangled cones detangle
well.
a
b
Fig. 24.23  Applied techniques of the Silhouette Soft® –
forehead lifting (a) U technique (b) Angle technique
(©Medbook Co., Ltd. All rights reserved)
24.4.6 Eyebrow Lifting (Fig. 24.23)
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

161
Before
After
Fig. 24.24  Combined procedure of the Silhouette Soft® and bi-directional cog thread – photos before and after the
procedure. Silhouette Soft® 8 cone×4 ea. + QT lift 41 cm × 4 ea (©Medbook Co., Ltd. All rights reserved)
a
b
Fig. 24.25  Difference in the directions of thread insertions. (a) Traditional thread. (b) Silhouette Soft® (©Medbook
Co., Ltd. All rights reserved)
24.5
Useful Tips
Summary
Tips for the Silhouette Soft® Technique:
Position of the Procedure
As other threads have similar progres-
sion vectors, it is convenient to perform the
procedure by sitting at the upper side of the
patient. On the other hand, as threads of the
Silhouette Soft® have various vectors
(Fig. 24.25), the position of the physician
changes in various ways. Therefore, if the
physician is not both handed, it is advisable
to become familiar with the most comfort-
able position for the procedure.
24.5  Useful Tips

162
Prevention and Treatment of the Entry
Point Dimple (Fig. 24.26)
• Causes
–– When an entry point hole is not suf-
ficiently procured.
–– In inserting a needle, it does not go
into the original hole perpendicularly
but inserted in other direction.
• Prevention
–– Make the hole bigger than the needle
diameter in making an entry point:
Using an 18G needle or awl, perform
dissection/revolving/subcision.
Tip for the Silhouette Soft® Technique:
Recommended Position for the Procedure
• Angle technique
–– Rt. horizontal suture → From the top
of the patient’s head
–– Lt. horizontal suture → From the left
of patient’s face
–– Rt/Lt vertical suture → From the
right of patient’s face
• PMA technique (U technique)
–– Rt → From the right side of the
patient’s face
–– Lt  →  From the left side of the
patient’s face
• Necklace technique (treatment for dou-
ble chins)
–– Rt  →  From the side of the right
shoulder of the patient
–– Lt  →  From the top of the patient’s
head
–– A needle goes in perpendicularly.
Until the black line enters to the skin
level which is marked at the end of
the needle (5 mm location), it should
keep the originally procured hole
(viz., it shall enter smoothly without
resistance up to the black line). In
such case, do not pinch too strongly,
and pinch softly so that the originally
procured hole exposes well.
• Treatment
–– Dissect the space the dermis/subcu-
taneous with the disinfected curved
scissors.
In case you need to solve through molding
(massage) in f/u after performing a Silhouette
Soft® procedure
• Clear abnormality (e.g., severe unevenness in
the left and right).
• Pain or asymmetry when the mouth opens
widely.
• When the skin is pushed upward and down-
ward using the hand, something hard is pal-
pable or a dimple appears.
Tip!
When the Patient Complains that the Cone
Is Touched at the Procedure Site
This is claimed mainly within several
days after the procedure; sensing cones
along the route of the thread when touched
at the initial stage is not problematic.
24  Insertion Method of Bi-directional Needle Thread (Silhouette Soft®)

163
a
b
Fig. 24.26  Cause and
prevention of dimple
after the Silhouette
Soft® procedure. When
a thread is inserted in a
straight line, a dimple
does not occur at the
entry point, but in
techniques where the
direction of the thread
changes, cautions must
be taken against
dimples at the entry
point. In the technique
like (b), dimples can
occur a lot at the red dot
area (entry point). The
first figure in (a) shows
insertion of needle into
an entry point. If the
route is procured along
the direction of the
thread when making an
entry point like in the
second figure, dimples
can be prevented
(see Fig. 43.9).
(©Medbook Co., Ltd.
All rights reserved)
Summary
Various Tips for the Silhouette Soft®
Procedures
• Method of holding a needle
–– In holding a needle, use the middle of
the distal phalanx with the thumb and
the index finger.
–– Depending on the case, sometimes
the needle must be held by the tip of
the fingers closely to the nails.
• In passing a needle
–– Depth
–– Direction of the bevel
–– The other hand: pinch or press
• For preventing dimples at the entry point
–– Dissection (disinfected scissors).
–– Dissect the space between the dermis
and the subcutaneous layer with
spring scissors.
• Position of the procedure for U
technique
–– Rt  →  From the right side of the
patient’s face
–– Lt → From the left side of the
patient’s face
• Necklace technique (treatment for dou-
ble chins)
–– Rt → From the side of the patient’s
right shoulder
–– Lt → From above the patient’s head
Side effects after Silhouette Soft® procedure
• Suture rupture
• Temporary entry point dimple
• Skin fold
• Bruise
• Hematoma
24.5  Useful Tips

165
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Considerations to Be a Thread
Lifting Expert
25.1
Temporal Muscle
Hypertrophy (or
Trigonocephaly)
If the temporal muscle is well developed or the
shape of the skull has a wide horizontal width
due to the trigonocephaly (so-called bulging
head-temporal area), a long cannula insertion
may face interference in its progression.
Namely, after a cannula enters into an entry
point, it must proceed at a consistent depth of the
subcutaneous layer, but in such case, as the can-
nula tilts, it may go more deeply than intended
gradually, resulting in inadvertent penetration of
the fascia up to the muscle layer.
• Solution
• Rather than gripping the end of the cannula, it
is helpful to grip as closely as possible to the
entry point in proceeding at a consistent depth
within the tissues.
25.2
Temporal Hollowness
If a temple area is sunken, a situation which is
directly opposite from the temporal muscle hyper-
trophy occurs. In this area, a cannula passes more
superficially than usual (intended). On the con-
trary, before zygomatic arch area, it tends to pass
through the deeper area so that it can touch a mus-
cle. Especially, if it is accompanied by zygomatic
arch prominence, this can be even more severe.
• Solution
• If a tumescent solution or diluted lidocaine
is injected using a cannula sufficiently in to
the subcutaneous layer, the hollowness is
adjusted, and passage of the cannula will
be easy.
• If the temporal hollowness is corrected first
using fillers, passaging a cannula becomes
easy.
25.3
Zygomatic Bone Prominence
Zygomatic bone is rather developed in Asian
faces. When you want to proceed a cannula or a
needle from the temple area toward the anterior
cheek through zygomatic bone prominence, it is
not easy to pass at a constant depth because it
must pass a severe curve. Also, as this area has
little fat and is dense, more force is needed in
passing through with a cannula.
• Solution
• By passing while holding a cannula or nee-
dle to bend, going along the curve becomes
easy.
• It is also a good method to avoid curves
when designing insertion routes.
25

166
25.4
Sunken Cheek
Sunken cheek stands out more as people grow
older mostly. It is considered to make a charming
face in Western country, but Asian women tend
not to like this. To correct this area, fillers are
sometimes used. In case of effective thread lift-
ing, they can achieve not only lower face lifting
but also correction of this sunken part.
This area requires thorough understanding of
anatomical
structure.
It
consists
of
the
zygomatico-­cutaneous ligament and the masse-
teric cutaneous ligament; it forms a diamond or
triangular shape (see Fig. 44.2). Sagging faces
have vectors toward the inferior or the medial
side in general, but this part faces toward the
inner (deeper) side (inner vector; see Fig. 22.13).
This area is one of the densest tissues in the face.
Therefore, in this area, insertion depth cannot be
controlled while passing a cannula, and much
force is exerted to pass. Also this area is not lifted
well even by pinching using fingers. When a
thread penetrates the very center of this area,
dimples or distortion of the skin (abnormal hang-
ing by cogs) occurs well (see Fig. 44.3).
• Solution
• In designing, it must be designed in a way
not to pass through the very center of the
sunken cheek. (Depending on the type of
the thread, a skillful practitioner may avoid
this side effects even though the thread
passes through the very center. But it is
advisable for beginners to avoid this area in
designing.)
• If the thread passes the side of the sunken
cheek area (diamond shape), passing
becomes easy, and the likelihood of side
effects can be reduced.
• However, if the procedure is performed
totally away from this area, the remaining
area would be lifted well, and this area
would not be lifted well, which may appear
somewhat lacking. In such case, by insert-
ing one to two short-/medium-sized cog
thread(s) to be hung up to the middle of the
sunken cheek in the last stage of the proce-
dure, it can have beneficial effects, and
occurrence of dimples can be reduced.
• As this area is not pinched well, it is advis-
able to press with fingers instead. If this
area is pressed by using the two or three
fingers of the opposite hand while the can-
nula or needle passes, it passes more
easily.
• Cautions
• It is advisable to have the patient acknowl-
edge existing sunken cheek prior to the
procedure. This is because in some cases,
the patient claims that sunken cheek which
did not exist appeared after procedure as
the patient did not recognize it before.
25.5
Operation Scar: Zygomatic
Bone Reduction Surgery,
Double-Jaw Surgery,
and Lifting Surgery
If there are remaining scars due to surgery on the
insertion route of thread, it is not easy for a can-
nula or needle to pass. Sometimes, even a needle
cannot pass well, and the skin is pushed toward
the direction of the progression during thread
insertion. Prior to the procedure, it is necessary to
check a history of operation and to observe care-
fully whether there is any scar during designing
process. Sometimes, patients hide prior surgical
experiences. In addition to the suture scars which
are visible, it is also necessary to inspect whether
there is a tissue adhesion on the insertion route
Tip!
Importance of 1), 2), and 3)
If an entry point is set in the hairline in
the temporal area, the above three consid-
erations are very important. In the period of
insufficient experience in the procedure, if
at least one of the above three conditions is
retained, one tends to become suspicious of
capacity of oneself due to inability to per-
form the procedure well. However, after
having acknowledged the above three fac-
tors and learning the solution, the proce-
dure can be performed more comfortably.
25  Considerations to Be a Thread Lifting Expert

167
within subcutaneous tissues, which can make a
cannula difficult to pass.
• Solution
• In designing, the scar areas must be
avoided.
• When a cannula or a needle does not pass
well, it can pass more easily by pressing
these areas with fingers
25.6
Liposuction
Patients who have undergone a liposuction on the
face have more fibrotic facial fat tissue than aver-
age person. In such case, as it affects passing of
cannula, inserting a cannula is not easy.
• Solution
• When a cannula or a needle does not pass
well, pressing the tissues using the second
and third fingers of opposite hand is useful
to pass.
• When holding a cannula, it is easier to con-
trol the force by gripping the tip of
cannula.
25.7
Acne Scars
If patients have severe rolling scars or boxcars
among types of acne scars, the bottom of the
scars have fibrotic connections with the subcuta-
neous tissues. When passing this area, they can
make a cannula or a needle hard to pass.
• Solution
• When a cannula or needle does not pass
well, pressing the tissues using the second
and third fingers of opposite hand is useful
to pass.
25.8
History of Lifting Procedure:
Thread Lifting and HIFU
In many cases patients considered the interval of
thread lifting treatment as 1 year. In such case,
the patients undergo a fibrotic change in subcuta-
neous fat tissues by previous thread insertion. It
is likely to meet resistance when a cannula or
needle passes the tissues.
Also, there are many patients who got HIFU
treatment several months before. In such case,
facial fat tissues generally get a fibrotic change.
Likewise, this affects passing of a cannula or a
needle.
• Solution
• When a cannula or a needle does not pass
well, pressing the tissues using the second
and third fingers of the opposite hand is
useful to pass.
Summary
Prognostic Factors that Affect the Outcome
of Thread Lifting: Checkpoints to Predict
the Prognosis Prior to the Procedure
1. Masseter Muscle Hypertrophy
If a patient has a square jaw due to a
masseter muscle hypertrophy, even
though simulation of lifting vector is
done with hands prior to the procedure,
lifting effect is minimal.
• Solution
–– To correct a square jaw, pretreat-
ment using the botulinum toxin is
Summary
Difference in Density of Fat Tissues
Depending on the Facial Area (Fig. 25.1)
• Fat is non-fibrotic from the temple to the
zygomatic arch.
• When passing the zygomatic arch, it is
fibrotic.
• The sunken cheek is the most fibrotic.
• After passing the sunken cheek, fat
becomes soft.
• It becomes more fibrotic as it is closer to
the medial cheek.
25.8  History of Lifting Procedure: Thread Lifting and HIFU

168
Fig. 25.1  Area where
passing of a cannula/
needle is demanding
(areas with dense
connective tissues)
needed. toxin, it is most effective
to perform the lifting procedure in
1 to 2 months, when the effect of
the reduction of the square jaw is
produced. However, in reality, the
botulinum toxin treatment is done
together on the same day as the
thread lifting procedure in many
cases.
–– When explaining a patient the
before and after effects of the pro-
cedure, rather showing the front,
show the side, emphasizing the
cleared jaw line and the corrected
jowl and marionette line. During
the explanation with a frontal
view, lifting simulation does
hardly make a square jaw to
become a V-line.
2. Amount of the Whole Cheek Fat/
Sagging of Localized Fat
• When treating patients with a lot of
fat in the cheek, as more pulling force
is required, the lifting effect may be
reduced.
• In that case, it can be solved by using
long threads rather than short threads
or increasing the number of short
threads.
• If there is sagging of the localized fat,
such as the jowl and the marionette
line, the lifting effect is kind of good.
3. Degree of Sagging of the Marionette
Line/Jowl
• In case that a patient has a mild to
moderate sagging of the marionette
line or the jowl, it is proper to make a
lifting effect. Prior to the procedure,
25  Considerations to Be a Thread Lifting Expert

169
it is useful to show the expected
result by simulating in the mirror.
4. Amount of Submandibular Fat
• If a patient has a double chin, favour-
able effects can be expected by using
long bidirectional threads. In the past,
liposuction was performed to correct a
double chin, but it can be treated only
through a simple thread lifting proce-
dure. In performing a lower face lifting
procedure, the chin contour becomes
clearer if the procedure is performed
with submandibular fat lifting.
Summary
A Checklist to Explain Patients Prior to the
Procedure
1. Checking Elevation of Lateral Canthus
• In inserting a thread from the mandi-
ble, passing the zygomatic arch and
toward the temple, elevation of the
lateral canthus can occur if the most
medial thread is close to the lateral
canthus (see Fig. 23.4). Most patients
do not want the elevation of the lat-
eral canthus after a lifting procedure.
This is because it can make them
look fierce. There are some young
patients who want the lateral canthus
to be elevated. In which case, the
desired result can be obtained by
designing the most medial thread to
be more medial than the normal
design. As most patients do not want
this, it is necessary to check this prior
to the procedure showing the mirror
and to keep 2FB (fingerbreadth) in
distance between the most medial
thread and the lateral canthus.
2. Showing a Simulation of Expected
Result
• As explained in Part 5–1, in perform-
ing a thread lifting, the most favor-
able vectors are the one from the
marionette line to the earlobe/from
the mandible, passing the zygomatic
arch and toward the temple/from the
nasolabial folds passing the zygo-
matic arch toward the hairline, etc.
Prior to the procedure, decide the
optimal vector with simulation using
a mirror. In pulling the skin with the
fingers, it is easy for patients to
understand if the explanations about
the difference in the types and num-
bers of threads are provided by dif-
fering the number of fingers. As the
vector considered by the physician
can be different from outcome
desired by the patient, this process is
necessary prior to the procedure (see
Part 1 – Design and Patient’s Choice).
3. Explaining Downtime of Entry Point/
Hairline Shaving
• Sites of entry points can be largely
divided into three categories.
① Side of the face (hairline or behind
the ears)
• As the entry point is not easily
seen, patients feel less discom-
fort, and it is convenient to dis-
infect before procedure.
② Location which can be exposed in
front view (medial to the hairline)
• Although disinfection is conve-
nient, in case of large entry point
hole, as it is easily exposed, it can
cause discomfort.
③ Temple area (located on the scalp,
inside hairline)
• If the entry point is located on
the scalp, there is the advan-
tage of not being exposed per-
fectly. But disinfection and
preparations prior to the proce-
dure are complicated, and hair
cutting is inevitable.
–– Usually cut about three to
five hairs for each entry
point (to minimize the num-
ber of hairs cut), which does
not cause discomfort to the
25.8  History of Lifting Procedure: Thread Lifting and HIFU

170
patient. In such case, if the hair
around the entry point sticks
out, it may interfere with the
procedure. Therefore, it is man-
datory to prepare the hair
tightly with tools (see Fig.
23.7).
–– In some cases, the hair around
the entry point is shaved not to
be tangled. As the interfering
factors disappear, it is conve-
nient for the practitioner, but it
must be explained to the
patient in advance and needs
consent.
4. Checking Asymmetry
• Most patients have asymmetry to a cer-
tain extent in their faces. But some
patients are concerned about their asym-
metry. In such cases, the sagged side is
lifted more to correct asymmetry.
• However, sometimes, patients and phy-
sicians do not realize the existing asym-
metry of the face prior to the procedure,
and patients claim that the procedure
results in the asymmetry. Even if it is
explained to the patient that the asym-
metry existed before, the patients do not
accept it well. Therefore, when design-
ing, it is necessary to check thoroughly
if there is any asymmetry.
• Some patients want a perfect correction
of severe asymmetry. In such case, it is
advisable that the physician explain the
patient honestly the expected result
showing in the mirror. And it is neces-
sary to pay attention to lift more the
sagged side during the procedure.
25  Considerations to Be a Thread Lifting Expert

Part VII
Procedures for Each Area

173
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Forehead (Eyebrows)
Considerations
The forehead area has small amount of soft tis-
sues, and wrinkles are created by expressions in
the frontalis muscle. To lift the top part of the fore-
head, the following considerations must be made.
• It is advisable to numb the function of the
muscles which lower the forehead downward.
Simultaneous use of botulinum toxin helps.
• Supplementing the volume and adjusting the
hollowness in the wrinkle area must be
considered.
• It is difficult to pull the forehead through sim-
ple lifting. Prior to the thread lifting, by dis-
secting soft tissues, it is necessary to pull the
entire forehead upward.
• Forming a fixing point is more difficult in the
forehead area than other areas.
If the effect is not satisfactory after the initial
procedure, additional procedures must be consid-
ered. Also, toxin treatments on the frontalis mus-
cle must be considered in addition.
1. Type of Thread
• QT lift/Blue Rose Forte/ VOV(short can-
nula and inner needle)
• Silhouette Soft®/silk heart
2. Thread Insertion
• Insertion (driving) depth
–– Subcutaneous (above muscles)
–– Below muscles
• Depth of anchoring: under the muscle
3. Considerations for Side Effects
• Bleeding
–– Bleeding in the forehead lifting procedure
occurs more often than in the cheek lifting
procedure. In designing entry points, exits,
and progression of threads, it is advisable
not to overlap with blood vessels.
–– For preventing bleeding
• Use a cannula over a needle.
• Using a cannula in the driving route of
the thread, anesthetize with lidocaine
including epinephrine.
• In designing, set a location by observing
and avoiding the blood vessels.
• Headache
–– In general, pain is experienced after the
procedure up to around one week
–– Perform a combined botulinum toxin
treatment routinely to the frontalis/corru-
gator muscle and prescribe the NSAID
together.
4. Combined Treatment
• Botulinum toxin
• Filler
• HIFU
26

174
Summary
Simulation Prior to the Procedure (Frontalis
Pulling/Traction Test)
• Perform simulation by showing a mirror to
the patient prior to the procedure, and the
degree of the effect must be understood.
When the frontalis muscle is pulled upward
pressing near the hairline, people whose
eyebrows lift have the anatomical structure
in which the frontalis muscle reacts in con-
stant direction from the hairline to below
the eyebrow.
• On the other hand, when the frontalis mus-
cle is pulled upward pressing near the hair-
line, people whose eyebrows do not lift
much have the anatomical structure in
which the reactions above and below the
frontalis muscle based on the center of the
forehead are separate (probably, it is
thought to have developed in the fascia at
the middle point of the frontalis muscle or
attached to the bone). In such case, when
the skin is pulled upward from the center of
the forehead, the eyebrows slightly lift.
Therefore, for the patients who did not get
satisfactory results from the frontalis pull-
ing/traction test prior to the procedure,
prior explanations are advisable.
• Lifting eyebrow lines and lifting drooped
double eyelid lines should be considered
separately. Until the mid-­40s, when the
eyebrows are lifted, the double eyelid lines
elevate together, but if there is a skin laxity
for those in the 50s or older, even the eye-
brows are lifted, and changes to the double
eyelid lines may be minimal, which needs
to be confirmed to the patient as well.
Fig. 26.1  Eyebrow
lifting – simple fixing
method. (Entry points
and the number of
threads to be inserted
differ depending on the
patients)
26  Forehead (Eyebrows)

175
26.1
Simple Fixing Method (Fig. 26.1)
• Method of fixing by pulling the forehead with
cogs.
• If there is a thick soft tissue including subcuta-
neous fat, the effect is also weak.
• If there are too little subcutaneous tissues, since
they are conglutinated, pulling cannot be achieved.
• Lifting the forehead using the simple fixing
method is insufficient.
• To display effects, supplemental procedures
are required.
• After dissecting the loose connective tissue
layer below the muscles of the forehead, pull
upward using cog threads. Additional inser-
tion of spike form threads would be helpful to
prevent sagging down.
• A number of threads is necessary and dissec-
tion in an accurate layer is required.
• When using the above dissecting method,
some effects may be expected also for the
patients who have forehead tissues with strong
conglutination.
26.2
X-Cross Method (Fig. 26.2)
• The X-cross method is a more effective lifting
method fixing the forehead skin and the sub-
cutaneous tissues.
Fig. 26.2  Eyebrow
lifting – X-cross
method. (Designing
must differ depending
on the patients)
26.2  X-Cross Method

176
• After fixing through knotting, with the func-
tion of the cog in the opposite direction, it has
the function of preventing the pulled skin from
sagging down.
• There is lifting effect only if the pulled skin
can drive above the insertion hole level.
• Instead of cutting and removing the opposite
cogs, additional fixation can be achieved by
inserting the remaining threads into the scalp.
26.3
Anchoring Method (Fig. 26.3)
1. Anatomy
• Be careful with the STA (supratrochlear
artery) or SOA (supraorbital artery): it
passes the eyebrows and comes out of the
subcutaneous layer.
• Check driving in the lateral – SV(sentinel
vein), SfTA(superficial temporal artery),
and SfTV (superficial temporal vein) (if
checked while lying down, blood vessels
show better).
• Dispersion of the frontalis muscle.
2. Designing
• Near the curvature of the frontal bone: in
inserting a cannula, set an entry point and
exit where the curves are minimized.
• If the patient’s hairstyle normally exposes
the forehead, set the entry point above the
hairline so as not to expose the entry point.
• The end of the thread at the exit point is on
the corrugator muscle or the muscle fiber.
• The number of threads differs depending
on the degree of sagging.
Fig. 26.3  Eyebrow
lifting – Anchoring
method. (In many cases,
anchoring must be done
inside the hairline, and it
must be done in the area
where the thread can
drive in a straight line as
much as possible. If
there is a severe curve, it
is difficult for the thread
to progress, and the
likelihood of side effects
is high)
26  Forehead (Eyebrows)

177
When lifting the forehead using the anchoring
method, aging changes must be well understood.
In general, as the skin around the eyes and the
eyebrows are laxed, lifting of the lateral part is
important.
It is recommended to insert and pass the thread
in a deeper layer while performing forehead lift-
ing. Caution must be taken to avoid unevenness
and bumpiness due to a thin tissue coverage in the
forehead. When lifting procedure is done on the
lateral side of the face, it is important to bear in
mind and avoid injury to major arteries and nerves
As nerve pathway is also mostly in the super-
ficial layer in the area where the threads are
inserted, deep-layer lifting is safe, provided, in
the case of the procedure of the lateral part, sag-
ging of the eyebrows may occur by damage to the
facial nerve zygomatic branch.
26.3  Anchoring Method

179
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B. Kim et al., The Art and Science of Thread Lifting,
Wrinkles Around the Eyes
27.1
Summary of the Eye Area
Lifting
27.1.1 Lifting of the Eye Area
Laxity of the skin and the soft tissues in the eye
areas is severe. The factor which must be decided
foremost in treating the eye area is to check
whether the patient is the adequate subject of the
procedure. Lifting which uses absorbable threads
are not fundamentally surgical; therefore, the
process of removing the skin or soft tissues is not
involved. Accordingly, a surgical effect cannot be
expected.
Through simulation, the degree which can be
improved through the absorbable thread lifting
must be clearly explained. Satisfaction will
decrease when the procedure is performed on a
patient whose effect is hardly expected. The
patient may need to get additional surgical treat-
ments. In pulling with threads, many cases
require dissection of tissues.
Reasons for considering surgical treatments
first for lifting of the eye area compared to other
areas are as follows:
• In general, the mechanism of lifting is evenly
pulling the tissues below a certain fixing point
in the head.
• Compared to this, the eye area tends to have
more laxity in the skin and the soft tissues of
the eyelids and the eye area than the fore-
head outside. Namely, the areas which needs
the most pulling are the eye area and the eye-
lids rather than the forehead. Therefore, if it
is pulled by a certain length around the eye
area, this does not result in a sufficiently sat-
isfactory result compared to the forehead
area.
• To the contrary, as surgical methods directly
removes the excessive tissues of eye area and
the eyelids which have the most severe laxity,
a better result can be obtained.
27.2
Anatomy of the Eye Area
27.2.1 Anatomy
In performing an absorbable thread lifting proce-
dure to elevate the eye area, it is advisable to
insert the thread into the supra-periosteal plane in
the frontalis m. area and into the subcutaneous fat
layer in the temporalis m. area.
Due to the possibility of damage in the super-
ficial temporal vessels, bleeding must be mini-
mized by using the pinch technique (Fig. 27.1).
The frontal branch of the facial n. forms many
smaller branches (Fig. 27.2), and therefore,
unless they are damaged all at once, nerve dam-
age to the extent of raising clinical problems does
not occur easily. However, the insertion layer
must always be clearly understood and controlled
smoothly to avoid nerve and vessel damage.
27

180
Fig. 27.1  Pathway of
the STA. (Published
with kind permission of
© Kwan-Hyun Youn
2018. All rights
reserved)
Fig. 27.2  Facial nerve
temporal branch.
(Published with kind
permission of ©
Kwan-Hyun Youn 2018.
All rights reserved)
27  Wrinkles Around the Eyes

181
27.3
Techniques Which Can
Be Used in the Eye Area
27.3.1 Preconditioning by Dissection
with Tumescent Technique
As a method which can be applied to certain
areas only, there is a technique by tumescent
dissection.
Lifting using threads can be approached from
two perspectives. Firstly, it is a method of directly
pulling tissues using a thread. This is a method
used in all areas and is a fundamental model.
Secondly, this is a method of fixing by using the
thread after dissecting a specific layer of the tissue
and pulling the tissues along the surface of dissec-
tion. Even before inserting the thread, this tumes-
cent dissecting method causes lifting to occur
naturally from dissecting and pulling. Provided, if
pulled tissues are not fixed, the lifting effect disap-
pears immediately. Namely, this is a method of
dissecting a specific layer using the tumescent and
fixing the area by inserting a cog thread.
This makes inserting of absorbable threads
convenient, and it has been experienced that this
reduced pain and bleeding. An objective study on
the effect and duration of this technique is
expected to be searched. Because, when a PDO
(which is an absorbable thread ingredient) meets
the tumescent which includes saline solution,
there is a possibility that decomposition acceler-
ates; this would be a very important study. In case
of the authors, when we actually perform the pro-
cedure, after performing layer dissection through
the tumescent solution, a post processing is per-
formed in which the tumescent solution is
squeezed with hands and removed.
27.3.2 Method of Forming a Fixing
Point in the Eye Area
Forming a fixing point
• Fix using bi-directional cogs
• Fix using the tying method
• Combination of tying method and X-cross
method for fixation with bi-directional cogs
• Fascia anchoring method
The tying method and the X-cross method are
used a lot around the eye area.
27.3.3 Tying Method or Simple Cog
Insertion Method (Fig. 27.3)
• The effect on the eye area is better when it is
pulled farther away.
• To prevent the fierce impression by elevation
of lateral canthus area only, it is recommend-
able to pull after performing wide hydro-­
dissection using tumescent solution.
• The layer of hydro-dissection is the layer
below the frontalis m. in the forehead area
and the layer between the deep temporal
fascia and the superficial temporal fascia or
the subcutaneous fat layer in the temple
areas.
• If the cog thread is inserted and pulled after
dissection, tissues are much more easily pulled
than when there is no dissection.
• For fixing afterward, it can be helpful to use a
thread in a spike form additionally.
• If sufficient dissection is done, fixing by
inserting many spike threads only without bi-­
directional cogs is also effective.
27.3.4 X-Cross Method (Fig. 27.4)
• Similarly with the tying method, this is a
method of inserting the remaining thread into
the scalp instead of cutting and removing the
opposite cogs after tying.
• As a function of cogs in opposite direction,
longer and stronger effect can be expected.
• Basically, also around the eye area, the soft
tissues are not easily lifted; lifting through
hydro-dissection is recommended.
• In case of the X-cross technique, it is impor-
tant to fix the cogs on opposite directions.
• For lifting, pulled skin must have gathered
somewhere.
• As it is good to have the skin gather above the
entry point, for this, insertion of the cog in an
opposite direction must be done so that the
cogs in the top hold the skin well.
27.3  Techniques Which Can Be Used in the Eye Area

182
Fig. 27.4  Lifting the
eye area – X-cross
method. The fixing point
can be formed more
strongly
Fig. 27.3  Lifting the
eye area – tying method.
(This is a method which
can be used on patients
whose eye area wrinkles
can be improved by
slightly elevating the
skin in the eye area and
the temple area)
27  Wrinkles Around the Eyes

183
27.4
Cautions
The eye area lifting is a procedure that lifts both
the lateral part of forehead and temple area simul-
taneously. Therefore, procedures are done in two
areas which have anatomical difference. To be
safe, the anatomical structure, blood vessel path-
way and depth, and nerve pathway and depth
must be all understood for both sides. At the same
time, a combination treatment with botulinum
toxin for muscle hyperactivity should also be
taken.
However, the more important than anything
else is not to cause wasting by unnecessarily rec-
ommending thread lifting procedures to patients
who need surgical treatments.
27.4  Cautions

185
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
V-Line (Lower Face)
Considerations
Lower Cheek Lifting
• Making a suitable fixing point affects lifting
outcomes in this area especially.
• The lower cheek is an area where sagging of
fats and laxity of fibrotic tissues are severe as
aging progresses.
• If the fixing point is weak, the effect is mini-
mal or duration is short.
• It is important to select the method of forming
fixing points depending on the condition of
the patient.
Forming Fixing Points
• As V-line lifting using bi-directional cog
threads has weak fixating ability, it has less
effect and shorter efficacy in patients with
more subcutaneous fat in the lower cheek.
• For patients who have thin tissue coverage in
the face, satisfactory results can be obtained
even just with a simple cog thread insertion or
tying method.
• For those whose skin in the lower cheek is
laxed or has excessive fat, forming strong fix-
ing points is essential. The fascia anchoring
method is necessary.
• Considering the folding phenomenon of the
skin which necessarily occurs in forming fix-
ing points, it is advisable to make entry points
above the hairline as much as possible.
28.1
Fascia Anchoring Method
(Fig. 28.1)
• This is the most strong and effective lifting.
• The technique is complicated and cautions
must be taken in consideration of avoiding
injury to blood vessels and nerves. Anatomical
structure and technique must be well
understood.
• It is a true lifting technique not just tightening.
• An entry point should be made inside the hair-
line not to show the pulled skin because pulled
skin nearby anchoring area can be gathered
around the entry point.
• Proceeding in a consistent layer is important
to avoid dimpling of the skin.
28

186
• Dimple can occur in the exit area where the
thread comes out and can be resolved by tak-
ing adequate procedure.
28.2
Tying Method (Fig. 28.2)
• Pulling force is not so strong and the lifting
method is similar to the function of gathering
bi-directional cogs.
• The skin and the subcutaneous layer gather at
the middle point of the bi-directional cogs.
• If the gathering point is not adjusted well, it
causes the zygomatic arch to appear promi-
nent, reducing satisfaction.
• It is not a powerful lifting method, so its effect
would be restricted on people with lots of
­subcutaneous fat in the lower cheek and thick
tissue coverage.
• Its effect is good on people who have thin skin
and less subcutaneous fat.
• Selecting the right patient is important, and if
suitable patients are chosen, it can be done
easily, and the result is also good.
• It is necessary to insert sufficient amount of
threads.
28.3
X-Cross Method (Fig. 28.3)
• Basically, this technique is similar to the tying
method.
• By not cutting the cogs in the remaining area
and pushing them toward the opposite direc-
tion, this strengthens the power of cogs in the
fixing area.
• As the procedure is easy and it is stronger than
the tying method, this is a preferred technique.
• As we can gather lifted skin to specific point,
various designs are possible. It is useful to have
it gather within the hair not to show it as much
as possible, which requires skills accordingly.
Fig. 28.1  V-line
lifting – fascia anchoring
method using long
threads This is the most
important lifting
procedure skill
28  V-Line (Lower Face)

187
Fig. 28.2  V-line
lifting – tying method.
(It is relatively easy and
has favorable effects.
Designing is important.
It is advisable to make
entry points at invisible
areas as much as
possible)
Fig. 28.3  V-line
lifting – X-cross method
Form stronger fixing
points
28.3  X-Cross Method

188
Fig. 28.4  V-line lifting – before and after photos
Before
After
28  V-Line (Lower Face)

189
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Nasolabial Folds
29.1
Anchoring Method (Fig. 29.1)
29.2
Method of Fixing
with Bi-Directional Cogs
(Fig. 29.2)
29
Considerations
• Thread lifting and volumizing effects
are considered simultaneously.
• Selecting fixing point is difficult.
• Pulling the fat layer above the nasola-
bial folds using bi-directional cogs. In
such case, the zygomatic bone area can
be enlarged due to the gathering func-
tion of the bi-directional cogs. Through
diagnostic process, if zygomatic bone is
expected to be widening after the proce-
dure,
other
methods
must
be
considered.

190
Fig. 29.1  Nasolabial
fold lifting – anchoring
method. (Through
simulation, vectors must
be understood
accurately)
Fig. 29.2  Nasolabial
fold lifting – techniques
with bi-directional cogs
29  Nasolabial Folds

191
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Marionette Line
Considerations
–– The marionette line must be designed consid-
ering the treatment of the lower cheek and
jowl.
–– Injecting fillers alone in the sunken area to
soften the marionette line can aggravate the
sagging of the face. The lower cheek area
which makes the marionette line must be
lifted toward the ear (Fig. 30.1).
–– The procedure pulling the sagged lower cheek
area upward must be considered with filler
injection simultaneously.
• Wrinkles in the marionette area need to be
pulled toward the ear.
• Due to the characteristics of lifting, if the skin
is pulled, the pulled skin must be gathered
somewhere.
30
Fig. 30.1  Vectors of
marionette line lifting.
Simulation must be
performed to test which
pulling vector is
effective. Then,
understand the optimal
vectors and design
accordingly

192
• Some of the excessive skin gathers anterior to
the ear, and the procedures must be done in
detail to decrease the degree of the folds and
wrinkles as much as possible.
30.1
Angle Technique (Fig. 30.2)
• After inserting the bi-directional cog thread
in the entry point, bend the direction in the
middle and progress to the marionette line
area.
• The cogs in the marionette part play a pulling
role, and the cogs in the head side play the role
of fixing the pulled skin.
• An additional benefit of angle technique is to
restore the sunken cheek area from the soft tis-
sue gathering effect of bi-directional cogs.
• Skin dimpling inevitably occurs in the area of
entry point marked in red dot; the degree of
pulling must be controlled closely to mini-
mize this.
30.2
L Shape Technique (Kim’s
Technique) (Fig. 30.3)
• The L shape technique is different to the angle
technique; the two ends of the thread come out
through the exit point in blue dot.
• Various types of cannula or long needle with
threads can be used.
• Although it shows more effective tissue gathering
and stronger lifting effects than the angle tech-
nique, this also requires detailed ­procedure as
more wrinkles and dimple can result in the skin.
Fig. 30.2  Marionette
line lifting – angle
technique. Lifting is
performed by inserting
the thread right above
the zygomatic arch (red
dot), bending in the
lower area of the ear to
proceed to the
marionette area,
removing the cannula,
and pulling the thread
30  Marionette Line

193
30.3
Anchoring Technique:
Pulling Method Behind
the Jaw Line (Fig. 30.4)
Fig. 30.3  Marionette
line lifting – L shape
technique
Summary
Setting an Entry Point Around the Mastoid
Process
Bruising and Swelling
• This point is also used in performing
double chin lifting.
• Pain may occur during or after the
procedure.
• There are some people who have dense
and thick surrounding tissues. In such
case, it may be very difficult to make an
entry point or to proceed with a
cannula.
• If an experienced physician performs
the procedure, a good outcome can be
obtained but as beginners may experi-
ence difficulty with controlling pain,
entry point dimples and driving of
cannula. The procedure can be done
easily without these problems if the
entry point is set in the area where
the skin is right behind the mandibu-
lar angle rather than mastoid process
area
(Post-Mandibular
Anchoring
Technique; see Fig. 24.19).
30.3  Anchoring Technique: Pulling Method Behind the Jaw Line

194
30.3.1 Designing
Entry point: set two entry points vertically in 1FB
intervals (1.5 cm) behind the mandibular angle.
• If the sagging in the cheek area is severe, the
effect of the angle technique or L shape tech-
nique may be insufficient.
• In such case, for more effective lifting, the
pulling inevitably needs to be done from
below the ear beyond the mandibular angle.
• It is recommended to perform lifting causing
the skin to fold slightly using the anchoring
method.
30.4
Tornado (Twister Thread)
Supplementary Method
(Fig. 30.5)
• If rigid and twisted spring form threads
named “tornado” (twister) are inserted into
the marionette area, the lower cheek and the
marionette
fold
can
be
improved
simultaneously.
• It may be the combined effect of denaturation
of fat and tissue fibrosis
• The procedure is easy and simple. If the effect
is insufficient after the procedure, other proce-
dures must be considered in additional.
Fig. 30.4  Marionette
line lifting – anchoring
technique – pulling
method behind the jaw
line. It is important to
perform on suitable
patients. If the patient
group is selected after
well understanding the
contents in Part 5-1
Designing and Choice of
Patients, good results
can be expected. This is
a very useful technique
30  Marionette Line

195
Fig. 30.5  Marionette
line lifting – tornado
supplementary method.
This is a technique using
the characteristics of
thread of spring type.
Strictly speaking this is
not a lifting procedure
30.4  Tornado (Twister Thread) Supplementary Method

197
© Springer Nature Singapore Pte Ltd. 2019
B. Kim et al., The Art and Science of Thread Lifting,
Jaw Line (Double Chins)
31
Fig. 31.1  Lifting double chins – necklace technique
Considerations
• This displays a good effect on patients whose
excessive subcutaneous fat is the cause for the
sagging of the neck.
• In case of those whose subcutaneous fat is
thin, sinking and contracture occur highly.
• This is a technique which must be supported by
the skill which can proceed evenly in the layer of
the same depth along the facial and neck curves.
• Cautions must be taken against cases of bleed-
ing and nerve damage. As the driving of the
greater auricular nerve behind the ear is super-
ficial, cautions must be taken.
• In passing the lower jaw area, cautions must
be taken against damaging the salivary gland.
• Prior diagnosis is required to see whether the
neck sagging is resulted from enlargement of
the salivary gland.
• The difference in the locations of the skin and
the subcutaneous fat layer when one is lying
down and sitting down is large. Designing
must be done when sitting down. The design-
ing must be done in a way so that the thread
does not pass up to the body of the mandible.
Summary
Mechanisms of the Necklace Technique
Mechanism of Lifting Double Chin Using
the Necklace Technique
• By pulling the sagged fat in the center
(Fig. a) toward both sides and lifting up
muscles and deep fat, it is a mechanism
of repositioning fat.
• Using 12 cones or 16 cones, set an entry
point at the center and set an exit on
both sides.
• This is a concept which is directly oppo-
site to the technique which pulls from
each of two sides using two threads. The
direction of the cone is directly opposite
compared to the technique which pulls
from two sides.
a
b

198
31.1
Necklace Technique
31.1.1 Designing
• Entry point: set two entry points in 1FB
(1.5 cm) interval in the center line of submen-
tal area.
• Exit: near the SCM (sternocleidomastoid
muscle)  – length of one side to be around
9 cm.
–– If the exit is located more behind than
the SCM, discomfort may be experi-
enced from pulling during neck rotation
movement.
–– Moreover, tissue becomes denser as mov-
ing toward posterior area of the neck;
therefore more force is required for pass-
ing a cannula or needle.
31.1.2 Making an Entry Point
• Make a sufficiently large hole using a puncture
needle (because dimple frequently occurs).
31.1.3 Insertion
• Position: neck flexion makes double chins to
be exposed.
• Depth: insert thread slightly deeper than the
cheek area using the V-pinch technique (into
deep subcutaneous tissue).
31.1.4 Traction and Cutting
• After thread insertion is completed, pull each
half of the thread at both sides.
• (Pulling a right half of the thread by a right-­
handed person) While holding the end of the
thread with the left hand, push the skin to the
center of the chin with a snap using the thumb
of the right hand. In such case, the assistance
holds a left half of the thread so that it is not
move.
Fig. 31.2  Double chin lifting – design of necklace tech-
nique: entry point and exit point
Fig. 31.3  Entry point
31  Jaw Line (Double Chins)

199
Entry point
Exit
Fig. 31.4  Double chin
lifting – design of
necklace technique:
entry point and exit
point
31.1.5 Side Effects: Pain and Dimples
• Right after the procedure or the next day,
patients claim stiffness in the submental
area (feeling of pressing/embracing the
neck).
• After 2–3/3–4 days, pain disappears (day 1,
painful; day 3, slightly improves but still
remains; day 4, pain disappears).
• If the patients feel stiff in the entry point, dim-
ples are usually seen in this area.
31.1  Necklace Technique

200
• If patients flex the neck after the procedure,
entry point dimples can be easily seen. In case
of severe dimples, it is necessary to dissect tis-
sues between the subcutaneous fat and dermis
and to explain to the patient. If left untreated,
severe dimples are not spontaneously resolved
with time.
31.1.6 Cautions in Choosing Patients
1. Indication (cases with good effect)
• When a patient has a mild skin laxity and a
moderate amount of fat
• When double chins appear
• When skin and fat thickness is 1.5 cm or
more while pinching
2. Contraindication (cases with poor effect)
• When there is severe skin laxity and lit-
tle amount of fat (especially in old
patients).
• If skin laxity is severe like the Turkish
neck, as the skin gathers in the center
part of the neck, it can be more
wrinkly.
31.1.7 Factors Which Affect
the Outcome of the Procedure
1. When effects are good
• If the curve connecting the entry point and
the exit in both sides makes a smooth arc
(Fig. 31.9a)
a
b
Fig. 31.5  Comparison of
methods for double chin
lifting. (a) Conventional
technique: entry point located
below both ears/exit located at
the center. (b) Necklace
technique: entry point located
at the center/exit located on
both sides
31  Jaw Line (Double Chins)

201
• If the depth of thread insertion is consis-
tent and deep within the subcutaneous
layer
2. When effects are poor
• If the curve connecting the entry point and
the exit in both sides makes a W shape (or
seagull shape) (Fig. 31.9b)
–– In such case dimple frequently occurs at
the entry point.
–– Using
the
conventional
technique
(Fig.  31.5a) may be a better choice
rather than necklace technique.
• If depth of the thread insertion is
inconstant
–– The curve connecting the entry point
and the two sides of the exit may be
determined not only by designing of
physicians but also by the condition of
the patients (patients’ factors – length
of a mandibular body and angle
between a horizontal line and a mandi-
ble body).
Before
After
Fig. 31.6  Double chin lifting – before and after (exten-
sion and flexion) photos of the necklace technique
Tip!
Rather than inserting into the posterior to
SCM (sternocleidomastoid muscle) by
elongating the thread, it is important to pro-
ceed at a deep and constant depth of the
subcutaneous layer!
It is necessary to explain possibility of
dimple prior to the procedure to patients.
1. If the distance from the very center of the
bi-directional thread to the cog/cone is too
long, the effect of lifting at the very center
of the chin may decrease. If insertion is
done after making an additional knots at
the center of the bi-­directional threads, the
lifting effect of the very center of the chin
is better and duration becomes longer (in
case of Silhouette Soft®).
2. Rather than setting the entry points of
the two threads at the very center, if the
entry point of the first thread is set
slightly more to the left from the center
line and the entry point of the second
thread is set slightly more to the right
from the center line, having only the
thread at the very center of the double
chins without any cog/cone can be
avoided (in case of Silhouette Soft®).
31.1  Necklace Technique

202
a
Fig. 31.9  Relationship
between dimple and
design in performing the
necklace technique. (a)
Design which does not
result in dimple. (b)
Design which results in
frequent occurrence of
dimple (if this design is
used, dimple occurs
frequently as force
gathers at the entry point
which is at the very
center of the thread as
the figure in the right)
Fig. 31.7  Double chin lifting – before and after photos of the
necklace technique. Two threads of the Silhouette Soft® (12
cones) were used for double chin lifting. There are two entry
points at the center, and two exists below the ears
Before
After
Fig. 31.8  Double chin lifting – before and after photos of the necklace technique
Before
After
31  Jaw Line (Double Chins)

203
31.2
Method of Anchoring Below
the Ear (Conventional
Technique)
• This is a method of lifting by fixing near the
mastoid behind the neck or dense subcutane-
ous tissues in the below.
• The lifting effect is strong, but sometimes it
can cause severe pain.
• In some cases, the skin may fold a lot, but this
is a hardly visible area.
31.3
Method of Combining
the Neck: Marionette
• This technique can be used when it is neces-
sary to treat the neck and the marionette line
simultaneously.
• This is a method of lifting the neck and the
lower cheek simultaneously using an anchor-
ing method below the mastoid.
• Long threads must be used for anchoring
method. In this case, tying technique using
two bi-directional cogs is rarely used.
• Long Silhouette Soft® threads or long PDO
threads (QT lift) are used. Lower mastoid area
is an adequate fixing point as it is a lesion
where tissue movement is limited.
31.4
Method of Tying or Simple
Burying
• This is a method of lifting the skin and the
subcutaneous fat in the laxed neck area using
bi-directional cogs or unidirectional cogs.
• Effects are good when the skin is not thick and
the amount of the subcutaneous fat is not much.
• In case there is lots of subcutaneous fat, the
effects disappear quickly if the function of the
fixing point is not strong.
• However, if the PDO dissolves and disap-
pears, it causes fibrosis and contraction of sur-
rounding tissues and stimulates the dermis; in
some cases the best outcome shows after a
period of times.
• Designing must be done while sitting up
straight to prevent the thread from passing
above the mandibular angle.
b
Fig. 31.9  (continued)
31.4  Method of Tying or Simple Burying