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

205
Fig. 31.12  Double chin
lifting – simple burying
method
31.4  Method of Tying or Simple Burying

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B. Kim et al., The Art and Science of Thread Lifting,
Neck Wrinkles
32.1
Method of Filling Wrinkles
• In many cases, horizontal wrinkles in the neck
are difficult to solve.
• Even if the skin is pulled surgically, that is
also difficult to solve.
• The cause of the occurrence of the horizontal
wrinkles in the neck is reduction in the volume
of the dermis and the subcutaneous layer.
Therefore, if adequate volume is supple-
mented, neck wrinkles can be improved.
• However, the neck is thin skin and a lot of
movement, it is not easy to make it completely
disappear.
• By inserting threads which can fill in volume
along the wrinkles, the wrinkles can be
improved (Fig. 32.1).
• Strictly speaking this is filling rather than
lifting.
• Rather than inserting the thread in the form of
simple monofilament, by inserting mesh form
threads, effects can be expected from the con-
nective tissues growing and filling inside.
• To optimize the proliferation effects of the tis-
sues, combining with various supplemental
treatments can be considered.
32
Considerations
• Skin laxity and subcutaneous fat must
be considered at the same time.
• If the skin and the subcutaneous tissue
are not thick, sinking can occur easily
by superficial insertion of threads.

208
Fig. 32.1  Neck wrinkle lifting method of filling wrinkles. Strictly speaking, this is not a lifting. This is a petit wrinkle
cosmetic procedure using threads
32  Neck Wrinkles

Part VIII
Evaluation of Procedure Outcome

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B. Kim et al., The Art and Science of Thread Lifting,
Method of Evaluating the Effect
of Thread Lifting
GAIS score is generally used for evaluation of
thread lifting effect (Table. 33.1). The contents of
the GAIS score are as follows:
When interpreting the GAIS score, you have
to keep in mind two facts. Firstly, the smaller the
number, the better effect it means. Secondly, the
GAIS score does not evaluate the effect objec-
tively, but tells the degree of improvement
subjectively.
It would be nice to measure the effect of thread
lifting through an evaluation tool that is objec-
tively quantified. Although not perfect, the judg-
ment method using the Morpheus which will be
talked about later can be a solution to objective
result evaluation.
33
Table 33.1  Global Aesthetic Improvement Scale (GAIS)
Degree
Description
1  Exceptional
improvement
Excellent corrective result
2  Very improved
patient
Marked improvement of the
appearance, but not completely
optimal
3  Improved
patient
Improvement of the appearance,
better compared with the initial
condition, but a touch-up is
advised
4  Unaltered
patient
The appearance substantially
remains the same compared with
the original condition
5  Worsened
patient
The appearance has worsened
compared with the original
condition

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Evaluation of the Outcomes
Using Morpheus® System
34.1
Simulation Using Morpheus®
34.1.1 Evaluation of Outcomes
It is not easy to simulate soft tissue changes
before and after the procedure by computer.
However, due to technology development, this
has become possible to a certain extent. In case
of the Morpheus® equipment, we can simulate
the changes in volume and soft tissue
movement.
Figures 34.1 and 34.2 below show the simula-
tion of midface thread lifting, frontal cheek filler,
and chin filler using the Morpheus® equipment,
comparing it to the result of the actual
procedure.
34.1.2 Judging Outcomes
Figure 34.3 This figure shows the volume change
after thread lifting, frontal cheek filler, and chin
filler mentioned above using Morpheus®. These
are virtual images of posttreatment by simulation
using Morpheus system.
34
Before
Result of Morpheus simulation
After
Fig. 34.1  Simulation vs actual result of the procedure – front. These are photos of simulation of below the eyes and
frontal cheek filler, chin filler, and facial lifting and the actual procedures performed on the same areas

214
In such case, the area marked green means the
area showing changes in volume in the before
and after photos. Namely, the areas newly filled
with volume are marked in green.
Based on analysis of the figure, the change in
volume of the frontal cheek and the chin areas are
results of filler procedures. However, the changes
are also observed in temporal area where no
insertion procedure was performed. Nonetheless,
there was an increase in volume. The reason for
this and the production process can be seen in the
sequential photos from Fig. 34.4a to f.
34.1.3 Interpretation of the Result
Simulation of thread lifting can be done through
Morpheus®. At the same time, it is possible to
evaluate the outcome of lifting by measuring the
volume increase of temporal area.
The volume increase in the green areas can be
quantified with Morpheus® system. it is believed
that it can be tried for analyzing the outcome of
thread lifting in a form different from the GAIS
score. This is an area which requires additional
researches.
Before
Result of Morpheus simulation
After
Fig. 34.2  Simulation vs result of actual procedure – 45 degrees. These are photos of simulation of below the eyes and
frontal cheek filler, chin filler, and facial lifting and the actual procedures performed on the same areas
Fig. 34.3  Simulation of result using Morpheus®. Volume
changes after designing using Morpheus system –filler
injection simulation to the chin and the frontal cheeks.
The areas marked green are areas of increase in volume
after simulation. Temple area changes are not by filler but
by thread lifting
34  Evaluation of the Outcomes Using Morpheus® System

215
Fig. 34.4  Simulation using Morpheus®. (a) Select a face
to perform simulation of lifting. (b) Designate the range to
apply lifting. (c) Perform tasks of moving the facial soft
tissues upward within the range. (d) Show before and after
photos of simulation. (e) The area of increased volume
before and after the simulation is marked in green. From a
different perspective, the size of the increased volume in
the green part can be predicted to a certain extent. (f) The
area of increased volume before and after the simulation
view from the different direction
a
b
34.1  Simulation Using Morpheus®

216
c
d
e
Fig. 34.4  (continued)
34  Evaluation of the Outcomes Using Morpheus® System

217
34.2
Evaluation of Before
and After Photos Using
Morpheus®
As seen in Figs.  34.5 and 34.6, the volume
increase in the temporal area due to thread lifting
is well presented. It is exactly consistent with the
simulation photo by Morpheus®.
If development of technology and physician’s
know-how are combined, it can be used in objec-
tive evaluation tools of thread lifting in the future.
34.3
Potential and Future
of the Morpheus® System
34.3.1 Use
• Morpheus® system would be used in various
fields.
• Simulation of procedure result, catching char-
acteristics such as facial asymmetry, evalua-
tion after the procedure and comparison of
before and after, etc. are already being used.
• If AI (=artificial intelligence) system develops
more, it is expected that simulation in various
forms according to the needs of customers can
be developed in the form of real-time
showing.
Fig. 34.4  (continued)
f
34.3  Potential and Future of the Morpheus® System

218
Fig. 34.5  Evaluation of before and after actual procedure using Morpheus. The area of volume increases after the
actual procedure is marked in green. Green area in the frontal hairline and left neck is considered artifact
Fig. 34.6  Evaluation of before and after actual procedure
using Morpheus®. Volume increase after the actual proce-
dure (green area). The increased volume in the temporal
area is visible. It is exactly consistent with the simulation
photos
34  Evaluation of the Outcomes Using Morpheus® System

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B. Kim et al., The Art and Science of Thread Lifting,
Utilization of Morpheus®
As it can be seen in the Fig. 35.1, various measure-
ments can be seen utilizing Morpheus. It is possible
to assess the change of the patient’s face objectively
based on numerical data.
Change in volume before and after the proce-
dure can also be known (Fig. 35.2). Volumization
can be evaluated after procedures for various
areas of the face through color coding.
The Fig. 35.3 shows changes in contour for a
specific sagittal and (axial) transverse cross
section.
35
Fig. 35.1  Easy consultation – measure angle at lateral view. After the actual procedure

220
Fig. 35.3  Cross
section. Prior to the
procedure: after
Morpheus designing
Fig. 35.2  Easy consultation – evaluation. Based on actual before and after procedure photos, various measurements
can be calculated. Through colors, these measurements can be visualized
35  Utilization of Morpheus®

Part IX
Side Effects and Treatments
There is a saying that “without experiencing various kinds of side effects, do
not say that you know the procedure.”
Side effects after procedures are experienced by anyone who has per-
formed procedures. The more the clinical experiences, the higher the likeli-
hood of experiencing side effects. When physicians experience side effects,
their relationship with the patient deteriorates and they sometimes experience
despair. In some cases, they give up the procedure. The authors have experi-
enced side effects of thread lifting procedures consecutively at some point
and were concerned for a long time.
Although there are various types of side effects of thread lifting, there is
no side effect as serious as vascular complication of filler. Even if side effects
occur in thread lifting, in most cases, they are solved with simple treatments.
We would like to introduce the side effects prevention technique and the
­coping method which have been acquired through the clinical experience,
sincerely hoping that our readers will be free from despair and worries from
side effects.

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B. Kim et al., The Art and Science of Thread Lifting,
Dissatisfaction
The most common complaints related to thread
lifting procedures are that the effects are not
meeting the patient’s expectations. Especially,
when procedures are done using threads without
cog or short threads with cogs, dissatisfaction
occurs a lot. However, due to the development of
threads produced using upgraded manufacturing
methods recently and techniques, satisfaction
level of patients has been much improved.
To reduce dissatisfaction of the effects after
the procedure, it is important to help patient set
realistic goals and expectations based on the
types and number of threads and the condition of
the patient’s face. Also, satisfaction increases
only if patient’s expectations are similar to the
result of the procedure. Only if overall satisfac-
tion level of thread lifting increases, thread lifting
can become more popular and grow further.
The reason for the dissatisfaction after thread
lifting can be classified into four categories. This
is a subjective categorization by the authors, but
if they are categorized prior to approaching them,
it helps with post-conditioning.
36.1
Unrealistic Expectation
of Patients
This would probably happen in all cosmetic pro-
cedures. If there is a gap between the patient’s
expectation and the physician’s expectation,
proper consultation and further communication
are required to narrow the gap. The physician has
to set realistic and achievable goals to the patient
prior to procedure.
36.2
Patients for Whom
the Procedure Itself Is
Difficult
• Depending on the degree of aging and the
characteristics of the face, the result of thread
lifting varies. Different from surgical treat-
ment, thread lifting does not include the pro-
cess of removing tissues. Namely, it is a
process of rejuvenation through pulling and
gathering.
• After consultation, if simulation doesn’t
ensure good result, surgery may be recom-
mended than noninvasive procedure.
• Unrealistic expectation of patients
• Patients with challenging facial features
• Outcome limitation of thread lifting
products
• Technique issue of the physician
36

224
36.3
Structural Limitation
of Thread Lifting Products
There are various thread lifting products and
mechanism for each. As explained in detail previ-
ously, satisfactory results can be obtained based
on understanding well the histologic changes
from thread insertions in vivo and changes of the
appearance following histologic changes. It is
impossible to make results that can never be cre-
ated by the mechanism of a particular product.
The suitable product must be chosen based on
clearly understanding of mechanisms of each
product and comparing the level of objective
desired by the physician.
36.4
Technique Issues
of the Physician
• Whether there is a desired objective, the
choice of the right patient group, the right
product, and the right technique is important.
• If there is clear understanding of relationship
between mechanisms of aging and threads, we
can predict that this technique can make satis-
factory outcome in advance. Only when the
choice of the right product, right technique,
and right patient group is made, a desired
result can be obtained.
36  Dissatisfaction

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B. Kim et al., The Art and Science of Thread Lifting,
Stiffness and Pain
Pains are experienced in some cases after thread
lifting procedures.
37.1
Points to Verify
• Local or an area
• Accompanying with swelling or not
• Accompanying with fever or not
• Still or making facial expression
• What is felt at palpation: feeling of thread or
tissue hanging (whether it is touched strongly
differently from other areas)
37.2
Cause of Pain
37.2.1 Suspected Infection
• This mainly occurs at entry points or areas
where threads come out from. All four symp-
toms, fever, swelling, redness, and pain, occur.
If patient’s symptom is determined to be
related to infection, it is advisable to start
treating it as soon as possible.
• As an infection in a special form is related to
thread lifting, there is a case of hair getting
into the entry point. After observing carefully,
if it appears that hair has gotten in, it must be
removed. Cautions must be taken not to have
it cut during pulling. If the hair is completely
buried and is not visible, this generally does
not raise any issue, but it can also cause con-
tinuous infection in some case.
• In rare cases, although symptom of infection
is not clear, the entry point or the exit area
continues to swell. Sometimes, although there
is no fever or pain, it accompanies fluctuation
symptoms.
37.2.2 Pain Resulting
from Hematoma
If there was severe bleeding and hemostasis was
difficult, delayed hematoma may occur. During
observation, the swelling area gradually spreads
and accompanies bruising. In some cases, swell-
ing is severe in which case the patients suffer.
Swelling must be minimized through active com-
pression. As time passes, it naturally calms down.
As such it is necessary to ensure the patient.
37.2.3 Cog Hanging in a Specific Area
• Dimpling can occur if cog spikes hang
strongly in a certain area relatively. This
symptom occurs due to inconstant depth dur-
ing passing a thread, or the cog hangs strongly
at the bottom of the dermis near the exit. This
situation generally occurs accompanying pain.
• Dimpling from thread lifting is one of the
most common side effects, and as patient’s
37

226
discomfort is high, it is necessary to solve it as
soon as possible.
37.2.4 Skin Stimulated
by Thread End
• If the thread end is rigid and tapered, in some
cases the end area of the thread stimulates the
skin. In severe cases, it comes out penetrating
through the skin.
• Recently, some leftover threads are made in the
form of bending in 180 degrees to make the end
soft. This is to prevent the sharp end of the thread
from coming out penetrating through the skin.
37.3
Treatment According
to Cause of Pain
• If infection is suspected → oral antibiotics
• Pain from hematoma → observation and
compression
• Cog hanging in a specific area
–– From several days up to 1 month → mas-
sage or molding
–– After 1  month → dissection of tangled
tissues
• Skin stimulated by thread end → removal of
the thread end
37  Stiffness and Pain

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Bruise and Hematoma
When bleeding occurs during the procedure, it is
accompanied by bruise, swelling, hematoma, and
pain. The causes of bleeding are as follows:
Depending on the types of the threads and
technique, the causes of bleeding may differ.
Being cautious during the procedure is helpful to
prevent bleeding.
38.1
Damage of the Dermal Plexus
by Needle-Type Thread
When procedures are performed using needle-­
type thread or sharp cannula, bruise occurs com-
monly. Even without damages to large blood
vessels, as the dermal plexus can be damaged
easily, many areas can be bruised.
38
• Damage of the dermal plexus by needle-­
type thread (sharp cannula)
• Blood vessel damage at the entry point
• Bleeding on the route of cannula
insertion
Tip!
Even if the procedure is performed using a
cannula and if the anesthesia is done using
the dental lidocaine prior to the procedure,
bruise may occur. To prevent this, using a
cannula for anesthesia should be considered.
Right after the procedure
One week after the procedure
Fig. 38.1  Bruise after insertion of needle-type threads (mono PDO threads)

228
38.1.1 Prevention Method
1. Insert into the subcutaneous layer rather than
inserting into the dermis or hypodermis.
2. Insert with a blunt cannula instead of a sharp
cannula.
38.2
Bleeding at the Entry Point
• This can occur when making an entry point
using a sharp needle.
• Especially, it frequently occurs around the
hairline or the temporal area. Palpation of the
pulse of the artery and careful visual ­inspection
of the vein can be helpful to prevent overlap-
ping the entry point and vessels.
• Superficial temporal artery and vein (STA and
STV)
• Sentinel vein (SV)
38.2.1 Prevention Method
–– Palpation and inspection of vessels during
designing.
–– SV inspection and STA palpation are better
checked at supine position.
Fig. 38.2  Important
blood vessel related to
bleeding at entry
point – superficial
temporal artery.
Published with kind
permission of ©
Kwan-Hyun Youn 2018.
All rights reserved
38  Bruise and Hematoma

229
38.3
Bleeding on the Route
of Cannula Insertion
While inserting a cannula, severe bleeding
occurs sometimes. In such case, it is a case of
damage in large blood vessels or branches
rather than the dermal plexus, and it can
develop into hematoma. Especially, in case of
insertion with a sharp cannula, the occurrence
of bleeding is higher. Also in case of a blunt
cannula with a blunt end, caution must be
taken as tissue damage and bleeding can some-
times occur in the area where the tissues are
dense.
38.3.1 Prevention Method
Subcutaneous layer where the blood vessels are
sparsely distributed is a proper layer for inser-
tion. The closer it is to the SMAS, the more likely
damage occurs to large blood vessels.
a
b
Fig. 38.3  Important
blood vessels related to
bleeding of the entry
point – tips for
designing. (a) Left:
prior to marking the
sentinel vein (visible
with the naked eye);
Right: mark the sentinel
vein in blue. (b) If visual
inspection and palpation
of blood vessels cannot
be done well, perform at
supine position or make
a bed tilt downward.
Blood vessels can be
easily observed
38.3  Bleeding on the Route of Cannula Insertion

230

Fig. 38.4  Bruise and swelling due to bleeding after
thread lifting. Damage of the tissues and bleeding around
the mouth caused by a sharp cannula
Summary
Late Onset Bleeding
A late-onset bruise and swelling can occur
a few days later. This rarely happens for
procedures using cog threads. This can be
caused by blood vessel damage through
repetitive stimulation of cogs even if no
bleeding occurs during the ­procedure.
Severe bleeding does not occur. Bruise can
occur around the orbital area or temporal
area accompanied with slight swelling.
Under this circumstance, applying com-
pression to the affected area can make
symptoms subside.
38  Bruise and Hematoma

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B. Kim et al., The Art and Science of Thread Lifting,
Skin Fold
Within 3–4  days after thread lifting proce-
dures, some patients claim that “the threads
appear protruded.” Although the threads do not
actually protrude, a surface of the skin looks
elevated along the route of thread insertion
while making specific facial expressions (e.g.,
smiling).
39.1
Things to Be Checked
Through Examination
• Whether folds are visible with no expression
• Whether it aggravates with facial expressions
(especially, when the pronunciation “ee” is
made)
• Whether it feels even with palpation
39.2
Causes and Solutions
1. When forward/reverse passing of a cannula
or needle is overly repeated to insert one
thread
–– Minimal swelling occurs along the route of
the thread.
Solution
In this case, skin fold is occurred by tempo-
rary swelling and generally subsides sponta-
neously later.
2. When one of the many threads is pulled by too
strong force
–– Especially, if four threads are inserted in
each side, this side effect is usually claimed
from the fourth (the most medial) thread.
This is because the fourth thread passes the
area that is closest to the orbital area and
the skin in this area is thin.
Solution
1. Increase the number of threads (e.g., 4 → 6).
2. Pull each thread with the same force.
3. When a thread is inserted into the superficial
subcutaneous layer or hypodermis
Solution
Insert thread into a deeper subcutaneous layer
4. When the number of threads is not sufficient
to pull the fat tissue
• When patients have much fat in his/her
face, lots of lifting capacity are needed. But
this can occur if the number of threads is
not enough to hold the weight.
Solution
1. In case of short threads, increase the num-
ber of threads.
2. Insert more short threads additionally between
long threads to play a supporting role.
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Protrusion of Threads
After several days or weeks, patients visit the
clinic claiming that “the thread is sticking out.”
The causes of thread protrusion can be catego-
rized as follows:
In general, this does not accompany infection.
It is necessary to check whether the thread is
actually sticking out. If removal is necessary, it
can be removed with simple measures.
40
• Protrusion outside the skin
• Protrusion within the mouth (intraoral)
• Thread near protrusion

234
40.1
Protrusion Outside the Skin
Fig. 40.1  Protrusion of the thread (outside the skin) and
the removed thread. A spiral-type PDO thread was
inserted in the frontal cheek. Protrusion of the thread
occurred in several days after the procedure. It was
removed by pulling the end of the protruded thread with a
needle holder
Protruded thread
Removed thread
Fig. 40.2  Protrusion of the thread (outside the skin) and
removed thread. A bi-directional PDO cog thread was
inserted in the temporal area (see Fig. 6.21). Thread at the
entry point was protruded in several days after the proce-
dure. It was removed by pulling the end of the protruded
thread with a needle holder
40  Protrusion of Threads

235
40.2
Protrusion Within the Mouth
(Intraoral)
Fig. 40.3  Protrusion of the thread (intraoral) and
removed thread. A bi-directional PDO cog thread was
inserted in the lateral cheek. The patient visited clinic
claiming pain and protrusion of thread within the mouth
in several days (according to the patient, the patient expe-
rienced the feeling of the thread being cut while laughing
aloud during a meal with friends) Although the thread was
cut, the bi-directional part of cog remained, but as the cog
was too small and not fixed, it drove downward. It appears
to have penetrated the muscle and the oral mucosa. It was
removed by pulling the end of the protruded thread with a
needle holder
40.2  Protrusion Within the Mouth (Intraoral)

236
40.3
Thread Near Protrusion
(Impending Protrusion)
c
a
b
Fig. 40.4  Thread near
protrusion (impending
protrusion) and removed
thread. (a) It is more
visible while making a
facial expression. (b)
Pushing the skin with
the hand makes it more
visible. (c) The thread is
partially cut with
scissors holding with a
needle holder
40  Protrusion of Threads

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B. Kim et al., The Art and Science of Thread Lifting,
Migration of Threads
The symptom of migration of threads occurs
­several weeks after the procedure in general.
Causes of migration are as follows:
Patients may complain that the thread has
moved or that the thread is likely to come out.
As additional migration can stimulate the
skin at the end, it is advisable to remove the
thread.
41.1
Threads Without Cog
After insertion of the thread without cog, the
thread may migrate and be seen through right
below the skin. Especially, when it is inserted
into around the mouth, which is a dynamic
area with facial expressions, sometimes, it
can be seen through the thin skin of the jaw
line.
41
• Threads without cog
• Incorrect cutting of bi-directional cog
threads
• Breakage of PDO threads due to long-­
term storage

238
41.2
Incorrect Cutting
of Bi-directional Cog Threads
a
b
Fig. 41.1  Thread near protrusion due to migration (after
eyebrow lifting) and removed thread. (a) A bi-directional
PDO cog thread was inserted for eyebrow lifting. Eight
weeks after the procedure, the patient claimed “I feel like
the thread is about to come out through the eyelid.” After
stab incision, the thread was entirely removed. The cog
should have been inserted in both directions sufficiently
from the eyebrow to the hairline, but it was not inserted
sufficiently, and the center of the bi-directional cog was
cut. Thereafter, the thread which remains only unidirec-
tional cog moved slowly downward and appeared like the
above figure (see Fig. 41.2). (b) Based on a closer look at
the removed thread, as 8 weeks had passed after the pro-
cedure, the blue color which was a characteristic of PDO
thread disappeared, but it should be noted that the shape of
the cog still remained the same
When cutting, cog must be preserved bi-­
directionally for fixing. Otherwise, if the cutting
is done with only unidirectional cog remaining
by mistake, it can migrate to one side.
41  Migration of Threads

239
Right cutting line
of bi-directional
cog threada
Incorrect cutting
Fig. 41.2  Cause of migration of bi-directional cog thread
by incorrect cutting. As the reverse directional cogs play a
role of fixing point, if all reverse directional cogs are
removed, the thread easily moves toward the eyelids. The
reverse directional cogs must be kept
41.3
Breakage of PDO Threads
Due to Long-Term Storage
PDO, which is the key material of thread lifting,
easily breaks if exposed to the moisture in the air
and cannot restore its strength. Bi-directional cog
threads prevent migration through its reverse
directional cogs. However, if they are not stored
appropriately, these also can be broken into many
branches after insertion and migrate.
41.3  Breakage of PDO Threads Due to Long-Term Storage

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B. Kim et al., The Art and Science of Thread Lifting,
Bulging at Entry Points
If too many threads are inserted through one
entry point, many ends of threads gather and may
look bulging. Even they are cut properly during
the process, bulging may occur due to facial
expressions. Especially while smiling, as the
skin-muscle movement goes superolaterally, the
threads migrate to form bulging.
42.1
Area of Occurrence
• If an entry point is made at a level where the
horizontal line of the lateral canthus and the
hairline meet, the likelihood of bulging increases
due to zygomaticus muscle movement.
• The likelihood of the occurrence is high if the
threads are not appropriately cut.
• In case many thick threads are inserted into
one hole (e.g., the likelihood of the occurrence
is high when three or four threads of 2-0 thick-
ness are inserted into one hole.)
42.2
Solution
• There is no need to cut the threads again by
incision if they do not protrude through the
skin. As time passes, this gets solved without
sequela afterward.
42.3
Prevention
• When designing an entry point, check the
movement of the skin based on the expression
of the zygomaticus muscle.
• Cut appropriately.
• Set an entry point at the eyebrow level or above.
42

242
a
b
c
Fig. 42.1  Occurrence of bulging in relation to number of
threads and location of entry point. (a) If four threads are
inserted into one entry point, the likelihood of occurrence
of entry point bulging is high. (b) By making two entry
points and inserting two threads each, entry point bulging
can be prevented. (c) If the entry point is located above the
hairline not to be exposed, this is a good method for
prevention
42  Bulging at Entry Points

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B. Kim et al., The Art and Science of Thread Lifting,
Dimple (a Dent in the Skin)
Most common side effect of cog thread lifting is
a depression or a dent in the skin. Especially, it
can occur like a dimple in the cheek area.
This can occur right after the procedure or in
several days to several weeks after the procedure.
This is less likely to occur in general after a
month passes.
It sometimes occurs and disappears on its own
but a patient claims discomfort and visits the
clinic. If physicians do not know how to solve a
dimple when they experience this side effect for
the first time after thread lifting, it can make them
embarrassed. But it improves easily by perform-
ing molding using fingers. Depending on the type
and insertion area of the thread, the likelihood of
occurrence differs. If the likelihood of occurrence
and the treatment method after the procedure are
explained to the patient prior to treatment, it helps
to have a good rapport with the customer.
43.1
Mechanism of Dimples
Formation
To understand the mechanism of dimples for-
mation after thread lifting procedures, it is
necessary to know the difference in density
of fibrotic tissues within the fat layer first.
The area where cogs hang properly after
thread insertion is where a certain amount of
fibrotic tissues are dispersed within the fat
tissues. In that way, the cog does not slip
after lifting and holds in position and it
results in good effect.
However, if there are too much fibrotic tissues
within the fat tissues, which are too dense, it is
difficult for a cannula or a needle to pass. Also, as
cogs can fix well in undesired locations rather
than their original locations, dimples are formed
easily.
43

244
43.1.1 Inconstant Insertion Depth
of Cogs
If a depth of thread insertion is not constant,
some cogs hang in the dense hypodermis, and
some cogs hang in the loose subcutaneous fat
layer, in which dimples can be formed.
Epidermidis
Corium
Superficial adipose
layer and retinaculum
cutis superficialis
Superficial fascia
Deep adipose layer
and retinaculum
cutis profunda
Deep fascia
Muscle
Fig. 43.1  Difference in density of fibrotic tissue within
the fat tissues in facial areas. Depending on facial area,
some fat tissues are divided into superficial fat layer and
deep fat layer and some fat tissues have only one fat layer.
What is important is the density of fat tissues. Soft fat
­tissues like cheese can be easily passed by a cannula or
needle. But they can’t easily pass in dense fat tissue. It is
useful for the procedure to understand which area in the
face has soft or dense fat tissues (see Fig. 6.69)
43  Dimple (a Dent in the Skin)

245
• Pinch technique is used variously to prevent
blood vessel damage and to insert the thread at
constant depth. However, if the force of pinch
is not adequately controlled, this can cause
sinking of the skin.
• Through pinch technique, the subcutaneous
fat layer is elevated and insertion with con-
stant depth can be performed. But sometimes
sinking can occur unexpectedly. Physicians
who have performed liposuction probably
have experienced a dent in the skin through
the same mechanism.
• As shown in Fig. 43.2b, if the thread does not
adequately passed the correct layer, namely,
insertion is done from the side rather than the
middle part of the pinch, sinking can occur.
a
b
Skin (Derma)
Subcutaneous
Fat
Fig. 43.2  Mechanisms of formation of dimples – when insertion depth is not consistent. (a) Depth of thread insertion
is not consistent. (b) Dimple from insertion at inconstant depth during pinch technique (cross section)
43.1  Mechanism of Dimples Formation

246
43.1.2 Sinking of Cutting Parts
In some thread lifting technique, the end of the
thread should be cut and buried sufficiently
within the fat layer. But if the buried cogs hang in
dermis layer or dense fibrotic tissues of fat layer,
sinking can occur.
Dermis
Subcutaneous fat
Showing changes afterwards. Sinking
Fig. 43.3  Mechanisms of formation of dimples – sinking of cutting parts. The last part of the cut thread must be suf-
ficiently buried in to the subcutaneous layer. Sinking occurs if it hangs in the bottom part of the dermis
43  Dimple (a Dent in the Skin)

247
Dermis
Subcutaneous fat
Fig. 43.4  Mechanisms of formation of dimples
43.1.3 When Some Cogs Are Not
Hung Consistently
in the Dermal Layer
The pink circled dotted line in Fig. 43.4 shows
the area where cogs hang in the dermis. When a
thread with strong cogs hangs partially in the der-
mis or hypodermis inconsistently, the skin where
the cogs hang strongly can be sunken.
43.1  Mechanism of Dimples Formation

248
43.2
Type of Dimples Depending
on Area
43.2.1 Dimples in the Route
of Thread Insertion
a
b
Fig. 43.5  Causes of
dimples – dimples in the
route of thread insertion.
(a) Insertion method
without exit points. (b)
Temporal anchoring
method
Fig. 43.6  Area of
occurrence. It frequently
occurs where the
subcutaneous fat tissues
are too fibrotic or where
change of facial
expression results in
excessive motion of
muscle (elliptical area in
orange – near the oral
angle)
43  Dimple (a Dent in the Skin)

249
1. Management of dimples (in case of dimples
in Rt. side).
① Put on a glove on the Lt. hand and lay the
index finger on the inner side of the dimple
in oral cavity.
② Position the index finger of the Rt. hand
right on the dimple, and push the skin
downward giving snaps in the direction
of the extended line of the thread
insertion.
③ It is untangled with a feeling of clicking
and the cog hangs at the original location.
2. When dimples suddenly occur after excessive
motion of facial muscles
Sometimes dimples do not occur after the
procedure but can appear later after laughing
aloud or eating food with the mouth wide
open.
① Cause
Due to change in the facial expressions
(esp, contraction of the zygomaticus mus-
cle), dimples are formed suddenly while
the tissues where the thread is inserted
move with the muscle motion, and the cog
is fixed at a new location (about 2–5 mm,
superior-­lateral) other than the original
location.
② Area of occurrence
The area within approximately 2FB (fin-
ger breadth) distant from the oral angle and
where the subcutaneous tissues are very
fibrotic, dimples are easily formed through
changes in facial expressions.
③ Solution
(a) Put on a glove on the Lt. hand and lay
the index finger on the inner side of the
dimple in oral cavity.
(b) Position the index finger of the Rt. hand
right on the dimple and push the skin
downward
giving
snaps
inferomedially.
(c) It is untangled with a feeling of clicking
and the cog hangs at the original location.
④ Progress
• Dimples usually form within 1 to 2 weeks
after the procedure rather than right after
the procedure.
• It rarely occurs after a month.
• This can recur at home even after solving
by maneuver with fingers in clinic.
Accordingly, by showing the maneuver
with fingers in a mirror, it can be solved by
oneself when it recurs at home.
• It is recommended that physicians provide
explanations about the likelihood of dim-
ples and easy solutions prior to the
procedure.
3. Prevention of dimples
When inserting a thread into the medial side
of the face, the likelihood of dimples increases
if the thread is inserted up to the area close to
the oral angle. If the threads in ③ and in ④
(Fig. 43.7) are inserted up to the blue line, rather
than going up to the elliptical area in orange,
dimples resulting from facial expressions can be
prevented.
43.2  Type of Dimples Depending on Area

250
43.2.2 Dimple at Exit Point
(U Technique: Anchoring
Method)
This is the case right after cutting the thread at the
exit point, which is the last stage of the procedure
(Fig. 43.8).
The mechanism is illustrated in Fig. 43.3.
However, it flattens simply by pushing the
skin while giving snaps with the fingers. In some
cases, dimples form in the exit point in several
days after the procedure like in Fig. 43.5. In such
case, it can be solved by the same method as
managing dimples in the route of thread
insertion.
Fig. 43.7  Prevention of
dimples
Fig. 43.8  Cause of dimple – dimple at exit point
43  Dimple (a Dent in the Skin)

251
43.2.3 Dimple at Entry Point
(U Technique: Anchoring
Method)
43.2.3.1  Mechanisms of Formation
of the Entry Point Dimple
• Basically, as thread lifting is a method of pull-
ing sagging skin, some areas are slightly
folded or wrinkled. As the pulled skin is not
gone, if the bottom part is pulled upward, a
dimple can naturally occur to a certain extent
at the entry point.
• A fixing point is formed laterally to the hair-
line. Therefore, even if some skin is folded,
entry point dimple is rarely exposed as entry
point lies on the scalp.
• However, as a severe dimple which forms in
the entry point occurs due to inappropriate
technique, a delicate skill is needed while lift-
ing with temporal fascia anchoring.
Summary
Distinguishing entry point dimples – normal
dimple vs side effects
When both ends of the thread are slightly
pulled using one hand while the thread is
inserted from the entry point to the exit point
in a U shape:
• If dimple forms → incorrect procedure
• If no dimple forms → normal

43.2  Type of Dimples Depending on Area

252
43.2.3.2  Prevention of Entry Point
Dimple
• Make an appropriate size of hole for an entry
point.
• Make a route for easy passing for the thread to
pass easily in a U shape.
• Especially, it is necessary for the thread not to
hang in the bottom of the dermis at each entry
point (Fig. 43.9).
43.2.3.3  Treatment
① Dissection using scissors
Dissect the space between the dermis and
the subcutaneous fat using scissors with sharp
ends.
a
a
b
b′
c
c
b
Fig. 43.9  Causes and prevention of entry point dimple.
(a) In making an entry point, after puncturing a hole (a)
perpendicularly, make a passage in both directions. Once
the thread is inserted at a constant depth within the subcu-
taneous fat from b-a-c, a dimple does not form even if the
thread is pulled. (b) In case of making inappropriate size
of holes for an entry point or inserting the thread through
a new hole due to incorrect passage of a cannula/needle
rather than ready-made hole, a dimple forms if the thread
is pulled
43  Dimple (a Dent in the Skin)

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B. Kim et al., The Art and Science of Thread Lifting,
Sunken Cheek
There is an area where the cheek is slightly hol-
low on the side of the face. This is called “sunken
cheek,” which is considered to make a charming
face in Western country. However, Asian women
tend not to like this. Sunken cheek is not notice-
able in some young patients, but it stands out
more as they grow older.
Sometimes patients who originally had sunken
cheeks complain that the cheek sunk after lifting
procedure. Or they claim there is asymmetry
between the left and the right. These can happen
if the physicians did not confirm to the patients
prior to the procedure.
Only when the physicians are aware of the
cause and clinical meaning of the sunken cheek
prior to the procedure, claims of patients after the
procedure can be avoided.
44.1
Anatomical Structure
• It is a structure consisting of the zygomatic-­
cutaneous ligament and masseteric-cutaneous
ligament (Fig. 44.1).
• The location on the cheek and the angle of
sagging differ between individuals.
44

254
a
b
c
d
Fig. 44.1  Marking the
sunken cheek area. (a)
Normal state. (b) If the
skin on the zygomatic
arch is lifted, it goes up
well (upward vector). (c)
If the skin on the
zygomatic arch is
pushed downward, it
does not go down well
but moves toward inside
(inward vector). (d)
Using a pen, mark the
sunken cheek area in a
triangle or a diamond
shape
44  Sunken Cheek

255
44.2
Clinical Importance
• If the skin is pushed inferior-laterally with the
hand, significant feature can be observed.
When the skin of other facial parts is pushed
upward/downward with fingers, the skin is
moved in accordance with the direction of the
fingers upward/downward. However, when
the skin on sunken cheek is pushed superome-
dially, it is moved in the same direction, but if
it is moved inferolaterally, it can be observed
that the skin is folded inward (namely, the
inner vector affects). The skin of other facial
parts is moved in the direction of the fingers in
upward/downward vector, this area is affected
by upward/inner vector (Fig. 44.2).
• As this area has little fat and consists of liga-
ments and fibrotic tissues, it is hard to pass
during the procedure. Moreover, once cogs
hang here, they are fixed and nearly at stand-
still. As a result, sinking occurs even further
after the procedure.
44.3
Cautions
• Confirm to patients whether there is a sunken
cheek prior to the procedure.
• Check if there is any difference between the
right and the left sides prior to the procedure.
• Explain that even the lower cheek is lifted
well this area may not be resolved well.
Fig. 44.2  Sunken
cheek. Sunken cheek is
noticeable in older
patients. As it is an area
of severe skin adhesion,
cautions must be taken
during thread lifting
procedures
44.3  Cautions

256
Dermis
Subcutaneous fat
Existing
adhesion
area
Fig. 44.3  Cause of dimple – when cogs hang in the area
of severe adhesion. Green line indicates existing adhesion
→ the skin is sunk originally. The interval between cogs
(blue) is consistent. Nonetheless, as some cogs hang in
fibrotic and dense area (red dotted line), the existing sink-
ing aggravates
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257
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B. Kim et al., The Art and Science of Thread Lifting,
Temporary Paralysis of the Facial
Nerves
45
In some cases, patients and physicians both become
surprised by the asymmetrical facial expressions
after the procedure. Especially, they discover that
when the patients attempt to look in the mirror with
eyes open, the eyebrows do not elevate well or
asymmetry shows in facial expressions. Sometimes
it could be unilateral or bilateral.
45.1
Cause
If local anesthetic agent is injected for pain con-
trol, this could anesthetize not only the sensory
nerves but also motor nerves. It is unlikely that a
cannula would damage to motor nerves which is
located in the space between the SMAS and the
muscle. However, due to the diffusion of lido-
caine, motor nerves can be anesthetized.
45.2
Clinical Features
• “It is hard to close the eyes” (anesthesia of the
orbicularis oculi muscle) → Paralysis of the
zygomatic branch due to anesthesia of the
zygomatic arch
• “It is hard to open the eyes” (anesthesia of
the frontalis muscle)  →  Paralysis of the
frontal branch due to anesthesia of the
temple
• “The mouth turns” (anesthesia of the zygomati-
cus major/minor muscle)  →  Paralysis of the
buccal branch due to anesthesia of the side
cheek
• In most cases, the patients confirm this while
looking in the mirror right after the proce-
dure, but sometimes they recognize after
going back home (in 2–3 h after the proce-
dure). This is the case that they do not check
thoroughly right after the procedure and find
out after looking in the mirror closely at
home.
45.3
Solution
• Reassurance.
• If the procedure is performed in the afternoon, it
usually recovers by the evening or before going to
sleep at night. Sometimes, the symptom remains
until the dawn and restores in the morning.

258
Summary
When local anesthesia for thread lifting
and botulinum toxin treatment on forehead
are performed simultaneously
If various procedures are performed at
the same time, usually, the long procedure
is done first and the simple procedure is
done lastly. Botulinum toxin treatment on
the forehead needs to set injection points
while moving the frontalis muscle and the
eyebrows. But if the frontalis muscle is
temporarily paralyzed after the thread lift-
ing, it is difficult to set the injection point
on the ­forehead. Therefore, it is advisable
to treat the botulinum toxin first in the mus-
cle areas where temporary paralysis can
occur and then perform the thread lifting
thereafter.
45  Temporary Paralysis of the Facial Nerves

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B. Kim et al., The Art and Science of Thread Lifting,
Lateral Canthus Elevation
Elevation of the lateral canthus after the proce-
dure can be obtained only when outstanding
techniques are used. Usually, this effect could be
achieved with temporal anchoring method. But
many patients tend to claim that they look fierce
after the procedure due to this effect.
46.1
Cause
In Fig.  46.1, it can occur when the distance
between the fourth thread and the lateral canthus
is shorter than about 2FB.
46.2
Solution
• Set an entry point to make at least 2FB in dis-
tance between the fourth thread and the lateral
canthus.
• Do not pull too strongly during traction of the
fourth thread (use an even and firm pulling).
46.3
Prevention
• During designing prior to the procedure, it
must be explained to the patients that the lat-
eral canthus may be elevated after the
procedure.
• Although the lateral canthus can be elevated
slightly immediately after the procedure,
when the swelling is released within 2–3 days,
it restores to normal. However, as some
patients could overreact to the elevation of the
lateral canthus, caution must be taken.
46