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Dermatologica Sinica
journal homepage: www.dermsinica.org

Brief Report

The applications of real‑time imaging with transillumination,

ultrasound, and Doppler for thread lifting
Yu‑Hsin Wang1,2,3,4, Ching‑Sheng Yang2, Kuang‑Cheng Chang5, Shyue‑Luen Chang1,2,3,4, Chun‑Yu Cheng1,2,3,4, Yau‑Li Huang1,2,3,4*
Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, 2Department of Dermatology, Chang Gung Memorial Hospital and Chang Gung
1

University College of Medicine, Taoyuan, Taiwan, 3Department of Aesthetic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan, 4Department of Aesthetic
Medicine, Chang Gung Clinic, Taipei, Taiwan, 5Renew Clinic, New Taipei City, Taiwan

Abstract
Thread lifting has gained popularity in recent years because of its minimally invasive properties. Regardless of the technique used, the key
is threading in the optimal anatomical plane and suspending the correct target tissue. Failure to meet these objectives may result in chronic
pain; contour irregularity; thread migration or exposure; and nerve, vessel, and gland injuries. The knowledge of facial anatomy alone is
insufficient to corroborate the anatomical variations of a patient. Ultrasound‑guided thread lifting can be performed because the trocar presents
a hyperechogenic signal with bayonet and reverberation artifacts. Ultrasound is an effective tool because it can provide real‑time images of
the layers of the facial anatomy, fat pads, muscles, fascia, ligaments, superficial muscular aponeurotic system, arteries, and parotid duct.
Transillumination, however, can be conducted to verify the presence of superficial vessels and prevent venipuncture and injury to homonymous
arteries. The combination of transillumination and ultrasound provides three‑dimensional information. In this study, to evaluate facial anatomy
and guide threading, reconfirm the position of the thread, and prevent malpractices, practical strategies such as transillumination, ultrasound,
and Doppler imaging are recommended for improving patient safety during, before, and after the procedure.

Key words: Real‑time imaging, thread lifting, transillumination, ultrasound

Introduction in chronic pain  (11%), contour irregularity  (2.8%–14.6%),

The certified use of thread lifting, by the U. S. Food and Drug
Administration, for rejuvenation of ptotic skin of the face
in 2004, has caused the development of various thread lifts
techniques and threading methods. This is due to its minimally
invasive properties and features such as speedy recovery,
minimal downtime, absence of scars, and less extreme
complications. Regardless of the technique used, the key is
threading in the correct anatomical plane and suspending the
correct target tissue. Failure to meet these objectives may result
thread migration or exposure (7.8%–11.2%), and nerve, vessel,
and gland injury (0.02%).[1‑3]
Furthermore, because most neurovascular structures are below
the superficial muscular aponeurotic system  (SMAS), the
optimal zone of the trocar passage should be maintained at
Address for correspondence: Dr. Yau‑Li Huang,
Department of Dermatology, Chang Gung Memorial Hospital, Linkou, No. 5,
Fuxing St., Guishan Dist., Taoyuan 33305, Taiwan.
E‑mail: henryhuang0219@gmail.com

Submitted: 15‑Oct‑2021     Revised: 09‑Jan‑2022

Accepted: 14‑Jan‑2022      Published: 30-Mar-2022 This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
Quick Response Code: is given and the new creations are licensed under the identical terms.
Website: For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
www.dermsinica.org

How to cite this article: Wang YH, Yang CS, Chang KC, Chang SL,
DOI: Cheng CY, Huang YL. The applications of real-time imaging with
10.4103/ds.ds_1_22 transillumination, ultrasound, and Doppler for thread lifting. Dermatol
Sin 2022;40:44-7.

44 © 2022 Dermatologica Sinica | Published by Wolters Kluwer ‑ Medknow

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Wang, et al.: Real-time imaging for thread lifting

the subcutaneous and subdermal levels for accurate superficial
thread lifting. Because thread lifting is blindly carried out
and as the subcutaneous fat in temporal areas is thin (2.2 mm
in average),[4] it is difficult to ensure that the trocar drives
along the facial contour at a consistent depth, particularly in
Asian subjects wherein the skull is larger than the face. In
clinical practice, a surgeon usually lets the trocar go too deep,
piercing the SMAS without realizing it. Furthermore, despite
knowledge of facial anatomy, the anatomical variants of a
patient are difficult to confirm. This study aimed to recommend
the use of a dual‑image device to improve patient safety in
thread lifting.
Methods
This study was approved by the Institutional Review
Board of the Chang Gung Memorial Hospital  (approval
number: 202000871B0; approval date: 2020.05.27).
A vein viewer (Christie Medical Holdings, Inc., Memphis, TN,
USA) and a handheld ultrasound device with a 10 MHz ultrasound
transducer and color Doppler mode (LeSonoLU700L, Leltek,
Inc., Taiwan) were used as auxiliary imaging tools for thread
lifting. The examination of patients was performed before the
thread lifting procedure. First, a vein viewer was used to locate
the veins in the treatment zone to avoid venipuncture. Next,
ultrasound was conducted to check planes, identify customized
danger zones, and locate critical structures.
During the procedure, the trocar and the thread were placed in,
using real‑time handheld ultrasound imaging. When the trocar
path was on the upper face, the ultrasound probe was vertically
placed in the preauricular area. When the trocar path reaches
the center face, the target for lifting, the ultrasonic probe was
positioned diagonally along the line from the earlobe to the
corner of the mouth. A reconfirmation ultrasound examination
was performed when threads visible on ultrasound were
employed [Figure 1].
Results
The dual image, when combined with color Doppler, can
provide real‑time information about the facial anatomical
layers, fat pads, muscles, fascia, ligaments, SMAS, and
vessels. Moreover, when the vein viewer was used while the
ultrasound probe was placed vertically in the preauricular area,

a b c d

f
g

Figure 1: A diagram illustrating how real‑time imaging is applied in a 40‑year‑old  female for facial thread lifting. First, the real‑time imaging examination
is performed before the procedure. The operator can outline the veins with transillumination (Vein Viewer, Christie Medical Holdings, Inc., Memphis,
TN, USA) while planning the threading route to reduce the risk of venipuncture. Through the ultrasound (LeSonoLU700L, Leltek, Inc., Taiwan) with
Doppler mode, one can identify the real‑man anatomical layers, such as 10 layers in the temporal regions, and can illustrate the crucial structures
that are prone to injury during threading. Next, during the procedure, the operator can insert the cannula precisely at a consistent depth and relative
avascular plane with the guidance of ultrasound. Portion a, e: Transillumination of the upper and lower face. Portion b: Ultrasound image of the temporal
area. Portion c: Doppler image of the temporal area. Portion d: Ultrasound‑guided thread lifting, clinical image. Portion f: Ultrasound image of the
buccal area. Portion g: Ultrasound‑guided thread lifting, ultrasound image. SQ: Subcutaneous layer, STF: Superficial temporal fascia, IF: Innominate
fascia, sDTF: Superficial layer of deep temporal fascia, TFP: Temporal fat pad, dDTF: Deep layer of deep temporal fascia, BFP: Buccal fat pad,
TM: Temporalis muscle, TB: Temporal bone, FbSTA: Frontal branch of superficial temporal artery, FA: Facial artery, SV: Sentinel vein, FV: Facial vein,
SMAS: Superficial muscular aponeurotic system.

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Wang, et al.: Real-time imaging for thread lifting

10 anatomical layers and crucial structures in the temporal
regions were shown. These regions included the subcutaneous
fat layer, the superficial temporal fascia, the innominate fascia,
the superficial layer of the deep temporal fascia, the temporal
fat pad, the deep layer of the deep temporal fascia, the buccal fat
pad, the temporalis muscle, temporal bone, sentinel vein (SV),
and frontal branch of the superficial temporal artery. Moreover,
as the trocar path progressed, the second ultrasound window
with the ultrasonic probe was placed diagonally along the line
from the earlobe to the corner of the mouth. This revealed the
facial artery (FA), facial vein (FV), SMAS, and target buccal
fat pad [Figure 1].
Discussion
Ultrasound is suitable because it can detect trocars, cannulas,
and threads in certain situations. The trocar displays a
hyperechogenic signal with bayonet and reverberation artifacts,
as shown in [Figure  1]. Moreover, the combined use of
ultrasound and color Doppler imaging can provide real‑time
information of the facial anatomy and can guide threading.
It can also be used to determine the depth, thickness, and
volume of the target tissue as well as to distinguish between
superficial and deep fat compartments for superficial and deep
plane thread lifting.[5]
In addition, when making an entry point and during
thread lifting, the SV, middle temporal vein, inferior
palpebral vein, and FV are susceptible to venous injuries.
Transillumination may include details in the third
dimension to help locate some of these superficial vessels
to prevent venipuncture and injury to the accompanying
homonymous arteries.
Thread‑lifting‑associated nerve injuries require special
consideration for two reasons. First, while there are several
vector directions that can be chosen depending on the
lifting targets, the trocar or cannula route can cross‑facial
nerve  (FN) branches along all these vectors. The lifting
targets include the vector that passes from the marionette
line to the ear lobule, the vector that passes through the
mandibular zygomatic arch temple, and/or the vector that
passes through the nasolabial fold‑zygomatic bone hairline.
However, threads with cogs may hook or twine nerves and
surrounding tissues, causing neuropraxia. Second, although
the branches of the FN are difficult to detect with ultrasound,
the surrounding vessels in the danger zones can help
distinguish the branches. The SV, for example, indicates the
temporal branch of the FN upon transillumination and FA/
FV at the antegonial notch indicates the marginal mandibular
branch of the FN.
Further, transillumination, ultrasound, and Doppler imaging
can be used to establish the three‑dimensional structure of facial
anatomy. However, further research, accumulation of case data,
and statistical analyses are required. In our experience, it was
observed that the instances of loose embedding and the need
for secondary correction were significantly reduced with the
use of imaging‑assisted thread lifting. Further, this experience
demonstrates that the dual‑image device is useful at three stages
during the clinical process: before the procedure for anatomical
evaluation, during the procedure for guidance, and after the

Table 1: The application of real time imaging in the thread lifting

Real‑time imaging Before During procedure After Key
for thread lift
Purpose Assessment Entry Path Target Reconfirmation Precise procedures
or dealing with
malpractice
Plane Layers, soft‑tissue Anchoring Superficial or deep Superficial or deep Location of Effective and
volume, and depth to DTF (ROOF, SOOF, DMCF, (ROOF, SOOF, thread* efficient lift in the
BFP) fat compartment DMCF, BFP) fat right plane
compartment
Danger zone Pitanguy line, ‑ Pitanguy line, Antegonial notch ‑ Avoid
mid‑zygomatic arch, mid‑zygomatic arch, neurovasculoductal
McGregor‘s patch, McGregor‘s patch injury
and antegonial notch
Nerve Facial nerve ‑ TFN, ZFN, BFN MMFN ‑ Avoid neuropraxia
Artery FbSTA, ZOA, TFA, FbSTA FbSTA, ZOA, TFA FA/AA ‑ Avoid vascular
FA/AA injury
Vein SV, MTV, IPV, FV/ SV SV, MTV FV/AV ‑ Avoid
AV venipuncture
Duct Parotid duct ‑ Parotid duct ‑ ‑ Avoid ductal injury
Tools TI + US + D TI US + D US + D US Simple and
practicable
*Only when threads visible on ultrasound were employed, such as silhouette. FbSTA: Frontal branch of the superficial temporal artery, ZOA:
Zygomatico‑orbital artery, TFA: Transverse facial artery, FA: Facial artery, AA: Angular artery; DTF: Deep temporal fascia, SV: Sentinel vein, MTV:
Middle temporal vein, IPV: Inferior palpebral vein, FV: Facial vein, AV: Angular vein, ROOF: Retro‑orbicularis oculi fat, SOOF: Suborbicularis oculi fat,
DMCF: Deep medial cheek fat, BFP: Buccal fat pad, TFN: Temporal branch of the facial nerve, ZFN: Zygomatic branch of the facial nerve, BFN: Buccal
branch of the facial nerve, MMFN: Marginal mandibular branch of the facial nerve, Tl: Transillumination, US: ultrasonography, D: Doppler

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Wang, et al.: Real-time imaging for thread lifting

procedure for reconfirmation and prevention of malpractices. In References

most cases, if the surgeon is well trained, he or she can proceed
normally but benefit from preoperative anatomical assessment
based on transillumination, ultrasound, and Doppler imaging.
For select cases with a higher risk of complications, such as
when the patient has too little subcutaneous fat or has received
facial surgery, real‑time imaging is conducted during, before,
and after thread lifting to improve patient safety [Table 1].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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