Minimally Invasive

Aesthetic Surgery
Techniques
Botulinum Toxin, Filler,
and Thread Lifting
Won Lee
Editor

123
Minimally Invasive Aesthetic Surgery
Techniques
Won Lee
Editor

Minimally Invasive
Aesthetic Surgery
Techniques
Botulinum Toxin, Filler, and Thread
Lifting
Editor
Won Lee
Yonsei E1 Plastic Surgery Clinic
Anyang, Kyonggi-do, Korea (Republic of)

0th edition: © MD World Book Publishing 2022

ISBN 978-981-19-5828-1    ISBN 978-981-19-5829-8 (eBook)
https://doi.org/10.1007/978-981-19-5829-8

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Preface

Minimally invasive plastic surgery has become the fastest growing cosmetic
field. However, the use of unscientific methods and misunderstood treatments
persist. Complications develop because of two causes: (1) the variations in
facial anatomy and (2) the doctor’s negligence. Continuous learning and
studying is essential for better results.
MIPS is a small group of board-certified Korean plastic surgeons who
innovate upon and study minimally invasive procedures. Our aim was to find
methods to constantly improve patient results and to consequently share the
knowledge to improve the patient results on a larger scale. We publish articles
and present at several conferences to share our experiences and findings. We
are publishing this book containing the latest scientific knowledge related to
botulinum toxin, filler injections, thread lifting, and other minimally invasive
esthetic procedures.
There are various innovative techniques for administering botulinum
toxin. While botulinum toxin type A has been used widely, type B and E will
also be used soon. Botulinum toxin microinjection techniques are also essen-
tial to know about. More and more techniques will be developed.
Filler injections are commonly used for increasing volume. Easy injec-
tions and immediate results have helped the technique grow rapidly. However,
several vascular and nonvascular complications can occur. The latest compli-
cations are discussed in this book.
Thread lifting is also a fast-growing technique for esthetic fields, with the
development of several techniques for the face, neck, and body area. We have
described many of the techniques in this book.
Patient safety is the most important aspect of these medical procedures
and should be performed using science-based knowledge. Extensive anatomi-
cal knowledge is crucial for successful minimally invasive esthetic proce-
dures. We have included several illustrations and cases to facilitate the
increase in anatomical knowledge.
I am greatly honored to work with Dong Wan Seo, Gi Woong Hong, Kyun
Tae Kim, Eun-Jung Yang, Jeongmok Cho, Hyun Woo Cho, Young Dae
Kweon, Bong-il Rho, Chang Woon Yun, Soo Yeon Park, Hyun Jin Yang, Jin
Young Kim, Won Kyung Kang, Kyu Hwa Jung, Yongwoo Lee, and Young
Choon Jung.
Finally, as always, with a lot of love, I am thankful to Seung Hyun, Hyun
Ji, and Jung Youn.

v
vi Preface

Minimally Invasive Plastic Surgery Association, South Korea

Anyang, Kyonggi-do, Republic of Korea Won Lee

Contents

1 Artistic
 Approach for Minimally Invasive Plastic Surgery����������   1
Dong Wan Seo and Won Lee
2 Anatomical
 Considerations for Botulinum Toxin Injections ������  17
Gi Woong Hong and Won Lee
3 Clinical
 Injection Techniques for Botulinum Toxin����������������������  27
Kyun Tae Kim and Won Lee
4 Anatomical
 Considerations for Filler Injection����������������������������  35
Gi Woong Hong and Won Lee
5 Physical
 Properties and Rheological Approach for Hyaluronic
Acid Fillers����������������������������������������������������������������������������������������  47
Eun-Jung Yang and Won Lee
6 Practical
 Techniques for Hyaluronic Acid Filler Injections��������  57
Jeongmok Cho and Won Lee
7 Doppler
 Ultrasound-Guided Hyaluronic Acid Filler Injection
Techniques����������������������������������������������������������������������������������������  77
Hyun Woo Cho and Won Lee
8 Filler
 Injection Complications and Hyaluronidase����������������������  99
Won Lee
9 Anatomical
 Considerations for Thread Lifting���������������������������� 115
Gi Woong Hong and Won Lee
10 H
 istory, Principles, and Adjuvant Therapy
for Thread Lifting���������������������������������������������������������������������������� 123
Young Dae Kweon and Won Lee
11 The
 Basic Techniques for Thread Lifting�������������������������������������� 131
Bong-il Rho, Chang Woon Yun, Soo Yeon Park, and Won Lee
12 The
 Techniques and Considerations for Thread Lifting�������������� 145
Won Lee and Chang Woon Yun
13 Minimally
 Invasive Rhinoplasty: Augmentation Rhinoplasty
with Cogged Threads ���������������������������������������������������������������������� 155
Hyun Jin Yang and Won Lee

vii
viii Contents

14 Submental
 Contouring Using Elastic Threads������������������������������ 187
Jin Young Kim, Jeongmok Cho, and Won Lee
15 Submental
 Liposuction and Thread Lifting���������������������������������� 197
Won Kyung Kang and Won Lee
16 Short
 Scar Rhytidectomy Combined with PDO Threads������������ 203
Soo Yeon Park, Kyu Hwa Jung, and Won Lee
17 Complications
 of Thread Lifting and Treatments������������������������ 213
Yongwoo Lee and Won Lee
18 Body
 Contouring Using Threads and Fat Graft �������������������������� 223
Young Choon Jung and Won Lee
About the Editors

Jeongmok Cho    Incline Plastic Surgery Clinic,

Seoul, Republic of Korea

Hyun Woo Cho    Ipche Plastic Surgery Clinic,

Seoul, Republic of Korea

ix
x About the Editors

Gi  Woong  Hong    SAMSKIN Plastic Surgery

Clinic, Seoul, Republic of Korea

Kyu Hwa Jung    Liting Plastic Surgery Clinic,

Seoul, Republic of Korea

Young  Choon  Jung    Hershe Plastic Surgery

Clinic, Seoul, Republic of Korea
About the Editors xi

Won  Kyung  Kang    BORA Plastic Surgery

Clinic, Ansan-si, Kyonggi-do, Republic of Korea

Kyun  Tae  Kim    Yonsei Dain Plastic Surgery

Clinic, Seoul, Republic of Korea

Jin  Young  Kim    OhKims Oh Plastic Surgery

Clinic, Goyang-si, Gyeonggi-do, Republic of
Korea
xii About the Editors

Young Dae Kweon    Kang Nam Plastic Surgery

Clinic, Osan, Kyonggi-do, Republic of Korea

Won  Lee    Yonsei E1 Plastic Surgery Clinic,

Anyang, Kyonggi-do, Republic of Korea

Yongwoo  Lee    LIKE Plastic Surgery Clinic,

Seoul, Republic of Korea
About the Editors xiii

Soo  Yeon  Park    MadeYoung Plastic Surgery

Clinic, Seoul, Republic of Korea

Bong-il  Rho    Glovi Plastic Surgery Clinic,

Seoul, Republic of Korea
xiv About the Editors

Dong  Wan  Seo    Da Vinci Plastic Surgery

Clinic, Seoul, Republic of Korea

Eun-Jung  Yang    Plastic and Reconstructive

Surgery, Yonsei University College of Medicine,
Seoul, Republic of Korea

Hyun  Jin  Yang    BaroYL Plastic Surgery

Clinic, Seoul, Republic of Korea
About the Editors xv

Chang Woon Yun    View Plastic Surgery Clinic,

Seoul, Republic of Korea
 Artistic Approach for Minimally
Invasive Plastic Surgery 1
Dong Wan Seo and Won Lee

Plastic surgeons should offer satisfactory services
in their field and should carry out evaluation stud-
ies of various reconstruction surgeries. In addi-
tion, they should study beauty outcomes after
procedures. The rapid development of new tech-
nologies and products has improved beauty out-
comes. With the development of social media and
the rapid sociocultural changes, beauty trends
have also rapidly evolved. Esthetic physicians
should always be aware of these rapid changes in
beauty trends and should obtain satisfactory out-
comes with these newly developed products.
In this chapter, we shall describe the general
considerations for satisfactory outcomes of esthetic
procedures using minimally invasive approaches.
Additionally, we shall verify the basic abilities of
the clients before performing the esthetic proce-
dures, so as to better analyze the outcomes.
patient’s expectations from the procedure. He
should inform the patient about the limitations
of the procedure, and all the information given
should be recorded in a chart as this will be
helpful in case of any future conflict due to
dissatisfaction.
1.1.2 Patient’s Past History
Past surgeries/procedures could affect the future
procedure. Sometimes they potentiate each
other, but in some scenarios, the previous proce-
dure hinders the latter. Previous scars and/or
contractures always affect future procedures, so
verifying the patient’s past history is very impor-
tant before performing the new procedure
(Table 1.1).

1.1 Patient Analysis Table 1.1  Patient’s past history

Time of
1.1.1 Patient Expectations Location operation
Botulinum toxin
Before beginning, the doctor should inquire Filler injection
about the requests of the patient and the Thread lifting
Face-lift operation
D. W. Seo Bone contouring
Da Vinci Plastic Surgery Clinic, surgery
Seoul, Republic of Korea Ultrasound/
radiofrequency
W. Lee (*)
devices
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea Liposuction/fat grafts

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 1
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_1
2 D. W. Seo and W. Lee

1.1.3 Current Status of Patient be recorded on charts and photographs taken.

Esthetic surgery is a field of medicine that is
highly influenced by the patient’s point of view,
and it is subjective in different aspects. Thus,
the patient’s preoperative objective status should
There are multiple methods of preoperative
evaluation, such as 3D and video analyses. The
preoperative status of the patient should there-
fore be analyzed using objective tools (Figs. 1.1,
1.2 and 1.3).

Fig. 1.1 QuantifiCare
3D photo analysis

Fig. 1.2  Morpheus 3D

analysis

Fig. 1.3  Vectra analysis

1  Artistic Approach for Minimally Invasive Plastic Surgery
1.2 Plan of the Procedure
1.2.1 Choice of the Procedure
The doctors should consider the best procedure
to obtain the best result, based on the patient’s
information and analysis. At times, a staged pro-
cedure might be needed to obtain better results.
In other circumstances, performing multiple pro-
cedures in different stages will yield a better
result than when all the procedures are performed
at once. In addition, doctors should consider per-
forming several procedures so as to reduce the
limitations of a single procedure (Table 1.2).
1.2.2 Choice of the Material
Recently, many tools have been developed, such as
botulinum toxin, hyaluronic acid (HA) filler, non-
HA filler, lifting threads, and skin boosters, but
their outcomes are very different. Therefore, a care-
ful choice of the material should be made while
taking the following points into consideration:
• Optimization of the results: The doctor should
choose the best materials for the expected
result. Sometimes, different results can be
obtained with the same material because of
differences in the doctors’ experiences.
Table 1.2  Symptoms and possible procedures (volumization, filler, fat graft; lifting, endotine, thread; neuromodula-
tion, botulinum toxin; tightening, micro-insulated needle radiofrequency system, microfocused ultrasound, energy-
based devices)
Symptom
Forehead Sunken, deflation, wrinkle, asymmetry
Eyebrow Deflation
Temple Sunken
Upper eyelid Sunken, deflation
Lower eyelid Sunken, deflation, wrinkle
Nose Shape, volume, wrinkle
Malar region Shape, volume, wrinkle
Cheek Sunken, deflation, wrinkle
Nasolabial fold Sunken, deflation, wrinkle, asymmetry
Lip Shape, volume, wrinkle, asymmetry
Marionette line Sunken, deflation, wrinkle, asymmetry
Chin Shape, volume, wrinkle
Neck Deflation, wrinkle, asymmetry
3
• Duration of the results: Even though the
immediate results can be satisfactory, when
the results are short-lasting, the satisfaction
rates are low. To gain the patient’s confi-
dence, the doctor should use good-quality
products.
• Safety of the product: Botulinum toxin is
known to be powerful and should therefore be
used with caution. Unlike autograft products,
synthetic products should be considered as
foreign bodies as they produce inflammatory
reactions. Therefore, doctors should take into
consideration the wound healing process and
its complications (scar formation and
hyperpigmentation).
• Revision/additional procedures: When there
are complications or dissatisfactory results,
alternative solutions should be proposed.
• Convenience and quick response: Many
patients who undergo minimally invasive pro-
cedures seek for short-lasting procedures,
with immediate results and a short recovery
time.
• Combined procedures: Always consider per-
forming combined procedures to obtain better
results.
• Economy: Although the aim is to obtain a sat-
isfactory result, the cost of the procedure
should not be a burden to the patient
(Table 1.2).
Method
Volumization, lifting, neuromodulator injection, tightening
Lifting, neuromodulator injection
Volumization
Volumization, lifting
Volumization, lifting, neuromodulator injection, tightening
Volumization, lifting, neuromodulator injection
Volumization, lifting, neuromodulator injection, tightening
Volumization, lifting, neuromodulator injection, tightening
Volumization, lifting, neuromodulator injection, tightening
Volumization, lifting, neuromodulator injection, tightening
Volumization, lifting, neuromodulator injection, tightening
Volumization, lifting, neuromodulator injection
Volumization, lifting, neuromodulator injection, tightening
4 D. W. Seo and W. Lee
1.3 Considerations
for the Design
1.3.1 Esthetic Aspects
• Beauty: The ultimate goal of minimally inva-
sive procedures is a satisfaction aesthetically.
Skillful procedures are needed to obtain the
best results, but the doctor’s appreciation of
beauty is also needed.
• Individual satisfaction: Beauty criteria cannot
be quantified. When published in the litera-
ture, results should be shown using statistical
numbers, but the search for individual esthetic
satisfaction is more important.
• Physiognomy: There is a unique field of study
in oriental culture, which is related with fortune
and destiny. This field of study takes into
account facial aspects. This should be taken into
consideration before carrying out procedures.
1.3.2 Functional Aspects
• Minimally invasive procedures should yield
three-dimensional (3D) results. These include
volume change, and displacement of tissue.
Filler injection adds volume by a direct method;
however, botulinum toxin injection and thread
lifting usually use tissue displacement.
• The human body is not a two-dimensional
(2D) picture. Specifically, facial muscles con-
tract continuously every second to produce
different expressions. A facial expression is
not only produced by a single muscle, but is a
consequence of balanced facial muscle move-
ments. Therefore, antagonistic muscles should
be taken into account when performing a pro-
cedure on certain portions of the face.
• The aging process never stops. Minimally
invasive procedures should also aim at improv-
ing the current aging aspect (of the patient)
and slowing down the effects of the aging pro-
cess. More extensive procedures can better
improve the current aging aspect of the patient,
but limitations always exist.
1.4 Beauty Criteria
It is not easy to find an objective definition for a
beautiful face. People usually concentrate on an
exact beauty point when they see a beautiful face
[1]. The angles between these beauty points are
very important points of attractiveness [2]. People
usually define beauty by following seven charac-
teristics of the face (Table 1.3) [3].
Among these seven characteristics, mini-
mally invasive procedures such as botulinum
toxin injection, filler injection, and thread lifting
can make improvements to the facial shape (1),
eyebrow shape (3), nose shape (5), and lip shape
(6). Operative methods such as forehead reduc-
tion or hair graft can improve forehead height
(2). Other operative methods and makeup tech-
niques can help improve the eye size and inter-
eye distance (4); moreover, multiple
energy-based devices and dermatologic solu-
tions can improve the skin (7).
The most common references for facial beauty
are symmetry, balance, and harmony [4–7].
Facial symmetry is satisfactory when the right
and left sides of facial parts, such as the nose or
lips, are adjacent. However, all facial contour and
volume cannot be exactly symmetrical. The most
important factor to consider is facial harmony.
Harmonious factors (such as Golden Mask) can
be converted into objective parameters and can
be used to better estimate esthetic proportions
(Fig. 1.4) [8].
These numeric proportions differ with countries,
continent, race, age, and gender. Since these param-
eters are based on 2D measurements, they cannot be
used to determine esthetic procedures, especially as
the face is a dynamic structure (due to the continu-
Table 1.3  The magnificent seven
1. Facial shape (cheeks and chin)
2. Forehead height
3. Eyebrow shape
4. Eye size and inter-eye distance
5. Nose shape
6. Lips (length and height)
7. Skin clarity/texture/color
1  Artistic Approach for Minimally Invasive Plastic Surgery 5

Table 1.4 Bannister classification [7]; PI, Prosopic

Index = (face length/face width) × 100
Bannister classification face type PI (%)
Type I Hypereuryprosopic <79.9
Type II Euryprosopic 80–84.9
Type III Mesoprosopic 85–89.9
Type IV Leptoprosopic 90–94.9
Type V Hyperleptoprosopic >95

Fig. 1.4  Golden Mask (redrawn from Reference 3)

ous movement of facial muscles). Therefore, the

doctor’s appreciation of the esthetic aspect is needed
to measure the harmonious proportions.

1.4.1 Facial Shape

Facial shape can be classified as follows

(Table 1.4, Figs. 1.5 and 1.6):
This classification is based on the proportion
of face length and face width and is applicable in
the field of plastic surgery. Nevertheless, a more
specific classification is needed to appreciate the
esthetic aspect [9].
The following classifications are used for
makeup studies, hairstyle studies, and fashion
studies and so would also be useful in the field of
esthetics (Fig. 1.7).
Younger individuals have wider upper and
midface, giving the characteristic “triangle of
youth” appearance (Fig. 1.8). As the aging pro-
cess evolves, facial balance is disrupted by loss
of midface volume, weakening of the retaining
Fig. 1.5  The determination of face length (FL) and face
width (FW)
ligaments, descent of soft tissue, and skin sag-
ging. Consequently, volume replacement and
face lifting vector should be considered to recon-
stitute the “triangle of youth” shape. There are
seven regions for these interventions: the fore-
head, temple, malar area, cheek, nasolabial fold,
marionette line, and chin. These regions deter-
mine the facial contour when the patient is
observed from a frontal view. Facial movement
and expression should be taken into consider-
ation during volumization, lifting, and neuro-
modulator injection.
6 D. W. Seo and W. Lee

Fig. 1.6  Illustration of the different types of face shapes

Fig. 1.7  Ten facial shapes

1  Artistic Approach for Minimally Invasive Plastic Surgery
Fig. 1.8  The triangle of youth
1.4.2 Forehead
1.4.2.1 The Proportion of Facial Length
and Forehead (Fig. 1.9)
The forehead to facial length proportion is known
to be 1:3 ideally. This proportion can be obtained
by performing hairline change procedures such
as hair removal by light amplification by stimu-
lated emission of radiation and hair graft opera-
tion, and/or eyebrow change procedures such as
tattooing, botulinum toxin injection, and lifting
procedures.
1.4.2.2 Forehead Shape (Fig. 1.10)
Forehead height, width, and shape are usually
determined from the shape of the hairline. The
definition of a satisfactory forehead shape will
vary depending on the individual’s perception
of beauty, but it is important to ensure symme-
try [10].
1.4.2.3 Forehead Volume and Curvature
Forehead volume and curvatures are among the
most important aspects to consider for minimally
invasive procedures and are important in the lat-
eral view of the face. Facial profile on lateral
7
view should take in account protrusions such as
the glabella, nasion, and nasal tip.
The curvature of forehead basically depends
on the shape of the frontal bone and on various
surrounding structures such as the muscle, subcu-
taneous fat, and skin. Neuromodulator injection
is effective when there is an irregularity during
muscle movement.
The perception of a satisfactory forehead
shape varies with gender and age. Young female
patients, especially, want their middle forehead
area to protrude more than the glabella area,
unlike male and middle-aged women patients
who tend to be uncomfortable with this promi-
nent forehead shape (Fig. 1.11).
1.4.3 Eyebrows
The shape of the eyebrows can be altered using
surgical procedures such as hair removal or hair
graft. However, many patients perform makeup
and/or have semipermanent tattoos. Lifting and
neuromodulator injection procedures could also
affect eyebrow shape; therefore doctors should
anticipate the results before carrying out these
8 D. W. Seo and W. Lee

Fig. 1.9  Proportion between the forehead and face length

Fig. 1.10  Forehead classification based on hairline shape

1  Artistic Approach for Minimally Invasive Plastic Surgery 9

procedures. Eyebrow shape should be considered

both individually and in relation to the shape of
the face (Figs. 1.12, 1.13 and 1.14).

1.4.4 Eyelid

Analyses of the two eyelids are usually per-

Fig. 1.11  Curvature of the forehead: the middle forehead
protrudes more than the glabella area
formed to ensure their attractiveness [11]. A
descended upper eyelid alters the double eyelid
shape. In addition, eyebrow descent occurs with
the aging process. Minimally invasive procedures
such as thread forehead lifting are helpful, but
usually, surgical procedures are performed
because of remnants on the skin [12]. Surgeons
should also take into account the possible aggra-

Fig. 1.12  Eyebrow shape considered in relation to facial shape

Fig. 1.13  Classification by eyebrow shape

10
Fig. 1.14 Golden ratio of the eyebrow and iris. ①
Horizontal line between the medial eyebrow and the lat-
eral eyebrow tail. ② The medial eyebrow should be more
medial than the medial canthus (vertical line from the side
of the nose). ③ The center of the eyebrow should be lateral
to the vertical line of the lateral iris. ④ The eyebrow tail
should be located medial to the line joining the lateral
nose and lateral canthus
vation of sunken eyelid after brow lift procedures.
Therefore, multiple parameters should be consid-
ered before carrying out the surgical procedures.
Sunken eyelids also alter eyelid shape and
could be corrected by volumization [13]. Before
performing volumization procedures, informed
consent should be obtained because of the possi-
bility of lowering the height of the eyelid. In
addition, consideration of a possible blepharop-
tosis should be made.
Focus should be laid on the lower eyelid
region as the aging process evolves. Multiple
procedures could be performed, such as micro-­
insulated needle radiofrequency device [14] or
microfocused ultrasound [15] procedures.
However, because of skin excesses and the dura-
tion of the latter procedures, surgical procedures
are usually preferred.
Tear trough deformity is common with aging,
but some young patients also face this problem.
Corrective volumization procedures such as filler
injection [16, 17] and microfat injection [18] are
often performed. However, overcorrection should
be avoided.
D. W. Seo and W. Lee
1.4.5 Nose
There are multiple studies on rhinoplasty in the
literature [19–21]. These techniques usually
involve major surgical procedures rather than
minimally invasive procedures. However, more
minimally invasive procedures such as filler
injection, volumization, and thread insertion are
being performed recently. Therefore, five aspects
should be considered [3]:
• Facial contour and shape.
• Skin texture and thickness.
• Proportion between other facial structures.
• The aim should be to obtain an improvement
rather than a perfect result.
• Esthetic component (Fig. 1.15).
1.4.5.1 The Radix
The radix height is related to the nasofrontal
angle. The ideal angles are 115–120′ and 120–
130′ in the male and female genders, respectively
(Fig. 1.16).
1.4.5.2 The Dorsum
The dorsum should be straight rather than devi-
ated. It should be 2 mm narrower than the radix
on frontal view.
1.4.5.3 Nasal Tip
The nasal tip skin thickness is thicker than that of
the dorsum. This difference should be taken into
account to avoid complications when performing
minimally invasive procedures. The tip defining
points should be symmetrical.
1.4.5.4 Columellar-Alar Complex
The male nasolabial angle is 90–95°, and the
female’s is 95–110°. The columella should be
2–3 mm wide on lateral view.
1.4.5.5 Nasal Base
Nasal base should be the same as the intercanthal
distance.
1  Artistic Approach for Minimally Invasive Plastic Surgery 11

Fig. 1.15 Sheens’
esthetic components of
the nose (redrawn) [19]

1.4.6 Lips

Lips are 3D structures, and they have a distinctive

Fig. 1.16  Ideal male and female nasofrontal and nasola-
bial angles
color compared to other facial structures.
Consequently, when performing any lip proce-
dure, the doctor should consider the 2D and 3D
aspects. They also have to take into account
changes in lip shape with facial expression.
[Frontal view].
Lip shape can be classified based on the shapes
of the Cupid’s bow, mouth corner, and lower lip
(Table 1.5).
These classifications cannot be used as esthetic
criteria because facial shape and proportion
should be considered as well. Nonetheless,
matching the lip class with the patient’s desire
will provide very helpful information before pro-
cedures. The classifications are based on 2D
analyses; however, lips are 3D structures. Volume
should therefore be determined. The aging pro-
12 D. W. Seo and W. Lee

cess decreases lip volume. The aims of lip aug- The upper lip to lower lip proportion is also an
mentation procedures should be the improvement important determinant of lip attractiveness. Lips
of lip fullness, restoration of atrophic region, and are known to occupy 9.6% of the lower face sur-
the precision of the vermilion border and phil- face area, and the recommended upper lip to
trum [22]. lower lip proportion is 1:2 [23]. However, the
preferable ratio varies with race, country, and age
(Fig. 1.17).
Table 1.5  Lips morphological classification
[Lateral view].
1. The shape of the Cupid’s bow Ricketts’ E-plane is recommended to evalu-
   (a) Straight
   (b) Curve
ate the protrusion of lips. The upper lip and
   (c) Deep curve lower lips should be behind the E-plane.
2. The shape of lip tail (mouth corner) Younger patients’ lips tend to be located more
   (a) Straight adjacent to the E-plane. Esthetically, lips
   (a) Dropped located anterior to the E-plane are not preferred
   (a) Elevated
3. The shape of lower lip line.
[24] (Fig. 1.18).
   (a) Straight Comparative analyses can be performed when
   (b) Curved comparing upper lip and lower lip with facial
   (c) Rounded convexity (G-Sn-Pg) [25] (Fig. 1.19).

Fig. 1.17  Upper lip to lower lip ratios

1  Artistic Approach for Minimally Invasive Plastic Surgery
Fig. 1.18  Lip protrusion criteria
Fig. 1.19  Lip protrusion stages
1.4.7 Chin
[Frontal view].
Microgenia is known to be related to meticu-
losity, indecisiveness, lack of exercise, and shy-
ness. Conversely, a protruded chin is thought to
be related to powerfulness, aggressiveness, and
overconfidence. Some studies describe correla-
tions between races and nationalities with the
adult’s average chin protrusion [26–29].
13
[Lateral view].
The lateral view should take into consideration
the lips, chin end, and curvature of neck area.
• The labiomental fold is the crease between the
lower lip and the chin area and is considered
to be related to the mandible bone vertical pro-
portion with facial height [30]. Its ideal
­location is the upper 1/3 region from the sto-
mion to the menton [31].
14
Fig. 1.20  The Riedel line [32]
• The Riedel line, which is a virtual line linking
the upper and lower lips to the pogonion,
should be taken into consideration. Generally,
the lower lip is 2–3 mm posterior to the upper
lip, and the pogonion is expected to not cross
the Riedel line (Fig. 1.20).
• The ideal cervicomental angle is 105–120°
and could be increased by liposuction and lift-
ing procedures (Fig. 1.21).
• The ideal chin should be located not more
than 3 mm away from the virtual line linking
the nasal tip to the upper lip [33].
D. W. Seo and W. Lee
Fig. 1.21  Cervicomental angle
1.5 Evaluation of the Success
of a Procedure
This evaluation takes into consideration the doc-
tor’s and the patient’s points of view. It is usually
based on subjective satisfaction rates, and the
Global Aesthetic Improvement Scale (GAIS) is
commonly used (Table  1.6). There also exist
other evaluation tools such as the Wrinkle
Severity Assessment Scale and the FACE-Q
scales. With recent scientific innovations, various
imaging tools have been developed, such as 2D
contour lines, 3D images of soft tissue volume
changes, and vector analysis.
1  Artistic Approach for Minimally Invasive Plastic Surgery
Table 1.6  Global Aesthetic Improvement Scale (GAIS)
Degree Description
1 Exceptional Excellent corrective result
improvement
2 Very improved Marked improvement of the
patient appearance, but not completely
optimal
3 Improved Improvement of the
patient appearance, which is better than
the initial condition, but a
touch-up is advised
4 Unaltered The appearance substantially
patient remains the same compared
with the original condition
5 Worsened The appearance has worsened
patient compared with the original
condition
References
1. Synnott A.  Francette PACTEAU, the symptom of
beauty, Cambridge, Mass.: Harvard University press,
1974. 232 pp. Culture. 1994;14(2):149–50.
2. Klopfer PH. Sensory physiology and esthetics: among
many species play seems to be a guide for conscious
action. Am Sci. 1970;58(4):399–403.
3. Swift A, Remington K.  BeautiPHIcation™: a
global approach to facial beauty. Clin Plast Surg.
2011;38(3):347–77.
4. Brookes M, Pomiankowski A.  Symmetry is
in the eye of the beholder. Trends Ecol Evol.
1994;9(6):201–2.
5. Concar D. SEX AND THE SYMMETRICAL BODY-­
creating balanced bodies is one of nature's biggest
challenges. New Sci. 1995;146(1974):40–4.
6. Enquist M, Arak A. Symmetry, beauty and evolution.
Nature. 1994;372(6502):169–72.
7. Grammer K, Thornhill R.  Human (Homo sapiens)
facial attractiveness and sexual selection: the role
of symmetry and averageness. J Comp Psychol.
1994;108(3):233–42.
8. Bashour M. An objective system for measuring facial
attractiveness. Plast Reconstr Surg. 2006;118(3):757–
74; discussion 775–6.
9. Fischer E. “Sternum und sterno-claviculargelenke.”
Skeletanatomie (Röntgendiagnostik)/Anatomy of
the Skeletal System (Roentgen Diagnosis). Springer,
Berlin, Heidelberg, 1968;481–504.
10. Rodman R, Sturm AK.  Hairline restoration: differ-
ence in men and woman—length and shape. Facial
Plast Surg. 2018;34(2):155–8.
15
11. Yu L.  Invited discussion on: anthropometry analy-
sis of beautiful upper eyelids in oriental: new eyelid
crease ratio and clinical application. Aesthet Plast
Surg. 2020:1–3.
12. Serdev N.  Miniinvasive face and body lifts: closed
suture lifts or barbed thread lifts. Norderstedt: BoD–
Books on Demand; 2013.
13. Chen C-C, Chen S-N, Huang C-L.  Correction of
sunken upper-eyelid deformity in young Asians by
minimally-invasive double-eyelid procedure and
simultaneous orbital fat pad repositioning: a one-­
year follow-up study of 250 cases. Aesthet Surg J.
2015;35(4):359–66.
14. Shin J-W, et  al. The efficacy of micro-insulated
needle radiofrequency system for the treatment of
lower eyelid fat bulging. J Dtsch Dermatol Ges.
2019;17(2):149–56.
15. Jeon HC, et  al. A new treatment protocol of micro-
focused ultrasound for lower eyelid fat bulging. J
Dermatol Treat. 2021;32(8):1005–9.
16. Morley AMS, Malhotra R.  Use of hyaluronic acid
filler for tear-trough rejuvenation as an alternative to
lower eyelid surgery. Ophthalmic Plast Reconstr Surg.
2011;27(2):69–73.
17. Kane MAC. Treatment of tear trough deformity and
lower lid bowing with injectable hyaluronic acid.
Aesthet Plast Surg. 2005;29(5):363–7.
18. Kim J, et  al. Percutaneous autologous fat injection
following 2-layer flap lower blepharoplasty for the
correction of tear trough deformity. J Craniofac Surg.
2018;29(5):1241–4.
19. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed.
St Louis: Quality Med. Publ.; 1997.
20. Peck GC.  Techniques in aesthetic rhinoplasty.
Philadelphia: Lippincott Williams & Wilkins; 1990.
21. Daniel RK. Rhinoplasty: An atlas of surgical techniques.
Berlin: Springer Science & Business Media; 2013.
22. Beer KR.  Rejuvenation of the lip with injectables.
Skin Therapy Lett. 2007;12(3):5–7.
23. Popenko NA, et al. A quantitative approach to deter-
mining the ideal female lip aesthetic and its effect
on facial attractiveness. JAMA Facial Plast Surg.
2017;19(4):261–7.
24. Ricketts RM. Planning treatment on the basis of the
facial pattern and an estimate of its growth. Angle
Orthod. 1957;27(1):14–37.
25. Coleman GG, et al. Influence of chin prominence on
esthetic lip profile preferences. Am J Orthod Dentofac
Orthop. 2007;132(1):36–42.
26. Aufricht G. Combined plastic surgery of the nose and
Chin. Resume of twenty-seven Years’ experience.
Plast Reconstr Surg. 1958;21(6):495.
27. Connor AM, Moshiri F.  Advancement genioplasty:
an important part of combination surgery in black
American patients. Am J Orthod Dentofac Orthop.
1988;93(2):92–8.
16
28. Rosen HM.  Aesthetic refinements in genioplasty:
the role of the labiomental fold. Plast Reconstr Surg.
1991;88(5):760–7.
29. Rosen HM.  Aesthetics in facial skeletal surgery.
Perspect Plast Surg. 1992;6(2):1–25.
30. Guyuron B, Michelow BJ, Willis L.  Practical clas-
sification of chin deformities. Aesthet Plast Surg.
1995;19(3):257–64.
D. W. Seo and W. Lee
31. Zide BM, Boutros S.  Chin surgery III: revelations.
Plast Reconstr Surg. 2003;111(4):1542–50.
32. Guyuron B. MOC-PS(SM) CME article: genioplasty.
Plast Reconstr Surg. 2008;121(4 Suppl):1–7.
33. Byrd HS, Hobar PC.  Rhinoplasty: A practical
guide for surgical planning. Plast Reconstr Surg.
1993;91(4):642–54; discussion 655–6.
 Anatomical Considerations
for Botulinum Toxin Injections
Gi Woong Hong and Won Lee
A good mastery of anatomy is very important in
minimally invasive procedures. Botulinum toxin
injection is the most common procedure in the
field of esthetic. To inject botulinum toxin prop-
erly, a mastery of the facial muscles is essential.
In this chapter, we shall describe the location of
facial muscles and important factors to consider
during botulinum toxin injection. We shall also
describe glands of the face where botulinum
toxin is injected for volume reduction.
2.1 Muscles of the Face
Botulinum toxin injections are most frequently
performed on weakening expression muscles and
masticatory muscles. Thus, having a knowledge
of facial muscle anatomy is essential for the
injection. It is worth noting that there exist some
anatomical variations between different individu-
als. Doctors should therefore remember the
approximate location of each facial muscles
including individual variations. Important mus-
cles of the face include the following (Fig. 2.1):
G. W. Hong
SAMSKIN Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_2
2
2.1.1 Frontalis Muscle
The frontalis muscle is located at the forehead
and usually functions in lifting the eyebrows. Its
antagonist muscles are the procerus, corrugator
supercilii, depressor supercilii, and orbicularis
oculi muscles. Its fibers run from the galea apo-
neurotica to the occipital muscle at the occipital
area. It extends to the superficial temporal fascia
laterally to form the superficial temporal septum
(STS) between both structures. The lateral side of
the frontalis muscle tends to extend over the
STS. Therefore, a full injection should be admin-
istered at the lateral side (Fig.  2.2). Otherwise,
only the lateral frontalis muscle will be able to
contract resulting in a condition called “samurai
eyebrow” (in oriental culture) or “Mephisto eye-
brow” (in western culture) [1].
A few years ago, some reports suggested
that the bifurcation of the frontalis muscle
occurred nearly 3.5 cm above from the superior
orbital rim. Reports suggested that there are no
fibers of the frontalis muscle at the upper and
medial portion, thus implying that botulinum
toxin injection is useless in these regions.
However, recent reports suggest that there are
cases where the bifurcation is located higher
above and that even though there is no muscle
in the gross view, there are muscle fibers histo-
logically. Consequently, it is recommended to
also perform botulinum toxin injection in the
upper medial portion (Fig. 2.2) [2].
17
18 G. W. Hong and W. Lee

Procerus Galea aponeurotica

Frontalis

Orbicularis oculi
Depressor supercilii

Temporalis Corrugator

Nasalis Levator labii superioris

alaeque nasi
Levator labii superioris
Zygomatic minor
Zygomatic major Depressor septi nasi

Risorius Masseter

Depressor anguli oris Orbicularis oris

Mentalis

Depressor labii inferioris

Platysma

Fig. 2.1  Muscles of the face

Fig. 2.2  Muscles of the forehead region

2  Anatomical Considerations for Botulinum Toxin Injections
The depth of the injection should be deter-
mined. The frontalis muscle is usually located
about 3–5 mm below the skin. Its width is vari-
able, so it is better to tell the patient to wrinkle
his forehead before administering the injection.
The frontalis muscle is the only muscle that
raises the eyebrows. Thus, a complete block
might result in severe eyebrow ptosis. Recently,
beginning with lower doses of botulinum toxin
for the initial injection and providing additional
doses subsequently based on the need has been
recommended.
2.1.2 Corrugator Supercilii Muscle
The frowning vertical wrinkle look at the glabella
is achieved by the deepest depressor muscle,
which is the corrugator supercilii muscle. This
muscle can be divided into a transverse and an
oblique head, but what is most important is the
pattern of the wrinkles on the skin surface. The
wrinkles appear when frowning for the first time;
then repetitive movement of the muscle can result
in scars that resemble wrinkles. Once the wrinkle
groove appears, it is not easy to solve the problem
just by injecting botulinum toxin. It is therefore
recommended to inject botulinum toxin in a
dynamic wrinkle state (Fig. 2.3) [3].
Fig. 2.3  Muscles of the glabellar region
19
The medial part of the corrugator supercilii
muscle originates about 2.9 mm lateral from mid-
line and 9.8 mm above the nasion. It runs in the
upward lateral direction to attach to the skin sur-
face. There are interpersonal variations in the
muscle’s insertion point, but the latter could be
estimated by following the skin dimpling when
the patient is asked to frown. The muscle’s loca-
tion is approximately lateral to the skin dimpling.
The portion of the muscle with the greatest thick-
ness is about 2–3 mm thick and is located between
the medial canthal line and the mid-pupillary line
(Fig. 2.4).
When administering botulinum toxin injection
in the corrugator muscle, the doctor should
­consider the “gliding plane” (the space between
the muscle and periosteum). Botulinum toxin can
Fig. 2.4  Position and muscle thickness of corrugator
supercilii muscle
20 G. W. Hong and W. Lee

diffuse into this space when it is administered

deeper beneath the muscle. From this space, it
could spread to the adjacent levator palpebrae
superioris muscle and cause blepharoptosis. It is
therefore recommended to avoid deep injections
of botulinum toxin at the level of the corrugator
supercilii muscle.

2.1.3 Procerus Muscle

A vertical wrinkle on the glabellar region is usu-

ally achieved by the corrugator; furthermore, a
horizontal wrinkle is the action of the procerus
muscle. The procerus muscle originates from
the nasal superficial musculoaponeurotic sys-
tem (SMAS) and inserts on the inter-eyebrow
skin. It runs from the supraorbital rim level to
the medial canthal line or nasion level (Fig. 2.3) Fig. 2.5  Three divisions of the orbicularis oculi muscle
[4]. A more specific mastery of the anatomy
(location and thickness) of the corrugator and
procerus muscles is important because both
muscles are relatively smaller compared to the
frontalis muscle.

2.1.4 Orbicularis Oculi Muscle

The orbicularis oculi muscle can be divided into

the orbital, preseptal, and pretarsal portions.
Clinically, it functions in closing the eye and
plays an important role in controlling facial
expressions around eyes. Crow’s feet develops
when the orbicularis oculi muscle contracts.
When an individual smiles, the pretarsal portion
crumbles and assumes full thickness. Botulinum
toxin can be administered to treat crow’s feet or
wide pretarsal fullness (Fig. 2.5) [5].
Anatomical and histologic studies have shown
that the functioning of the orbicularis oculi is not
affected by the aging process. Eyelid movement
is like an involuntary movement, and it occurs
more than a thousand times in a single day. As the
aging process develops, the orbicularis oculi
muscle still contracts, unlike its antagonist mus-
cles whose function decreases, causing the lateral
eyebrow to descend.
Fig. 2.6  Medial and lateral muscular bands of orbicularis
oculi muscle
The medial muscular band of the orbicularis
oculi muscle can be seen when it is hyperactive
and the skin is thin. When this muscle is hyperac-
tive, filler injection at the tear trough area cannot
solve the problem because of muscle lumpiness.
In this case, botulinum toxin can be helpful [6].
There is also a lateral muscular band, also
called the “malaris muscle.” Sometimes, this
muscle extends laterally to the zygomaticus
major muscle. However, this lateral band usually
runs more superficially and can therefore be dis-
tinguished from the zygomaticus major muscle
(Fig. 2.6) [7].
2  Anatomical Considerations for Botulinum Toxin Injections 21

Fig. 2.7  Muscles of the nasal region

2.1.5 Nasalis Muscle

The nasalis muscle causes oblique wrinkles on

the nose. It can be divided to alar and transverse
parts. The transverse parts extend upward to con-
nect to the procerus muscle (Fig. 2.7) [8].

2.1.6 Depressor Septi Nasi Muscle

It originates from the incisive fossa of the maxilla

and inserts on the nasal septum at the base of the
nose. Gummy smile is related to this muscle, and
botulinum toxin injection can improve this condi-
tion (Fig. 2.8) [9].

2.1.7 Levator Labii Superioris (LLS)

Muscle Fig. 2.8  Lip elevator muscles (medial parts)

The LLS originates from the lower portion of the

arcus marginalis and inserts on the mid-upper lip
portion. It is more deeply located than the orbicularis
oculi muscle. The levator labii superioris alaeque
nasi (LLSAN) is located medial to the LLS muscle;
however, the zygomaticus minor and zygomaticus
major muscle are located laterally. Clinically, the
LLS muscle elevates the medial part of the upper lip.
Therefore, botulinum toxin can be injected into this
muscle to decrease gummy smile (Fig. 2.8) [10].
2.1.8 Levator Labii Superioris
Alaeque Nasi Muscle
The LLSAN muscle is located superficially to the
LLS muscle and lines the lateral border of the
nose. It originates from the lateral portion of the
intercanthal area and inserts on the medial part of
the upper lip (Fig. 2.9) [10].
22
Fig. 2.9  Lip elevator muscles (lateral parts)
2.1.9 Levator Anguli Oris (LAO)
Muscle
The LAO muscle originates from the canine fossa
and inserts on the lateral part of the upper lip.
Unlike the LLS muscle, which originates from
the lateral portion and inserts on the medial upper
lip, the LAO muscle originates from the medial
portion and inserts on the lateral upper lip. The
LAO muscle is more deeply located compared to
the LLS, zygomaticus major, and zygomaticus
minor muscles (Fig. 2.8) [10].
2.1.10 Zygomaticus Major and Minor
Muscles
Both muscles act to pull up and laterally the cor-
ners of the mouth. The zygomaticus minor mus-
cle is located on the virtual line running from the
lateral canthal area to the mouth corner; however,
the zygomaticus major muscle is located on the
crossline of vertical lines from the lateral canthal
area and horizontal lines from nasal base
(Fig. 2.9).
G. W. Hong and W. Lee
It is reported that 30% of the human popula-
tion have a variation (a bifurcation) of the zygo-
maticus major muscle [11]. The zygomaticus
major and minor muscles are very important
muscle involved in the smiling process; thus bot-
ulinum toxin injection is not recommended.
However, when there is an asymmetry caused by
an ipsilateral hyperactivity, injection is usually
considered.
2.1.11 Risorius Muscle
The risorius muscle pulls the mouth corner later-
ally. Its location varies between individuals of
different races. When the muscle inserts on the
upper lip part, the smiling appearance is more
visible (Fig. 2.9) [12]. It originates from the fas-
cia of the parotid gland and inserts on the corner
of the mouth. Consequently, when botulinum
toxin is injected too superficially for masseter
reduction, the risorius muscle can be affected [9].
2.1.12 Depressor Anguli Oris (DAO)
Muscle
The DAO muscle originates from the mandible
and inserts on the mouth corner. This muscle
pulls down the mouth corner. The superficial
(skin) location of the insertion point of the DAO
muscle is important as it is at the labiomandibular
fold, together with the insertion points of the
zygomaticus major and platysma muscles. The
exact location of DAO is still controversial, but it
is recommended to inject botulinum toxin in the
point located 1 cm lateral to and 1 cm below the
mouth corner (Fig. 2.10) [13].
2.1.13 Mentalis Muscle
The mentalis muscle originates from the mandi-
ble mentum and inserts on the skin of the chin. It
consists of two fibers separated by the midline of
the face. When the muscle contracts, the chin
skin moves upward and assumes a “cobblestone
appearance” (Fig. 2.10) [14].
2  Anatomical Considerations for Botulinum Toxin Injections
Fig. 2.10  Muscles of the perioral region
Fig. 2.11  The two layers of the masseter muscle and
toxin injection points
2.1.14 Masseter Muscle
Masseter muscle botulinum toxin injection is one
of the most common procedures in Korea. The
masseter muscle is often divided into three parts:
a superficial layer, an inferior layer, and a deep
inferior tendon (DIT) (located in between the two
previous layers) (Fig. 2.11) [15].
The DIT is an important structure that causes
paradoxical masseter muscle bulging. When botu-
linum toxin is injected only in the deep layer of the
23
Fig. 2.12  Deep inferior tendon between the layers of the
masseter muscle
muscle, paradoxical bulging of the superficial layer
can occur. In such a case, an additional injection is
needed in the superficial layer (Fig. 2.12) [16].
2.2 Parotid and Submandibular
Glands of the Face
Recently, with the increased use of botulinum
toxin injections, a good knowledge of the anatomy
of the parotid glands became of paramount impor-
24
tance. The parotid gland is known to be bordered
superiorly by the zygomatic arch, posteriorly by
the earlobe, and inferiorly by the mandibular bor-
der. However, in cases of parotid gland hypertro-
phy, the gland tends to be located more posteriorly
to the mandibular ramus. The masseter muscle
does not usually cross the mandibular border and
is therefore distinguishable (Fig. 2.13) [17].
The parotid gland is divided into a superficial
and a deep lobe, with the facial nerve running
between the two lobes. There could also exist an
accessory parotid gland near Stensen’s duct area.
The parotid gland is a deeply located structure,
which is covered by the deep fascia of the
SMAS.  The gland’s capsule wraps its paren-
chyma. Therefore, when injecting botulinum
toxin into the parotid gland, the parotid capsule
might offer some resistance. This sometimes
occurs during masseter muscle injection as there
are situations where the parotid gland surrounds
the masseter muscle [18].
The submandibular gland is usually located on
the posterior 2/3 of the mandible border
(Fig. 2.13).
Fig. 2.13  Position of parotid and submandibular glands
G. W. Hong and W. Lee
Submandibular gland hypertrophy can be
detected on the surface of the face. It is also
deeply located and surrounded by deep fascia.
The mylohyoid muscle passes through the sub-
mandibular gland. Therefore, care should be
taken to avoid swallowing disturbances, when
injecting botulinum toxin [19].
2.3 Vessels of the Face
Botulinum toxin injection hardly causes vascular
problems. Filler injection can cause arterial
embolism and serious complications such as skin
necrosis and ocular complications. However,
even when botulinum toxin gets into vessels, it
does not cause systemic problems. Hence, bruis-
ing might be the only vascular complication of
botulinum toxin injection. Botulinum toxin is
usually administered by needle injection, and
even though the doctor may know the anatomy of
vessels, it is impossible to detour all variations.
Nonetheless, the main facial vessels are easily
identifiable.
The facial artery passes between the middle of
the inferior border of the mandible and the ante-
gonial notch and runs to the upper medial portion
of the face (Fig. 2.14).
Where the artery runs near the mandible area,
it is deeply located and therefore safe [20]. For
example, when injecting botulinum into the
DAO muscle, vascular injury hardly occurs
since the muscle is superficially located. Near
the nasolabial fold area, the facial artery gives
multiple branches to the nose and lips [21].
These branches tend to run superficially, so care
should be taken when injecting the LLSAN
muscle [22].
Bruising usually is a consequence of venous
rather than arterial injury. During crow’s feet
correction procedures, bruising occurs quite
often. The intercanthal vein can be ruptured
when administering botulinum toxin injection.
Veins are easily detectable in the supine rather
than upright position, so careful inspection is
needed [23].
2  Anatomical Considerations for Botulinum Toxin Injections
Fig. 2.14  Facial artery
pathway
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ing the location and boundary of the depressor anguli
oris muscle with reference to botulinum toxin injec-
tion. Plast Reconstr Surg. 2014;134(5):917–21.
14. Hur MS, et  al. Morphology of the mentalis muscle
and its relationship with the orbicularis oris and
incisivus labii inferioris muscles. J Craniofac Surg.
2013;24:602–4.
15. Kaya B, Apaydin N, Loukas M, Tubbs RS. The topo-
graphic anatomy of the masseteric nerve: a cadaveric
26
study with an emphasis on the effective zone of botu-
linum toxin a injections in masseter. J Plast Reconstr
Aesthet Surg. 2014;67:1663–8.
16. Lee JY, Kim JN, Yoo JY, Hu KS, Kim HJ, Song WC,
et  al. Topographic anatomy of the masseter muscle
focusing on the tendinous digitation. Clin Anat.
2012;25:889–92.
17. Nasr MW, Jabbour SF, Sidaoui JA, Haber RN,
Kechichian EG.  Botulinum toxin for the treatment
of excessive gingival display: a systematic review.
Aesthetic Surg J. 2016;36:82–8.
18. Kim HJ, Seo KK, Lee HK, Kim J. Clinical anatomy
for the face for filler and botulinum toxin injection.
Singapore: Springer; 2016.
19. Shan XF, Xu H, Cai ZG, Wu LL, Yu GY. Botulinum
toxin a inhibits salivary secretion of rabbit subman-
dibular gland. Int J Oral Sci. 2013;5:217–23.
G. W. Hong and W. Lee
20. Lee JG, Yang HM, Choi YJ, Favero V, Kim YS, Hu
KS, et al. Facial arterial depth and relationship with
the facial musculature layer. Plast Reconstr Surg.
2015;135(2):437–44.
21. Lee SH, Lee M, Kim HJ. Anatomy-based image pro-
cessing analysis of the running pattern of the peri-
oral artery for minimally invasive surgery. Br J Oral
Maxillofac Surg. 2014;52(8):688–92.
22. Nakajima H, et  al. Facial artery in the upper lip
and nose: anatomy and a clinical application. Plast
Reconstr Surg. 2002;109:855–61.
23. Lee HJ, et al. Description of a novel anatomic venous
structure in the nasoglabellar area. J Craniofac Surg.
2014;25:633–5.
 Clinical Injection Techniques
for Botulinum Toxin
Kyun Tae Kim and Won Lee
Botulinum toxin injection is the most common
esthetic procedure performed worldwide. In this
chapter, we shall discuss about the use of botuli-
num toxin in the field of esthetics. We shall also
discuss about the history, types, products, mecha-
nisms, and injection techniques. Finally, we shall
elaborate on the microbotox injection technique.
3.1 History
Botulinum toxin type A (BTA) was reported to be
used in the extraocular muscle to treat strabismus
in the early 1970s [1]. In 1987, Jean Carruthers
noticed crow’s feet wrinkles during botulinum
toxin injection in a patient with blepharospasm,
and Alastair Carruthers reported its use in reduc-
ing glabellar frown line for esthetic purpose [2].
In 1989, Clark and Berris reported the use of
BTA for correcting asymmetry induced by face-
lifts [3]. In the same year, the FDA approved the
use of botulinum toxin A (Botox) to correct
movement disorders of eyelid muscles. BTA has
been used for “off-label” indications such as uro-
logic disorders, gastrointestinal disorders, oph-
thalmologic disorders, and neurologic disorders.
K. T. Kim
Yonsei Dain Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_3
3
Its use has been approved to correct the glabellar
frown line and crow’s feet in the field of esthetic.
3.2 Botulinum Toxin Types,
Mechanism, and Usages
Botulinum toxin is made from the neurotoxin of
Clostridium botulinum. Seven serotypes (A, B,
C, D, E, F, and G) are known. Type A is the most
commonly used type, and type B is also manu-
factured. Types C and D are not suitable for
human, and type E can also be manufactured but
has a short duration of action. BTA is composed
of two chains, a 100 kDa heavy chain and a 50 kD
light chain, conjugated by disulfide bonds. BTA
is known to conjugate to SNARE (soluble
N-ethylmaleimide-sensitive factor attachment
protein receptor) proteins at nerve endings to
inhibit the secretion of acetylcholine, resulting in
a loss of motor end potential at neuromuscular
junctions. Usually, clinical paralysis of muscle
develops approximately a week after injection.
The vesicular SNARE (v-SNARE) targets synap-
tobrevin (VAMP) receptors; furthermore, the
t-SNARE (target SNARE) targets SNAP25
(synaptosomal-­ associated protein, 25  kDa) or
syntaxin, to cause paralysis. BTA functions by
targeting SNAP25.
The most commonly used botulinum toxin
products are onabotulinumtoxinA (Botox;
Allergan, Irvine, CA, USA), a­ bobotulinumtoxinA
27
28 K. T. Kim and W. Lee

Table 3.1  Most commonly used botulinum toxin products in Korea

Product name Brand name Manufacturer Conversion ratio with Botox
OnabotulinumtoxinA Botox Allergan, Inc., Irvine, CA, USA N/A
AbobotulinumtoxinA Dysport Ipsen, Ltd., Berkshire, UK 1:3 (Dysport)
IncobotulinumtoxinA Xeomin Merz Pharmaceuticals, Frankfurt, Germany 1:1
RimabotulinumtoxinB Myobloc Solstice Neurosciences, San Francisco, CA 1:1
PrabotulinumtoxinA Nabota Daewoong Pharmaceutical Co., Seoul, Korea 1:1
Neubotulinum toxinA Meditoxin Medytox, Inc., Seoul, Korea 1:1
Letibotulinum toxinA Botulax Hugel, Inc., Seoul, Korea 1:1

(Dysport; Ipsen, Ltd., Berkshire, UK), incobotu- B. Technique: The goal is to reduce the dynamic
linumtoxinA (Xeomin; Merz Pharmaceuticals, wrinkles of the forehead while preserving
Frankfurt, Germany), and rimabotulinumtoxinB natural eyebrow movement. The power of the
(Myobloc; Solstice Neurosciences, San frontalis muscle is variable, but it is recom-
Francisco, CA). Their clinical actions are similar, mended to inject between 10 and 20 units at
but they differ in chemical composition, associ- four to six points (Fig.  3.1). It is recom-
ated protein, and purification process. Their con- mended to avoid injecting 1–2 cm above the
version ratio is thus as follows: 1 unit of eyebrows. When the contralateral side is not
onabotulinumtoxinA = 1 unit of incobotulinum- injected, “Mephisto” or “Spock” eyebrow
toxinA  =  3  units of abobotulinumtox-
inA. Myobloc, which is a B serotype, is known
for its short duration of muscle paralysis. The
most commonly used products in Korea are
shown in Table 3.1.
The products are usually formulated in pow-
der form, and it is recommended to mix with
0.9% NaCl solution before use. Once mixed, the
solution loses its effectiveness after 6 weeks. The
effect of the product is known to last for
3–4 months, and 20% of injected patients report
prolonged effects (duration beyond 4  months).
When the dosage is increased, the effect lasts a
little longer. Usually, 0.5  mL or 1  mL syringes
are used with 30 G, 1/2 in. (13 mm) needles.

3.3 Upper Face Botulinum Toxin

Injections

3.3.1 Horizontal Wrinkle

of the Forehead

A. Anatomy: The frontalis muscle is a potent

eyebrow elevator, originating from the galea
aponeurotica and inserting on the dermal
layer. It is known to have two bellies
(branches), but variation exists.
Fig. 3.1  Horizontal wrinkles of the forehead. Five injec-
tion points are recommended. Muscle and subcutaneous
layers are recommended for the injection. Additional
injection can be administered at the blue circle
3  Clinical Injection Techniques for Botulinum Toxin
might develop. This parameter should there-
fore be taken into consideration.
3.3.2 Glabellar Frown Line
A. Anatomy: The corrugator supercilii and pro-
cerus muscle contract to form the glabellar
frown line. Horizontal fibers of the corrugator
form vertical wrinkles and originate from the
frontal bone to insert on the dermis of the
forehead. The procerus makes horizontal
wrinkles at the nasal root.
B. Technique: Make the patient to frown and
observe the power and asymmetry. Injections
are usually made at five points in a V pattern,
and it is recommended to inject more superfi-
cially at the lateral part. Furthermore, it is
recommended to inject 20 U. However, when
the power is high, 40  U can be injected
(Fig. 3.2).
3.3.3 Eyebrow Elevation
A. Anatomy: Eyebrow depressors such as the
lateral fibers of the orbicularis oculi muscle
are used with the corrugator supercilii.
Fig. 3.2  Glabellar frown line botulinum toxin injection.
Rectangle, deep muscle layer injections; X, midlevel
injection; asterisk, superficial injection
29
Fig. 3.3  Eyebrow lifting. Glabellar frown line with its
five injection points. Lateral injection is administered
superficially
B. Techniques: Injection points are the eyebrow
tail and the upper part of orbicularis oculi
muscle. The injections should be adminis-
tered in the dermal layer, and 2–5 U is recom-
mended (Fig. 3.3).
3.3.4 Crow’s Feet
A. Anatomy: The orbicularis oculi muscles have
three divisions: pretarsal, preseptal, and
orbital. It is recommended to inject botuli-
num toxin in the lateral orbital portion of the
muscle.
B. Techniques: Informed consent should be
obtained since botulinum toxin cannot
restore a perfect youthful impression. The
patient should also be informed that high
doses can reduce the wrinkles but could
cause unnatural facial expressions. Usually,
an injection of 2–4 U each is administered
at three points. The total recommended dose
is 8–16 U in women and 12–16 U in men. It
is better to administer the injection at least
1  cm lateral from the orbital rim so as to
avoid a spread to extraocular muscles. The
zygomaticus muscles should be avoided
(Fig. 3.4).
30 K. T. Kim and W. Lee

a b

Fig. 3.4  Crow’s feet wrinkle correction injection points. eyebrow. Conversely, when the eyebrow is highly arched,
When the eyebrow is lowly arched, it is better to inject it is recommended to inject below the lateral canthus
above the lateral canthus to ensure the elevation of the

3.4 Midface Botulinum Toxin

Injection Techniques

Usually, the aging process in the midface is char-

acterized by volume loss and descent of soft tis-
sue. Thus, filler injection and/or surgical
procedures are more effective. However, addi-
tional botulinum toxin injection could be helpful.

3.4.1 Bunny Lines

A. Anatomy: The nasalis muscle is composed of

an alar portion and a transverse portion. The
transverse portion originates from the maxilla
and inserts on the nasal septum. It causes the
nose to wrinkle when it contracts.
B. Techniques: Inject 2–5 U at three points (the
centers of the nasalis muscle and its bilateral
bellies). Inject superficially to avoid the LLS
and LLSAN muscles (Fig. 3.5).
3.4.2 Upper Lip
A. Anatomy: Due to the sphincteric function of
the orbicularis oris muscle, vertical wrinkles
can develop. Various causes are involved
such as smoking and UV-induced dermal
Fig. 3.5  Bunny line correction technique. Three points of
injection are recommended
atrophy. Once the wrinkle deepens, concom-
itant filler injection is recommended. The
orbicularis oris muscle originates from the
modiolus and inserts on the dermal and sub-
cutaneous layer.
B. Techniques: Muscle power should be evalu-
ated and overdose avoided. It is better to
obtain a suboptimal correction and recom-
mend additional procedures if need be.
Moreover, 1–2  U is injected in each point,
and a total of two to four symmetrical injec-
tion points are recommended (Fig. 3.6).
3  Clinical Injection Techniques for Botulinum Toxin
Fig. 3.6  Upper lip wrinkle correction. Two to four injec-
tion points are recommended for the upper lip
3.5 Lower Face Botulinum Toxin
Injection Techniques
3.5.1 Depressor Anguli Oris Muscle
A. Anatomy: The mouth corner descends and
accentuates the melomental fold and mario-
nette line when the DAO is contracted. DAO
muscle botulinum toxin injection results in a
lifting of the mouth corner and an increase
in smiling expression. The DAO originates
from the mandible and inserts on the
modiolus.
B. Techniques: The modiolus is known to be
located 11  mm lateral and 9  mm below the
mouth corner in Asians, and it spreads to the
mandible border [4]. It is recommended to
inject 2–2.5 U subcutaneously at a distance of
1–1.5 cm below the modiolus (Fig. 3.7).
3.5.2 Mentalis
A. Anatomy: A cobblestone appearance devel-
ops when the mentalis muscle is hyperacti-
vated and is also called “peau d’orange”
appearance. The mentalis muscle has two
opposite arms, and it originates from the inci-
sive fossa and inserts on the subcutaneous
layer and frenulum of the chin. It is more
31
Fig. 3.7  DAO injection technique. Inject 2–2.5 U ipsilat-
erally; observe symmetry and effectiveness 1–2  weeks
after
deeply located than the orbicularis oris and
depressor labii inferioris muscles.
B. Treatment: It is recommended to inject 5–10 U
2 cm above mandible border (Fig. 3.8).
3.5.3 Masseter Hypertrophy
A. Anatomy: Females have a masculine appear-
ance when masseter muscle hypertrophy
develops. Therefore, BTA injection is recom-
mended especially among the Asians. The
masseter is a masticatory muscle that origi-
nates from the zygomatic process of the max-
illa and inserts on the mandibular ramus and
angle. It is made up of a superficial and a
deep head and works in synergy with the
medial and lateral pterygoid muscles to pull
the chin upward.
B. Techniques: Muscle volume should be
reduced to resolve the hypertrophy. 25–35 U
is administered ipsilaterally at the thickness
point of the muscle. Be cautious not to inject
into the risorius and zygomaticus muscles
because their location overlaps with that of
the masseter muscle. Three ipsilateral points
of injection are recommended (Fig. 3.9).
32
Fig. 3.8  Mentalis injection techniques. Inject deeper at
the central point than the lateral points. Inject subcutane-
ous layer if needed
3.5.4 Platysma Bands
A. Anatomy: The platysma muscle originates
from the deltopectoral fascia and inserts on
the mandible border and SMAS of the lower
face. It functions as a depressor of the chin
and face and exists as bilateral fibers which
decussate some fibers at its center.
B. Techniques: Neck wrinkles are hard to elimi-
nate. However, BTA injection effectively
reduces the platysma band and improves jaw-
line. Surgical procedures are effective solu-
K. T. Kim and W. Lee
Fig. 3.9  Masseter hypertrophy injection technique. Deep
injections are recommended at three points (where muscle
hypertrophy is most prominent)
tions, but for those who do not want to
perform surgery, BTA is a safe and effective
solution. When a patient lifts his chin or
crunches, platysma bands are noticeable.
Inject BTA at three to five points in these
bands at a spacing of 1 cm. About 4–5 U is
recommended at each point of injection, and
a total of 30–40  U is recommended. Take
caution about deep injections and large doses
of injection, as these can cause dysphagia and
dysphonia (Fig. 3.10).
3  Clinical Injection Techniques for Botulinum Toxin
Fig. 3.10  Platysma band injection techniques. Three points on the medial band and four points on the lateral band are
recommended
3.6 Microbotox Injection
Technique
3.6.1 Techniques
The traditional botulinum toxin injection tech-
nique aims to paralyze the muscle so as to pre-
vent it from becoming wrinkled. Microbotox
injection is another technique that functions
differently. Generally, 100 U of BTA is mixed
with 4–5 mL of normal saline, and the injection
is administered in the intradermal or upper sub-
cutaneous level. Tiny blebs of injection are rec-
ommended and are injected at depths of
0.8–1 cm using 0.5–1 mL syringes and 30–32 G
needles.
33
3.6.2 Mechanism
The following are suggested mechanisms:
1. Regularizes (smoothens) skin texture by para-
lyzing the erector pili and superficial expres-
sion muscles.
2. Smoothening of skin’s contours by reducing
the secretion of sebaceous and sweat glands.
It also reduces the size of the pores.
3. Skin tightening and lifting by causing dermal
contraction.
4. Reduction of the power of the platysma to
reduce vertical bands and increasing the
prominence of the jawline by increasing the
cervicomental angle [5].
34
3.6.3 Indications
Microbotox injection technique is used to:
1. Decrease the pore sizes and improve the tex-
ture of the forehead.
2. Decrease the pore sizes and improve the tex-
ture of the cheek.
3. Improve jawline.
4. Reduce crow’s feet and lifting the eye tail.
5. Reduce perioral wrinkles.
3.7 Recent Consensus
on the Use of Botulinum
Toxin and Hyaluronic
Acid Filler
As facial anatomy develops and the aging pro-
cess is understood, the concept of aging also
changes. Fat atrophy and descend of facial tissue
are known to result from the aging process. In
these situations, the concomitant use of botuli-
num toxin and HA filler is recommended.
Recently, many doctors are approving concomi-
tant treatments [6–9].
3.7.1 Conceptualization
of the Aging Process
The aging process affects the epidermis, dermis,
subcutaneous tissue, and bone. Bone absorption
increases and bone volume decreases. Facial fat
atrophy develops, and antioxidation reactions
decrease. Overexpression of matrix metallopro-
teinase results in a decrease in collagen and elas-
tin, and thus a decrease in elasticity, which in turn
causes a descent of facial tissue. Combined treat-
ments are recommended because of the multiple
processes involved in the aging process. A few
years ago, botulinum toxin was mostly used for
defects of the upper face; moreover, the use of
HA filler was common for defects of the midface
and lower face. However, the indications have
evolved recently, and both are used for defects of
all the regions of the face.
K. T. Kim and W. Lee
3.7.2 General Techniques
Volume loss can be treated using HA filler.
Overactive muscles should be corrected by botu-
linum toxin injection. Not just the lower face por-
tion requires a combination of the two treatment
methods; the upper face is also a candidate. In
addition, microbotox can be used. Recently,
mesotherapy and skin boosters have been used
concomitantly to treat some conditions. The
choice of the technique depends on the patient’s
age, gender, race, and budget.
References
1. Scott AB, Rosenbaum A, Collins CC. Pharmacologic
weakening of extraocular muscles. Investig
Ophthalmol. 1973;12(12):924–7.
2. Carruthers JD, Carruthers JA. Treatment of glabellar
frown lines with C. botulinum-A exotoxin. J Dermatol
Surg Oncol. 1992;18(1):17–21.
3. Clark RP, Berris CE.  Botulinum toxin: a treatment
for facial asymmetry caused by facial nerve paralysis.
Plast Reconstr Surg. 1989;84(2):353–5.
4. Choi YJ, Kim JS, Gil YC, Phetudom T, Kim HJ,
Tansatit T, Hu KS. Anatomical considerations regard-
ing the location and boundary of the depressor anguli
oris muscle with reference to botulinum toxin injec-
tion. Plast Reconstr Surg. 2014;134(5):917–21.
5. Wu WTL. Microbotox of the lower face and neck: evo-
lution of a personal technique and its clinical effects.
Plast Reconstr Surg. 2015;136(5 Suppl):92S–100S.
6. Sundaram H, Liew S, Signorini M, Vieira Braz
A, Fagien S, Swift A, De Boulle KL, Raspaldo H,
Trindade de Almeida AR, Monheit G.  Global aes-
thetics consensus group. Global aesthetics consen-
sus: hyaluronic acid fillers and botulinum toxin type
A-recommendations for combined treatment and opti-
mizing outcomes in diverse patient populations. Plast
Reconstr Surg. 2016;137(5):1410–23.
7. de Maio M, Swift A, Signorini M, Fagien S. Aesthetic
leaders in facial aesthetics consensus committee. Facial
assessment and injection guide for botulinum toxin and
injectable hyaluronic acid fillers: focus on the upper
face. Plast Reconstr Surg. 2017;140(2):265e–76e.
8. de Maio M, DeBoulle K, Braz A, Rohrich RJ, Alliance
for the future of aesthetics consensus committee. Facial
assessment and injection guide for botulinum toxin
and injectable hyaluronic acid fillers: focus on the
midface. Plast Reconstr Surg. 2017;140(4):540e–50e.
9. de Maio M, Wu WTL, Goodman GJ, Monheit G,
Alliance For the future of aesthetics consensus com-
mittee. Facial assessment and injection guide for
botulinum toxin and injectable hyaluronic acid fill-
ers: focus on the lower face. Plast Reconstr Surg.
2017;140(3):393e–404e.
 Anatomical Considerations
for Filler Injection
Gi Woong Hong and Won Lee
Filler injection is one of the frequently practiced
minimally invasive procedures in the field of
esthetics. It is a relatively easy procedure
employed to correct wrinkles and for augmenta-
tion. However, filler injection could have tragic
complications (mostly vascular). The most
important tool of prevention is a good knowledge
of vascular anatomy. Although there are vascular
variations, it is important to know the basic anat-
omy. Furthermore, it is important to have a good
knowledge of the nerves of the face and the fat
compartment of the face. In this chapter, we shall
describe arteries, veins, nerves, and fat compart-
ments of the face, taken into account during filler
injection procedures.
4.1 Arteries of the Face
Dermal fillers are injected into the dermis and/or
upper subcutaneous layer and are therefore rela-
tively safe from vascular complications. However,
recently, firm consistent fillers are being used for
volumizing. They are injected into the deeper
layers, posing a relative danger because of pos-
sible vascular complications. Therefore, the most
G. W. Hong
SAMSKIN Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_4
4
important factor to consider before filler injection
is the level of mastery of vascular anatomy.
The external carotid artery divides into inter-
nal and external branches. The facial artery and
the superficial temporal artery are the main
branches of the external branch. Branches of
these arteries supply the lower face, midface, lat-
eral nose, and temple areas. The internal branch
of the external carotid artery runs into the skull
area. The maxillary artery is one its branches, and
it supplies the lower eyelid and periorbital area
through the infraorbital and zygomaticofacial
arteries [1]. The internal branches also supply the
face through branches of the ophthalmic artery. It
vascularizes the forehead, glabella, and nose
through branches of the supratrochlear artery,
supraorbital artery, and dorsal nasal artery
(Figs. 4.1 and 4.2) [2].
The facial artery branches from the external
carotid artery and runs along the mandible bor-
der; it then crosses the mandible at the masseter
muscle border to run across antegonial notch. It
runs toward the medial canthus, where it branches
horizontally giving rise to the labiomental, infe-
rior labial, and superior labial arteries. From
here, it extends upward near the nasolabial fold.
It further branches to give rise to the inferior alar
and lateral nasal arteries and continues on the lat-
eral border of the nose, where it is called the
angular artery [3].
The facial artery has some anatomical varia-
tions. Only 36% of Koreans have the previously
35
36 G. W. Hong and W. Lee

Fig. 4.1  Arteries of the

face, frontal view

Zygomaticofacial artery

Supra-orbital artery

Supratrochlear artery

Zygomatico-orbital artery

Superficial temporal artery

Angular artery

Transverse facial artery

Posterior auricular artery

Facial artery Internal carotid artery

External carotid artery

Parotid gland

Fig. 4.2  Arteries of the face, lateral view

4  Anatomical Considerations for Filler Injection
described anatomical pattern. In 44% of the
population, it does not run to the angular artery
but rather ends as the lateral nasal artery. Only
50% of population have a symmetrical arterial
supply [4].
It is known that in 30% of the population, the
facial artery does not run along the nasolabial
fold. Rather, it branches vertically toward the
infraorbital foramen and runs with the facial vein
along the border of orbicularis oculi muscle.
Tortuous facial arteries are located just beneath
the skin near the mouth corner, between the
zygomaticus major and the risorius muscles.
Therefore, precautions should be taken when per-
forming filler injection in this area [5]. It is known
that the facial artery runs near the nasolabial fold
in 40% of the population and crosses the nasola-
bial fold in 33% of the population [6].
The supraorbital, supratrochlear, and dorsal
nasal arteries, which are branches of the ophthal-
mic artery, anastomose with the facial artery in
the glabellar and nasal areas [7].
Another branch of the external carotid artery
is the superficial temporal artery (STA). It runs
upward and divides into anterior and posterior
branches. The anterior branch of the STA runs to
the lateral forehead area where it anastomoses
with branches of the ophthalmic artery [8]. The
pathway of the STA will be discussed in Chap. 9
when describing the anatomical considerations of
thread lifting. Before the STA divides into ante-
rior and posterior branches, it gives rise to two
arteries near zygomatic arch. These are the trans-
verse facial artery (which arises below zygomatic
arch and vascularizes the midface area) and the
zygomaticoorbital artery (which arises below the
zygomatic arch) [9].
Fig. 4.3  Arteries of the
perioral region
37
The internal branch of the external carotid
artery branches into the maxillary artery which
later gives rise to the infraorbital, buccal, and
mental arteries [10].
4.1.1 Arteries of the Perioral Region
The horizontal labiomental artery (which origi-
nates from the facial artery) runs horizontally
along with the labiomental crease in the middle
of mandible border. It branches into the vertical
labiomental artery which anastomoses with the
inferior labiomental artery or submental artery.
The inferior labial artery branches from the facial
artery near the mouth corner and runs along the
vermillion border. It is known that 50% of the
population have the horizontal labiomental but
no inferior labial artery. The inferior labial artery
is located near the wet mucosa, deep below the
orbicularis oris muscle, and runs to the dry muco-
sal area where it runs medially [11].
The superior labial artery bifurcates from the
facial artery at approximately 1  cm above the
mouth corner and runs horizontally about 0.5–
1.2  cm above the upper lip vermilion border
(Fig. 4.3).
It is uncommon for the superior and inferior
labial arteries to originate from a common
branch. The superior labial artery tends to run
beneath the orbicularis oris muscle and branches
to give the nasal septal artery near the philtrum
area. The nasal septal artery divides into deep
and superficial branches separated by the orbicu-
laris oris muscle. Its superficial branch runs to
the columella where it becomes the columellar
artery [12].
38
Supraorbital artery
Supratrochlear artery
Superior marginal
arterial arcade
Dorsal nasal artery
Medial palpebral artery
Inferior marginal
arterial arcade
Angular artery
Facial artery
Fig. 4.4  Arteries of the perinasal and periorbital regions
4.1.2 Arteries of the Perinasal Region
The inferior alar and lateral nasal arteries branch
off from the superior labial artery in 10% of the
population. The inferior alar artery follows the
inferior border of the ala; conversely, the lateral
nasal artery runs near the alar crease to the nasal
tip area (Fig. 4.4) [13].
The dorsal nasal artery is located at the nasal
dorsum, and it usually runs within the fibromus-
cular layer. The dorsal nasal artery and lateral
nasal artery run across the midline in 20% of the
population [14].
4.1.3 Arteries of the Periorbital
Region
The angular artery, which is a terminal branch of
the facial artery, is detected in 50% of the popula-
tion. In 25% of the population, it branches from
the ophthalmic artery; furthermore, it does not
exist in 25% of population (Fig. 4.4) [4].
G. W. Hong and W. Lee
Superior peripheral arterial arcade
Frontal branch of
superficial temporal artery
Lateral palpebral artery
Transverse facial artery
Superficial temporal artery
We previously described the pathway of the
facial artery. In 30% of the population, the facial
artery runs vertically at the level of mouth corner
and follows the lower border of orbicularis oculi
muscle. This type of artery is called “duplex type
facial artery” and forms the infraorbital trunk of
the lower eyelid (Fig. 4.5) [15].
On the medial side of the eyelid, there is the
medial palpebral artery derived from the supra-
trochlear artery. On the lateral side, there is the
lateral palpebral artery, which originates from the
lacrimal artery. The medial palpebral artery is
located below the palpebral portion of the orbicu-
laris oculi muscle (Fig. 4.3) [16].
4.1.4 Arteries of the Frontal
and Glabellar Regions
The supratrochlear artery, a branch of the oph-
thalmic artery, is located on the medial sides of
the forehead and glabellar regions. It runs
through the orbit to locate the vertical line of the
4  Anatomical Considerations for Filler Injection 39

Fig. 4.5  Duplex type

facial artery

Angular artery

Infraorbital trunk of
duplex type facial artery

Facial artery on
antegonial notch

medial canthus and then perforates the orbicu-

laris oculi muscle to vascularize the skin surface.
In 50% of the population, the supratrochlear
artery is located just beneath the vertical glabel-
lar wrinkle [17].
The supraorbital artery passes through the
supraorbital notch (foramen) and runs beneath
orbicularis oculi and frontalis muscles. Its perfo-
rating point is 3 cm lateral to medial canthus and
2 cm above supraorbital rim. It forms anastomo-
ses with the STA laterally and the supratrochlear
artery medially (Fig. 4.4) [18].

4.1.5 Arteries of the Temporal Fig. 4.6  Superficial temporal artery pathway

Region

The STA runs toward the temple area. After per-
forating the parotid gland area, it divides into
anterior and posterior branches at a point approx-
imately 18 mm anterior to and 37 mm above the
tragus (Fig. 4.6).
The anterior branch of the STA is wrapped by
the superficial temporal fascia and runs superfi-
cially to the frontalis muscle. Another branch of
the STA is the zygomaticoorbital artery which
runs toward lateral canthus and then upward to
the lateral eyebrow end [19].
The zygomaticotemporal artery originates
from the lacrimal artery and runs to the anterior
part of the temple area. The middle temporal and
deep temporal arteries supply the temporalis
muscle (Fig. 4.7) [20].
40
Fig. 4.7  Arterial supply of the temple area
4.1.6 Arteries of the Cheek Region
The transverse facial artery branches from the
STA inside the parotid gland and runs 1.5  cm
below the zygomatic arch level. It supplies the
posterior part of the cheek area. The anterior part
of the cheek area is supplied by the buccal artery
(derived from the maxillary artery) and the zygo-
maticofacial artery (derived from the lacrimal
artery) (Fig. 4.8) [21].
4.2 Veins of the Face
Venous complications are relatively less danger-
ous compared to arterial complications. Usually,
the veins of the face follow the arterial pathway,
but some exceptions exist (such as the inferior
ophthalmic vein or retromandibular vein). The
facial vein, which is the most important vein of
the face, runs straight compared to the tortuous
facial artery. It usually runs 1.5 cm posteriorly to
the facial artery. The facial vein runs downward
and anastomoses to the internal jugular vein.
However, when it is occluded, blood regurgitates
to the superior and inferior ophthalmic veins to
G. W. Hong and W. Lee
reach the cavernous sinus. Therefore, it should
be carefully avoided, especially during the cor-
rection of midcheek groove or during anterome-
dial cheek augmentation by filler injection
(Fig. 4.9) [22].
The horizontal wrinkle on the dorsum of the
nose is induced by aging. The intercanthal
vein, which connects the bilateral angular
veins, is located in 70% of the population. The
intercanthal vein runs above the procerus
muscle and is connected to the cavernous
sinus.  Thus, it should be carefully avoided
(Fig. 4.10) [23].
The middle temporal vein is located 2  cm
above the upper margin of the zygomatic arch
and lies between the superficial and deep layers
of deep temporal fascia in the temple area. It con-
nects to the superficial temporal vein and runs to
the supraorbital and superior ophthalmic veins
before finally connecting to the cavernous sinus.
During filler injection in the temple area, care
should be taken to avoid the middle temporal
vein (Fig. 4.11) [24].
Many veins are located in the soft tissue layers
of the face. Thus, the fillers should be injected as
gently as possible to prevent complications such
as bruising and swelling.
4  Anatomical Considerations for Filler Injection 41

Fig. 4.8  Arteries of the

cheek region

Fig. 4.9  Veins of the face

42
Fig. 4.10  Intercanthal vein
Fig. 4.11  Middle temporal vein location
4.3 Nerves of the Face
It is important to know the location, depth, and
innervation zones of the sensory nerves of the
face. This will secure a successful anesthesia
when performing minimally invasive procedures
such as filler injections.
There are 12 pairs of cranial nerves (CN) in
the face region: CN I olfactory nerve, CN II optic
nerve, CN III oculomotor nerve, CN IV trochlear
nerve, CN V trigeminal nerve, CN VI abducens
nerve, CN VII facial nerve, CN VIII vestibuloco-
chlear nerve, CN IX glossopharyngeal nerve, CN
X vagus nerve, CN XI accessory nerve, and CN
XII hypoglossal nerve [25].
Clinical doctors should have a good knowl-
edge of CN V and CN VII as these nerves can be
injured during facial surgeries or procedures.
G. W. Hong and W. Lee
4.3.1 Sensory Nerves of the Face
and Neck
The sensory nerves of the face and neck are
branches of the trigeminal nerves and cervical
plexus. The trigeminal nerve extrudes through
the skull foramen and innervates the skin of the
face, while the cervical plexus innervates the pos-
terior cheek, ear, and neck area (Fig. 4.12) [26].
4.3.1.1 Ophthalmic Nerve
The first branch of the trigeminal nerve is the oph-
thalmic nerve. It enters the orbit through the supe-
rior orbital fissure and branches into the frontal,
nasociliary, and lacrimal nerves. The frontal nerve
branches into the supraorbital and supratrochlear
nerves; furthermore, the nasociliary nerve branches
into the infratrochlear and external nasal nerves.
They provide the sensory innervation of the fore-
head, scalp, glabella, eyelid, and nose [27, 28].
4.3.1.2 Maxillary Nerve
The second branch of the trigeminal nerve is the
maxillary nerve. A first branch, the zygomatic
nerve, originates here and finishes as the infraor-
bital nerve after perforating the infraorbital fora-
men. The infraorbital nerve innervates the lower
eyelid, lateral side of the nose, and upper lip
area. The zygomatic nerve branches into the
zygomaticofacial and zygomaticotemporal
nerves [29, 30].
4.3.1.3 Mandibular Nerve
The mandibular nerve is the third branch of the
ophthalmic nerve. It supplies the sensory inner-
vation of the lower face and supplies some
motor fibers to the masticatory muscle. The
auriculotemporal nerve runs through the parotid
gland and innervates the anterior part of the ear-
lobe and temple area. The buccal nerve perfo-
rates the buccinator muscle to innervate the
cheek area, and the mental nerve innervates the
lower lip and chin after perforating the mental
foramen [31, 32].
4.3.1.4 Cervical Plexus
Cervical plexus innervates the posterior cheek,
ear, and neck area [33, 34].
4  Anatomical Considerations for Filler Injection
Zygomaticotemporal nerve
Auriculotemporal nerve
Zygomaticofacial nerve
Buccal nerve
Great auricular nerve
Transverse cervical nerve
Fig. 4.12  Sensory nerves of the face
4.3.2 Motor Nerves of the Face
The facial nerve innervates the expression
muscles of the face, and the mandibular nerve
innervates the masticatory muscle. The facial nerve
divides into five branches in the parotid gland and
runs to supply the facial expression muscles. It is
wrapped by the SMAS (Fig. 4.13) [35].
The temporal branch of the facial nerve fur-
ther branches into multiple nerves to innervate
the frontalis, corrugator supercilii, and orbicu-
laris oculi muscles, after passing through the
parotid [36]. The zygomatic branch innervates
the lower portion of the orbicularis oculi mus-
cle, and the zygomatic major and minor mus-
cles. The buccal branch runs along with the
parotid duct to innervate the lip elevator mus-
cles. The zygomatic and buccal branches meet
together on the lateral part of the nose and
innervate the nasalis, procerus, and corrugator
supercilii muscles [37]. The marginal mandib-
ular branch innervates the lower part of the
orbicularis oris, depressor anguli oris, depres-
43
Lacrimal nerve
Supraorbital nerve
Supratrochlear nerve
Infratrochlear nerve
Infraorbital nerve
Mental nerve
sor labii inferioris, and mentalis muscles [38].
The cervical branch innervates the platysma
muscle [39].
4.4 Fat Compartments
of the Face
Previously, the subcutaneous fat layer was
reported to be made up of a huge cushion-like
layer and a simple layer. However, as studies of
facial anatomy evolved, it was found to be made
up of multiple fat compartments [40]. It is divided
into superficial fat compartments (located above
to the SMAS) and deep fat compartments (located
below the SMAS).
In the middle face region, the superficial and
deep compartments are easily distinguishable.
However, these two fat layers have varied thick-
nesses and distributions in the upper and lower
face regions. Hence, these differences in distribu-
tion should be taken into consideration during
filler injection [41].
44 G. W. Hong and W. Lee

Fig. 4.13  The five branches of the facial nerve

Usually, the superficial fat compartment has

relatively larger adipose cells, and its volume is
increased by the aging process. Conversely, the
deep fat compartment has small-sized adipose
cells and decreases in size with age [42].
Some doctors suggest that it is not important
to divide these multiple compartments clini-
cally. Actually, they are not easily distinguish-
able on gross appearance; adding a filler
injection to a specific fat compartment is diffi-
cult because fat compartments are invisible.
However, these fat compartments are associated
with descent of skin and soft tissue and with the
Fig. 4.14  Compartments of superficial fat layer
wrinkle pattern of facial expression muscles.
More specifically, existing wrinkles deepen
with age as facial volume is lost and fatty layers Facial wrinkles and descent are related with
descend. It is therefore possible to predict the each fat compartments. Hence, it is important to
wrinkle correction procedure by studying the know anatomical locations of the superficial and
anatomical relationship between fat compart- deep fat compartments. The superficial fat com-
ments and wrinkles [43]. partments are shown in the figure below (Fig. 4.14):
4  Anatomical Considerations for Filler Injection
Recently, the forehead and glabellar area fat
compartment have been found to be associated
with wrinkles [44]. The middle face and lower
face fat compartments are also associated with
wrinkles in these areas.
Specifically, periorbital fat compartments,
such as orbital fat, medial and middle cheek fat,
sub-orbicularis oculi fat, and deep medial cheek
fat (lateral parts), are associated with a tear
trough, palpebromalar groove, and midcheek
groove [45]. The nasolabial fat and the medial
part of the deep medial cheek fat are associated
with nasolabial folds [46].
In the lower face area, the labiomental crease or
sulcus is associated with the lower lip region and
mental region fat compartments. The marionette
line (static labiomandibular fold) is associated with
the labiomandibular fat superomedially, and to the
inferior jowl fat laterally. As the aging process pro-
gresses, the labiomandibular fat decreases while
jowl fat increases, causing winkles to deepen [47].
Interestingly, superficial fat compartments’
borders tend to align with skin wrinkles; more-
over, the deep fat compartments do not. Exploiting
this phenomenon, deep fat compartments would
be the target of filler injection for the correction
of wrinkles.
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 Physical Properties
and Rheological Approach
for Hyaluronic Acid Fillers
Eun-Jung Yang and Won Lee
HA filler is the most commonly used filler world-
wide. HA filler has the advantages of being an
easy procedure, and the substance used degrades
easily. However, HA filler injection could cause
nonvascular complications such as granuloma
and delayed-type hypersensitivity reactions. In
this chapter, we shall discuss about HA filler
properties, rheology, and manufacturing process
to understand its usages. Furthermore, we shall
discuss about some possible nonvascular compli-
cations related to HA filler properties.
5.1 Hyaluronic Acid
HA is part of the composition of the skin, joints,
and vitreous bodies. A 70 kg human body con-
tains about 12 g of HA; 3 g of HA is produced
and degraded daily [1]. HA is a disaccharide
composed of glucuronic acid and glucosamine
(it is a glycosaminoglycan) (Fig.  5.1). HA is a
very polar substance and has high affinity for
E.-J. Yang
Plastic and Reconstructive Surgery, Yonsei University
College of Medicine, Seoul, Republic of Korea
e-mail: enyang7@yuhs.ac
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_5
5
water. It thus serves as a lubricant in the human
body [2].
HA filler is a gel-like structure which is com-
posed of HA and a crosslinker. HA also exist in
animal and bacteria. The raw materials for HA
used to be extracted from roosters’ combs, but
recently, it has been frequently extracted from
Streptococcus equi or zooepidemicus [3].
Animal-­ based HA is usually extracted from
roosters’ comb, while non-animal-based HA or
nonanimal stabilized HA is usually extracted
from bacteria. The structural differences are in
the length of the polymer chain. Non-animal-
based HA usually contain between 4000 and
6000 monomeric units and have an average
molecular weight of 1.5–2.5  MDa. Contrarily,
animal-based HA is made up of 10,000–15,000
monomeric units and weighs 4–6 MDa.
Hyaluronidase is the normal human enzyme
which degrades HA (Fig. 5.2). HA filler is com-
posed of a crosslinker which protects the HA
from hyaluronidase.
47
48 E.-J. Yang and W. Lee

Fig. 5.1 Chemical COO–Na+ CH2OH

structure of the O O
hyaluronic acid HO
disaccharide unit
O O
HO

OH NH
C=0
CH3

Na qlucuronate N-acetylqlucosamine

COO–Na+ CH2OH COO–Na+ CH2OH

O HO O O O
O O
HO O HO O
O
NH NH
HO C=O C=O
CH3 CH3
O
BDDE

O
CH3 CH3
C=O C=O
NH NH
O
O OH O OH
O O
O O O O
CH2OH COO–Na+ CH2OH COO–Na+

monomeric unit

Fig. 5.2  The mechanism of hyaluronidase

5.2 Manufacturing Process between the manufacturing companies. Thus dif-

of Hyaluronic Acid Filler
Since the US FDA approved the HA filler
Restylane in 2003, thousands of HA fillers have
been manufactured and put in the market.
Companies produce various HA filler products
by varying the manufacturing process to obtain
safer and long-lasting products [4]. The various
products differ by the amount of crosslinks, sta-
bility temperature, and manufacturing processes
[5]. The processes vary depending on whether we
want to obtain crosslinks resistant to high tem-
perature or long-lasting crosslinks. The washing,
autoclave, and dialysis processes are variable
ferent rheological results are obtained [6].
HA powder is mixed with normal saline to
obtain a flour-like dough. In this state, it is called
“free hyaluronic acid.” When the crosslinker is
added, crosslinked HA is obtained. BDDE
(1,4-butanediol diglycidyl ether) is the most fre-
quently used crosslinker (Fig. 5.3). Other cross-
linkers include PEG (polyethylene glycol) and
DVS (divinyl sulfone) [7]. BDDE is mostly used
because it is relatively safer.
During manufacturing process, sodium
hydroxide (NaOH) is used to create the ether
linkage of the hydroxyl chain. As such, the ether
linkage can form cross-linkages from HA chain
5  Physical Properties and Rheological Approach for Hyaluronic Acid Fillers 49

Fig. 5.3  BDDE (1,4-butanediol diglycidyl ether)

to another HA chain [8]. When there are many

crosslinks, cohesiveness increases, the HA prod-
uct becomes harder, and longevity is prolonged.
However, when the HA gel becomes too hard, it
is difficult to inject, and the probability for immu-
nologic reactions to occur increases.

5.2.1 Monophasic Vs. Biphasic Filler

The manufacturing process of HA filler can be

divided, based on the end product, into biphasic
and monophasic HA fillers. Biphasic HA fillers
mix relatively smaller amount of the crosslinker
compared to monophasic fillers. Usually, bipha-
sic fillers have harder particles and are not
deformable by external stress. The crosslinker
used differs among manufacturing companies,
but usually, less than 1% of the crosslinker is
used for biphasic fillers. Hence, small amounts of
crosslinker and uniform particles (obtained after
sieving) are used to improve on the hardness of
the HA gel. Non-crosslinked HA is used for
smooth injection.
Contrarily, monophasic fillers tend to have
smooth surfaces because of the grinding process.
They tend to have relatively larger proportions of
the crosslinker. They are relatively softer but
have high cohesivity. Examples of monophasic
fillers are Juvederm, Elravie, and e.p.t.q.
(Fig.  5.4). Examples of biphasic fillers are
Restylane, Yvoire, and Perfectha [9].
The washing process removes non-crosslinked
BDDE and residual impurities. Hence, the prod-
ucts should be strictly washed to obtain quality
products [10]. The autoclave process alters the
HA filler properties. The temperature, pressure,
Fig. 5.4 Monophasic HA filler after the washing
process
and timing should be appropriately monitored to
ensure the quality of the products is good.
5.3 Physical Properties of HA
Filler
Multiple parameters should be considered when
deciding on the physical properties of the HA
filler. These include gel elastic hardness, cohe-
sive force, particle size, and longevity [11, 12].
The choice of the physical properties of the man-
ufactured products needed will also depend on
the location of the body where it will used.
5.3.1 Viscoelasticity
Dermal fillers are usually injected into the super-
ficial dermal layer. Hence, the horizontal elastic
modulus is an important parameter to consider. It
can be described as a shear stress of deformation.
Elastic modulus (storage modulus, G′) is param-
50
eter of rheology which defines the ability of the
filler to resume its normal shape after a deforma-
tion by a shear stress (Fig. 5.5). Usually, a high
G′ value corresponds to a high restoration ability
after a deformation and known as “gel elastic
hardness” [13].
Elastic modulus measures the degree of resto-
ration after a deformation and is calculated as
shear stress divided by shear strain
 shear stress 
 G′ =  ering filler property, during injection into face.
 shear strain  .
Recently, fillers are have been increasingly
used for augmentation. Hence, the vertical elastic
modulus should also be considered in these cases.
G′ is related to gel hardness. However, the filler
substance should not only be hard but should also
be elastic. This is also important to tackle the sen-
sation of the presence of a foreign body. Hard
filler substances can make the patient to feel
uncomfortable as he/she might easily perceive it
as a foreign body.
SHEAR STRESS
Not
Aligned
Fig. 5.5  Shear stress. A force against the side of the solid
is called “shear stress,” and the degree of deformation is
called “shear strain”
Fig. 5.6  Normal stress.
Normal stress can
divided into compressive
stress and tensile stress.
Restoration ability after
deformation defines the
elastic modulus
SQUEEZE
COMPRESSIVE
STRESS
E.-J. Yang and W. Lee
The coefficient of kinematic viscosity is
another filler property to take into consideration.
Viscosity is a measure of how fast a filler can be
deformed by a constant stress such as compres-
sive stress or shear stress (Fig. 5.6). Viscosity is a
rheological term for easy spread by external
forces. The filler is injected by needle or cannula,
so viscosity affects the passing of the filler
through the needle or cannula. Understanding
shear rate and viscosity is helpful, when consid-
The filler is type of non-Newtonian fluid
(Fig. 5.7), and viscosity changes with the rate of
shear strain (Fig. 5.8).
Prefilled filler inside a syringe is likely to be a
solid product with high viscosity. When the filler
is injected, the shear stress increases and viscos-
ity decreases giving the filler a fluid-like aspect.
After the injection, shear stress decreases, and
the filler resumes its solid-like aspect. Complex
viscosity is a measure of resistance against
changes in shear stress rate, and when the com-
plex viscosity is high, it is difficult to inject the
filler.
Injection force is parameter that determines
how softly the filler is injected (Fig. 5.9). Small
needle diameter coupled with high injection force
can induce a high ejection force [14]. When nee-
dle diameter and the injection force are constant,
ejection force increases with increase in viscos-
ity. High ejection pressures increase the risk for
vascular complication such as skin necrosis, ocu-
lar complications, and stroke [15, 16].
NORMAL STRESS
TENSILE
STRESS
5  Physical Properties and Rheological Approach for Hyaluronic Acid Fillers 51

NEWTONIAN FLUIDS NON-NEWTONIAN FLUIDS

Viscosity (Pa.s) Viscosity (Pa.s)

Viscosity Remains Constant

V is
co
si t
Va

y
ri e
s

Shear Strain Rate Shear Strain Rate

Fig. 5.7  Newtonian fluids and non-Newtonian fluids. Water and oil are like Newtonian fluids because of their low
viscosity. The viscosity of Non-Newtonian fluids can be changed by applying an external force such as shear stress

NON-NEWTONIAN FLUIDS NON-NEWTONIAN FLUIDS

Viscosity (Pa.s) Viscosity (Pa.s)

YIELD
STRESS Solid-like at Low
Shear Rates

Fluid-like at High
Shear Rates
FLUID-LIKE

Shear Strain Rate Shear Strain Rate

Fig. 5.8  Hyaluronic acid filler viscosity changes with shear stress rate

5.3.2 Cohesiveness

Cohesive force is different from viscosity. It is

Fig. 5.9  Injection force. Ejection force is different due to
different filler property and needle diameter
the attractive force within fluid substances that
helps in maintaining the shape of the fluid. For
example, water and mercury are liquids but exist
in the form of spheres because of attractive cohe-
sive forces. Viscosity is the sticky property of the
filler to the needle lumen, while cohesion is
attractive property between particles of the filler.
Therefore, a low viscosity filler is likely to be
injected easily and will spread easily after injec-
tion (Fig. 5.10).
52
Fig. 5.10  Viscosity and
cohesive force. Viscosity
is the sticky property of
the filler to the needle
lumen and cohesive
force is attractive
property between
particles of the filler
Even if the filler spreads due to external shear
stress, when shear stress disappears the filler par-
ticle should aggregate. An ideal filler should have
enough cohesiveness and an appropriate balance
of viscosity and elasticity. Biphasic fillers, in par-
ticular, have hard particles and therefore possess
a relatively better elasticity. This implies a higher
elastic modulus against vertical shear stress.
Consequently, biphasic fillers are known to be
good candidates for chin augmentation and nose
augmentation. On the contrary, monophasic fill-
ers are known to possess a relatively low elastic-
ity but a high cohesiveness. If a manufacturer
desires to produce monophasic fillers with better
elasticity, HA should be mixed in higher concen-
tration, or more crosslinking will be needed.
However, high concentration or high crosslinking
can cause additional complications. High cohe-
siveness is important in maintaining the gel state
against vertical stress. High cohesive fillers are
recommended in the forehead and cheek area
because the particles aggregate with each other
against external stress. Recently, few fillers have
been manufactured with high elasticity and high
cohesiveness. HA filler properties can be esti-
mated using a rheometer. Physical parameters
(Table 5.1) and rheological parameter can be dis-
played by a rheometer (Fig. 5.11).
5.3.3 Degree of Modification
It is important to know the degree of modification
(MoD), which is a measure of the proportion of
original HA modified by the crosslinker. MoD is
the sum of fully crosslinked HA and pendant
crosslinked HA [17, 18] (Fig.  5.12). In other
E.-J. Yang and W. Lee
Table 5.1  Hyaluronic acid gel-associated rheological
and physical properties
Parameter Description
Elastic modulus Storage modulus, restoration of
(G′) deformation after an external stress
   • Unit: pascals, Pa
   • High G′ has high potency for
restoration from deformation
Viscous modulus Loss modulus of external stress
(G″)    • High G″ higher power is
needed to extrude from the needle
Tan delta (tan δ) Relative ratio of viscous modulus
and elastic modulus (G″/G′)
   • High elastic gel (e.g., gelatin);
tan δ is near 0
   • High viscous gel (e.g.,
honey); tan δ is near 1
Complex Total resistance to deformation
modulus (G*)    • Most HA filler G′ > G″,
( G′ ) + ( G′′ )
2 2
G∗ =
   • Most HA filler G* is near G′
Gel cohesion Aggregation property resisting
dispersion by an external force
   • Attractive force by each
molecules
   • Low cohesiveness filler
disperses easily
Concentration Total hyaluronic acid mounted in a
(mg/mL) 1 mL product
   • Crosslinked HA maintains
shape in the human body
   • Pendant-linked HA or free
HA degrades faster in the human
body
words, it corresponds to the percentage of cross-
linked HA disaccharide monomer with
BDDE.  An MoD of 20% means there are 20
crosslinked types for every 100 HA disaccharide
monomers. Low MoD means there are low con-
centrations of BDDE and minimally deformed
5  Physical Properties and Rheological Approach for Hyaluronic Acid Fillers 53

HA [19]. On the contrary, high MoD means HA
is highly deformed and is therefore subject to less
degradation inside the human body (prolonged
longevity).
However, the MoD should not be extremely
high because it will lead to increase in gel hard-
ness and low affinity to water, making the gel dif-
ficult to inject. In addition, high MoD filler might
induce rejection, capsular formation, and granu-
loma formation [20]. Another point of concern is
incomplete crosslinking. Pendant-type BDDE is
useless and does not contribute to the elasticity of
the filler product. Recently, the degree of cross-
linking (CrR) is now being measured. It is a mea-
sure of the ratio of fully modified HA to HA
disaccharide and can provide an estimate of the
elasticity of the product [19].

5.3.4 Particle Size

The company usually produces more than three

different product lines made of different particle
sizes. Restylane biphasic lines can be classified
into Vital (the smallest), Restylane (the middle
level), and Lyft (the largest). Vital is used in thin
skin areas, such as in periocular and pretarsal
rolling, and is also used as a skin booster [9].
Restylane is usually used for cheek and forehead
area, and Lyft is used for nose and chin augmen-
tation. Monophasic filler such as Juvederm prod-
ucts contains similar particle sizes and is
categorized based on the crosslinking ratio or
concentrations. However, the products still have
some different particle sizes. Juvederm volbella
Fig. 5.11 Rheometer

O O
OH H3C-C H3C-C
OH
HO NH NH
O HO O
O O O
NaOOC O HO O O HO O
NaOOC
O O OH O Epoxide group
HO HO
OH
O O O
O
a b c d
(<2ppm)*
O O O
O
OH OH
HO HO HO O

O CH2OH
COONa O COONa
O O O
O O O O O
OH HN
HN HO HO
C CH3 C CH3
O O

Fig. 5.12  Hyaluronic acid and crosslinker. (a) Fully crosslinked type. (b) Pendant type. (c) Inactivated type. (d)
Native-type BDDE
54 E.-J. Yang and W. Lee

is usually recommended for periocular and lip
regions, Volift is recommended for cheek and
forehead, and Volume is recommended for the
nose and chin. Particle sizes are measured using a
particle size analyzer (Fig. 5.13).
5.3.5 Hyaluronic Acid Raw Materials
and Water Affinity
HA concentration is the amount of HA in 1 mL of
product. The higher the concentration, the harder

Fig. 5.13  Hyaluronic acid particle size. (a) Particle size analyzer. (b) Average particle size detected was 432 μm. (c)
Microscopic view of particles
5  Physical Properties and Rheological Approach for Hyaluronic Acid Fillers
the product and the longer it exists. However, water
affinity also has to be considered. HA is known to
have more than ten times water affinity compared
to its molecular weight. Therefore, HA filler might
induce edema due to its affinity for water. The filler
conjugates with water and increases in volume
after being injected into the human body.
High filler concentration will have higher
affinity for water and induce edema [20].
Therefore, an ideal filler should induce less
edema and assume the desired shape by the con-
tribution of the HA filler itself. It is known that
5.5 mg/mL of HA is equivalent to 1 mL of water
HA filler and induces less edema. Unfortunately,
a good elasticity cannot be conferred by 5.5 mg/
mL HA [21]. For a good elasticity to be obtained,
the raw concentration should be increased to val-
ues, such as 15  mg, 20  mg, or 25  mg, and will
thus result in edema. Routinely, concentrations
higher than the hydration equilibrium concentra-
tions are used. High concentration HA products
(such as 20–24 mg/mL) pull adjacent water and
augment tissue.
References
1. Volpi N, Schiller J, Stern R, Soltes L. Role, metabo-
lism, chemical modifications and applications of
Hyaluronan. Curr Med Chem. 2009;16(14):1718–45.
2. Knopf-Marques H, Pravda M, Wolfova L, Velebny
V, Schaaf P, Vrana NE, et al. Hyaluronic acid and its
derivatives in coating and delivery systems: appli-
cations in tissue engineering, regenerative medi-
cine and immunomodulation. Adv Healthc Mater.
2016;5(22):2841–55.
3. Mei JF, Dong ZH, Yi Y, Zhang YL, Ying GQ. A simple
method for the production of low molecular weight
hyaluronan by in situ degradation in fermentation
broth. E-Polymers. 2019;19(1):477–81.
4. Sall I, Ferard G. Comparison of the sensitivity of 11
crosslinked hyaluronic acid gels to bovine testis hyal-
uronidase. Polym Degrad Stabil. 2007;92(5):915–9.
5. Micheels P, Sarazin D, Tran C, Salomon D.  Effect
of different crosslinking technologies on hyaluronic
acid behavior: a visual and microscopic study of
seven hyaluronic acid gels. J Drugs Dermatol.
2016;15(5):600–6.
6. Gold MH.  Use of hyaluronic acid fillers for the
treatment of the aging face. Clin Interv Aging.
2007;2(3):369–76.
7. La Gatta A, Schiraldi C, Papa A, D’Agostino A,
Cammarota M, De Rosa A, et al. Hyaluronan scaffolds
via diglycidyl ether crosslinking: toward improve-
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ments in composition and performance. Carbohydr
Polym. 2013;96(2):536–44.
8. Schante CE, Zuber G, Herlin C, Vandamme
TF. Chemical modifications of hyaluronic acid for the
synthesis of derivatives for a broad range of biomedical
applications. Carbohyd Polym. 2011;85(3):469–89.
9. Lee W, Hwang SG, Oh W, Kim CY, Lee JL, Yang
EJ.  Practical guidelines for hyaluronic acid soft-­
tissue filler use in facial rejuvenation. Dermatol Surg.
2020;46(1):41–9.
10. Edwards PC, Fantasia JE. Review of long-term adverse
effects associated with the use of chemically-modified
animal and nonanimal source hyaluronic acid dermal
fillers. Clin Interv Aging. 2007;2(4):509–19.
11. Fagien S, Bertucci V, von Grote E, Mashburn
JH.  Rheologic and physicochemical properties used
to differentiate injectable hyaluronic acid filler prod-
ucts. Plast Reconstr Surg. 2019;143(4):707e–20e.
12. Pierre S, Liew S, Bernardin A. Basics of dermal filler
rheology. Dermatol Surg. 2015;41(Suppl 1):S120–6.
13. Lorenc ZP, Ohrlund A, Edsman K. Factors affecting
the rheological measurement of hyaluronic acid gel
fillers. J Drugs Dermatol. 2017;16(9):876–82.
14. Lee Y, Oh SM, Lee W, Yang EJ. Comparison of hyal-
uronic acid filler ejection pressure with injection
force for safe filler injection. J Cosmet Dermatol.
2021;20(5):1551–6.
15. Sito G, Manzoni V, Sommariva R.  Vascular com-
plications after facial filler injection: a literature
review and meta-analysis. J Clin Aesthet Dermatol.
2019;12(6):E65–72.
16. Jones DH, Fitzgerald R, Cox SE, Butterwick K,
Murad MH, Humphrey S, et al. Preventing and treat-
ing adverse events of injectable fillers: evidence-­
based recommendations from the American Society
for Dermatologic Surgery multidisciplinary task
force. Dermatol Surg. 2021;47(2):214–26.
17. De Boulle K, Glogau R, Kono T, Nathan M, Tezel
A, Roca-Martinez JX, et al. A review of the metabo-
lism of 1,4-butanediol diglycidyl ether-crosslinked
hyaluronic acid dermal fillers. Dermatol Surg.
2013;39(12):1758–66.
18. Guarise C, Barbera C, Pavan M, Panfilo S, Beninatto
R, Galesso D.  HA-based dermal filler: down-
stream process comparison, impurity q­uantitation
by validated HPLC-MS analysis, and in  vivo resi-
dence time study. J Appl Biomater Funct Mater.
2019;17(3):2280800019867075.
19. Kenne L, Gohil S, Nilsson EM, Karlsson A, Ericsson
D, Helander Kenne A, et al. Modification and cross-­
linking parameters in hyaluronic acid hydrogels--def-
initions and analytical methods. Carbohydr Polym.
2013;91(1):410–8.
20. Keizers PHJ, Vanhee C, van den Elzen EMW, de
Jong WH, Venhuis BJ, Hodemaekers HM, et  al. A
high crosslinking grade of hyaluronic acid found in
a dermal filler causing adverse effects. J Pharmaceut
Biomed. 2018;159:173–8.
21. Grimes PE, Thomas JA, Murphy DK.  Safety and
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J Cosmet Dermatol. 2009;8(3):162–8.
 Practical Techniques
for Hyaluronic Acid Filler
Injections
Jeongmok Cho and Won Lee
HA filler is effective for the correction of facial
wrinkles and augmentation of depressed areas.
The main advantages are the ease to administer
additional injections and the ease to reverse the
process. In this chapter, we shall discuss about
the general considerations for filler injections and
elaborate on regional filler injection techniques
in the forehead, temple area, nose, tear trough,
anterior malar, lateral cheek, nasolabial fold,
chin, and lips.
6.1 Introduction
HA filler is effective for the correction of facial
wrinkles and augmentation of depressed areas.
Its main advantages are ease to administer addi-
tional injections and the ease to reverse the pro-
cess [1]. Different approaches should be used
unlike in traditional plastic surgery. Because of
the need for the results to last long enough, filler
injections should be administered repeatedly. The
following are important factors to consider dur-
ing these repetitive procedure:
J. Cho
Incline Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_6
6
• Safety of the procedure:
Minimal bruising and swelling.
No complications such as vascular
complication
• Long-term plan:
No overcorrection.
Repetitive plan considering time lapse.
6.2 Facial Fat Compartment
Changes by the Aging
Process
Two distinctive fat compartment changes occur
during the aging process: volume reduction and
descent migration [2]. A good knowledge of the
aging process is needed to ensure better results
from the procedures. Facial fatty layers are com-
posed of superficial (Fig. 6.1) and deep compart-
ments. It is known that in the deep compartments,
adipose cells are smaller than in the superficial
compartments [3]. When the deep compartment
loses volume, the superficial compartment loses
its support and a downward descent occurs [4].
57
58
More specifically, there are differences in volume
loss, and an understanding of the sequence of fat
reduction can enable doctors to make better plans
for the filler injection (Fig. 6.2) [5].
Fig. 6.1  Superficial fat compartments
Fig. 6.2  Clinical trends show that the periorbital and malar fat pads tend to be affected first in life, followed by the
lateral cheek, deep cheek, and lateral temporal areas
J. Cho and W. Lee
6.3 Purpose of Filler Injection
Filler injection has a dual purpose: volume aug-
mentation and volume restoration [2]. For 20s–
30s, filler augmentations are performed to obtain
a smooth contour, and so, the superficial fat com-
partment tends to be target for the augmentation.
Sometimes, the deep compartment is congeni-
tally absent, so injection should be made consid-
ering superficial or deep fat layer deficiency. In
the 40s–50s, the deep fat compartments tend to
lose volume, causing a descent of the superficial
fat compartment. Thus restoration of deep fat
compartments volume will provide a support
structure, and thus, additional volume restoration
will be a more convincing procedure.
6  Practical Techniques for Hyaluronic Acid Filler Injections 59

6.4 Wrinkle Evaluation
Several evaluation scales have been introduced.
The GAIS and Wrinkle Severity Rating Scale are
among the most commonly used scales. Some
companies also make use of other scales such as
the Merz Aesthetic Scale (Figs. 6.3 and 6.4) [6].
Scales are more objective in the evaluation of
symmetry. It is useful to discuss and tell patients
the limitation of the procedure, when the
improvement in the scale will be less than 2 units
after the first filler injection.
Apart from wrinkles, laxity can also be evalu-
ated using scales. Filler injection has a limitation
in improving soft tissue laxity, and so thread lift-
ing or surgical rhytidectomy might be needed to
complement the effects. Taking the patient’s sta-
tus and the limitation of procedure into consider-
ation can be helpful in achieving successful
results (Fig. 6.5).
Volumetric scales are also used (Figs. 6.6 and
6.7). When volume augmentation by filler injec-
tion seems limited, microfat injection should also
be considered.

0 1 2 3 4
No folds Mild folds Moderate folds Severe folds Very severe folds

Fig. 6.3  Nasolabial fold scales

0 1 2 3 4
No lines Mild lines Moderate lines Severe lines Very severe lines

Fig. 6.4  Marionette line scales

0 1 2 3 4
No sagging Mild sagging Moderate sagging Severe sagging Very severe sagging

Fig. 6.5  Laxity scales

60 J. Cho and W. Lee

0 1 2 3 4
Full upper cheek Mildly sunken Moderately sunken Severely sunken Very severely sunken
upper cheek upper cheek upper cheek upper cheek

Fig. 6.6  Anterior malar area volume deficiency scale

0 1 2 3 4
Full lower cheek Mildly sunken Moderately sunken Severely sunken Very severely sunken
lower cheek lower cheek lower cheek lower cheek

Fig. 6.7  Lateral cheek area volume deficiency scale

6.5 Safe Injection Techniques
6.5.1 Sharp Needle Vs. Blunt Cannula
Needle and cannula are used for filler injections.
Product package usually includes a sharp needle
as this is often used for basic procedures. Usually,
needle injection is performed perpendicularly to
the skin at the desired location, and an aspiration
test is often recommended. The advantage here is
that the filler is injected at a precise location.
More specifically, when injecting using the deep
layer bolus method, the filler can be injected layer
by layer. Sunken areas at specific locations are
also good candidates for needle injection. Needle
injection is also useful for superficial wrinkle cor-
rection since the injection is administered into the
dermal layer or subdermal layer precisely.
However, bruising and swelling are more com-
monly observed than with cannula injections.
The diameter and length of the blunt cannula are
chosen by the person who does the injection.
Usually, they create entry points on the skin area
for the cannula insertion. The cannula hole is usu-
6  Practical Techniques for Hyaluronic Acid Filler Injections 61

a b

Fig. 6.8  Filler injection. (a) Needle. (b) Cannula

Table 6.1  Comparison between needle and cannula injection

Needle Cannula
Size, length 27 G, 30 G × 1/2″ 23 G, 25 G × 1″, 2″
Pros Fast, direct, easy Less bruise, pain, swelling
Advantage Lifting effect Precise layer
Recommendation Superficial wrinkle, temple Volumizing area

ally little behind the tip area, making precise injec-

tion with cannula more difficult compared to
needle injection. When a cannula is used, an entry
point is first created using a needle with a larger
diameter. The retaining ligaments might also offer
some resistance to the cannula tip. Cannula injec-
tion has the advantages of causing less bruising and
swelling. For wide areas, such as in forehead aug-
mentation, using a cannula has more advantages as
fewer entry points will be created (Fig. 6.8).
The most important advantage of using a blunt
cannula is the reduction of the risk for arterial Fig. 6.9  Backflow migration by needle injection
wall penetration. When using needles, the needle
tip can be into an arterial lumen, so an aspiration a vessel, and filler injected within, leading to an
test is usually recommended. With a cannula, it is embolism [8]. Though the topic is controversial,
more difficult to penetrate an arterial wall. Thus, compression is believed to be a more likely cause
arterial complications are reduced. Previous stud- of skin necrosis than embolism.
ies reported that a 27 G cannula is same as 27 G Backflow through the needle path should also
needle and is statistically different from a 25 G be considered. A high pressure is often generated
cannula [7]. Therefore cannula diameters larger when the filler is injected, and this can cause the
than 25 G (e.g., 23 G cannula) are often recom- filler to migrate through needle path. The doctor
mended (Table 6.1). should also take into consideration filler regurgi-
Vessels are known to be more resistant than tation at the entry sites when performing molding
soft tissue to needle penetration. When perform- compression. Therefore, when the entry point is
ing an arterial cannulation or an intravenous near the desired location, filler backflow migra-
injection, adjacent skin stretching is needed. tion might occur (Fig. 6.9). Nasojugal injection is
However, a needle can unintentionally perforate often done using a needle [9].
62 J. Cho and W. Lee

Fig. 6.10  Same outer

diameter but different
inner diameters

Fig. 6.11  Cannula size and artery diameter

6.5.2 Choice of the Appropriate
Needle or Cannula
To ensure good results, appropriate needle and can-
nula are needed. The needle or cannula diameter is
often gauged and written, but the measurement
usually corresponds to the outer diameter. The size
of the inner diameter is rather more important
(Fig. 6.10). When the inner diameter is larger, less
pressure is applied, and a smoother injection can be
performed. In addition, there are some differences
in hole distances from the tip, hole shapes, and hole
sizes. These parameters should always be consid-
ered when choosing the appropriate cannula, to
ensure better results (Fig. 6.11). Most authors use
the 23 G 50 mm cannula, and for precise injection
(such as injection in the tear trough area), they use
a 25 G 40 mm cannula.
6.6 Regional Injection Techniques
6.6.1 Forehead
The forehead area usually occupies 1/3 of the face
and is the widest area for facial filler injection. A
large amount of filler is needed to cover all the
forehead. The strategy is to use a needle with
6  Practical Techniques for Hyaluronic Acid Filler Injections
Fig. 6.12 Forehead
augmentation. (a)
a
Design. (b) Anatomy
Fig. 6.13  Regional anesthesia
small amounts of the filler to fill the sunken areas.
Many patients have a prominent supraorbital
ridge with bilateral frontal bossing and a sunken
glabella area. It is relatively easier to use a needle
to inject perpendicularly and then perform mold-
ing to spread the filler. But since the forehead area
is wide, a cannula is recommended (Fig.  6.12).
Authors make the entry point at the upper border
area of the medial brow for esthetic reasons.
Most often, the patient feels uncomfortable
when the cannula tip scratches the periosteum of
63
Fig. 6.14  Cannula orientation for injection at the desired
location
the frontal bone. Regional nerve blocks at the
supraorbital nerve and supratrochlear nerve are
useful (Fig.  6.13). Local anesthesia could be
done using lidocaine plus epinephrine, but since
the pH is low, bicarbonate can be added to lessen
pain [10]. Ice pack application before the proce-
dure is also helpful.
Two entry points are made, puncturing bilater-
ally on the medial eyebrow. The cannula is posi-
tioned into the subgaleal level (Figs.  6.14, 6.15
and 6.16) and the injection administered into the
64
Fig. 6.15  Central portion augmentation is important
Fig. 6.16 Decussation injection is performed in the
medial forehead area
Fig. 6.17  Mild molding with gauze is recommended
supraperiosteal layer. Usually 3–4 mL of filler is
used. Reshaping using gauze is recommended
immediately after the injection (Figs. 6.17, 6.18,
and 6.19).
J. Cho and W. Lee
6.6.2 Temple Augmentation
Most often, patient who desire temple augmenta-
tion have multiple areas of facial depressions and
not just temple depression. The superficial fat
layers tend to be thin and so, superficial injec-
tions usually cause irregularities. The causes of
temple depression could be subcutaneous fat
reduction, prominent adjacent bone portion, or
temporalis muscle atrophy. Authors recommend
the injection to be administered into the deep
layer to avoid irregularities. A needle is used and
is inserted beneath temporal ridge and highest
portion of the temporalis muscle. Most often,
authors prefer to inject in the lateral most
depressed area of the rim (Fig. 6.20). The loca-
tion 1  cm lateral to and 1  cm above the lateral
eyebrow has increased risks of superficial tempo-
ral and deep temporal arteries injury. The needle
is inserted perpendicularly until it touches the
bone surface, an aspiration test is done for more
than 5 s, and the injection is gently administered
(Figs. 6.21 and 6.22). The filler product usually
has 25 G and 27 G needles inside its package, and
these needles can reach to the bone area. It is rec-
ommended to tell the patient to keep his/her
mouth opened during the procedure because the
temporalis muscle can become contracted during
the injection. It is also recommended to inject on
one side first and show the patient the results
before proceeding to the other side (Fig. 6.23).
6.6.3 Anterior Malar Area
The anterior malar area is one of the most impor-
tant areas for filler injection. A more 3D appear-
ance makes the face to look more attractive, and
a depression usually affects the nasolabial fold
deepening. The orbital rim should be marked
6  Practical Techniques for Hyaluronic Acid Filler Injections 65

Fig. 6.18  Pre- and post-procedure (three-quarter view)

Fig. 6.19  Pre- and post-procedure (lateral view)

66 J. Cho and W. Lee

before the procedure; space between virtual line tion (Fig.  6.26). The medial side of the vertical
running from the lateral side of the orbital rim to lateral canthal line is recommended for injection.
the mouth corner and vertical midpupil line Caution should be taken to avoid injecting later-
should be the projection area (Fig.  6.24). The ally because of the adjacent wide zygoma
entry point should be at least 1 cm away from the (Figs. 6.27, 6.28, 6.29 and 6.30).
desired filling area (Fig. 6.25). Orbital retaining
ligament should be considered during the proce-
dure. Filler injection in the orbital retaining liga-
ment might result in hardness and dimpling. It is
therefore preferable to inject above the ligament.
The ligament can also help to prevent filler migra-

Fig. 6.21 Aspiration test recommended for enough

seconds

Fig. 6.20  Temple area augmentation design Fig. 6.22  Gentle injection after touching the bone

Fig. 6.23  Pre- and post-procedural views (three-quarter view)

6  Practical Techniques for Hyaluronic Acid Filler Injections 67

Fig. 6.24  Anterior malar area augmentation. (a) Design. (b) Anatomy

Fig. 6.25  23 G needle is used at the entry point

Fig. 6.26  Cannula tip location should be felt by the left
hand
68 J. Cho and W. Lee

Fig. 6.27  Pre- and post-procedural views (three-quarter view)

Fig. 6.28  Pre- and post-procedural views (lateral view)

6  Practical Techniques for Hyaluronic Acid Filler Injections 69

Fig. 6.29  Pre- and post-procedural views (worm’s-eye view)

Fig. 6.30  Pre- and post-procedural views (bird’s-eye view)

70
6.6.4 Tear Trough Deformity
Correction
A softer filler is recommended for tear trough
deformity correction (Fig. 6.31). The skin is thin-
Fig. 6.31  Tear trough deformity correction design
Fig. 6.32  Soft filler is recommended. 25 G 40 mm can-
nula is used
Fig. 6.33  Pre- and post-procedural frontal views
J. Cho and W. Lee
ner, and the subcutaneous space is smaller.
Hence, irregularities might appear after filler
injection. When overcorrection occurs, the
patient might look artificial. Consequently, mul-
tiple suboptimal corrections are recommended. It
is difficult to dissolve HA partially. Therefore,
when overcorrection occurs, the HA should be
dissolved completely and the procedure repeated.
Authors prefer relatively short cannulas (25  G
40 mm) (Fig. 6.32). It is essential to use the left
hand to feel the anatomical structures when per-
forming the injection. The pre-septal space is the
anatomical target for the injection [11]; it is
located below the orbital rim and above the liga-
ment (Fig. 6.33).
6.6.5 Lateral Cheek
Sunken lateral cheek is common in individuals
who have slim faces. The anterior masseteric
ligament is located below the zygoma, and there
is not enough space for filler injection (it there-
fore easily assumes an irregular appearance).
Normally when patients open their mouth, a
bulkiness might be seen due to the mandibular
condyle. Therefore, when a filler is injected, the
patient might feel this area to be wider and bulk-
ier. He should therefore be informed before the
injection. The entry point should be at least
1 cm away from the desired injection area, and
authors use 23 G 50 mm cannula (Figs. 6.34 and
6.35). Usually 0.5–1.5  mL of filler is injected
(Fig. 6.36).
6  Practical Techniques for Hyaluronic Acid Filler Injections
6.6.6 Nasolabial Fold
The nasolabial fold is the most common area for
filler injection. It is important to know the cause
of the fold. It could be related to bone structure,
Fig. 6.34  Lateral cheek augmentation design
Fig. 6.36  Pre- and post-procedural three-quarter views
71
fat compartment shape, or facial expression mus-
cle. It is recommended to perform anterior malar
augmentation to correct anterior malar depres-
sion. The entry point is 5 mm away from the end
of the nasolabial fold, and a 23 G 50 mm cannula
is used (Figs.  6.37 and 6.38). A two-layer
approach is recommended. A deep injection is
made at the alar base area, but large amounts of
injection should be avoided because of the pos-
sibility for the filler to migrate to the facial
expression muscles. A superficial subdermal
injection (using needle or by cannula scratching
method) is also made. A step-by-step approach is
Fig. 6.35  Filler is injected superficially so as to avoid
aggregation
72 J. Cho and W. Lee

also recommended. Intradermal injection using a used and multiple undercorrections are recom-
needle should also be considered when there are mended (Fig. 6.39). Patients should be informed
many wrinkles. Usually, 0.5–1  mL of filler is of the possibility of filler migration to areas above
the nasolabial fold.

6.6.7 Lips

The indications of lip injection differ with ages.

As the aging process evolves, lip volume reduces,
and volume augmentation becomes solicited. For
young patients, mouth corner lifting is another
common procedure. Young patients tend to have
low lip fullness and/or asymmetry. Lips are

Fig. 6.37  Nasolabial fold correction design Fig. 6.38  Two-layer approach is recommended

Fig. 6.39  Pre- and post-procedural three-quarter views

6  Practical Techniques for Hyaluronic Acid Filler Injections
Fig. 6.40  Lip injection design
Fig. 6.41  Upper lip injection
highly vascular structures, so there is a relatively
lower risk of skin necrosis. However, there exist
high risks of bruising and swelling in this area.
Needle injection has the advantage of precision,
while cannula injection has the advantage of
causing less bruising. It is therefore recom-
mended to use the cannula for natural augmenta-
tion of the whole lip area and to use a needle for
border contour lines and specific asymmetry cor-
rections. Authors use 25 G 40 mm cannula. The
entry point is made 3 mm away from the lateral
mouth corner, and cannula tip can be approached
easily (Figs. 6.40, 6.41 and 6.42). Usually, 1 mL
of filler is used, and an ointment is applied for
73
Fig. 6.42  Lower lip injection
mild molding immediately after the injection
(Figs. 6.43 and 6.44).
6.6.8 Chin
Microgenia is an indication for chin augmenta-
tion by filler injection. The basic procedure
involves using a needle to inject perpendicularly
into the desired area. However, this method can
induce filler aggregation and lead to an artificial
look. Using a 23 G 50 mm cannula can help to
obtain an even (regular) chin augmentation and a
more natural look (Figs.  6.45, 6.46, 6.47 and
6.48). A cannula can also help to obtain a
smoother mandibular contour line. When the
injection is made superficially, a small amount of
filler can be used. Yet, it might result into irregu-
larities because of the movement of the mentalis
muscle. 1–2 mL of filler can be used, and botuli-
num toxin is administered concomitantly to
induce mentalis muscle hypoactivation.
74
Fig. 6.43  Pre- and post-lip filler injection images
Fig. 6.44  Pre- and post-lip filler injection images
Fig. 6.45  Chin augmentation design
6.7 Considerations for a Safe
Filler Injection
6.7.1 Pre- and Postoperative
Photographs
Patients tend to forget their preoperative appear-
ances. One common complaint after a procedure
is asymmetry. Preoperative recordings should
always be made to help account for preoperative
asymmetry. They should closely examine the
patient before the procedure to make preopera-
tive plans and use preoperative photographs to
J. Cho and W. Lee
Fig. 6.46  Submental approach using a cannula
obtain more precisions on the operative plan.
Postoperative photographs should also be taken
for the evaluation of the procedure.
6.7.2 Medical Chart Recording
The doctor should take note of the past history of
patients. Filler injections are usually performed
repetitively; thus a past history of the amount of
filler, site of injection, and filler brands should be
recorded. Medical history should include the
following:
6  Practical Techniques for Hyaluronic Acid Filler Injections
Fig. 6.47  Pre- and post-procedural lateral views
Fig. 6.48  Pre- and post-procedural worm’s-eye views
• Patient’s demographic information (age, gen-
der, name).
• Medical and medication history.
• Previous operation or procedure.
• Patient’s desire and expectation level.
• Status (depth) of the fold, wrinkles.
• Preoperative photograph.
• Anesthesia method.
• Filler amount, brands, technique, location,
cannula vs. needle.
• Complications (bleeding, pain, etc.).
• Post-procedural photograph.
• Next procedure plan.
75
References
1. Born TM, et  al. Soft-tissue fillers. In: Neligan PC,
editor. Plastic surgery. Vol II.  Amsterdam: Elsevier;
2018. p. 39–54.
2. Rohrich RJ, Avashia YJ, Savetsky IL.  Prediction of
facial aging using the facial fat compartments. Plastic
Reconstr Surg. 2020;147(1S-2):38S–42S.
3. Wan D, Amirlak B, Giessler P, et  al. The differing
adipocyte morphologies of deep versus superficial
midfacial fat compartments: a cadaveric study. Plast
Reconstr Surg. 2014;133:615e–22e.
4. Stuzin JM, Baker TJ, Gordon HL.  The relationship
of the superficial and deep facial fascias: relevance
to rhytidectomy and aging. Plast Reconstr Surg.
1992;89:441–9; discussion 450.
76
5. Wan D, Amirlak B, Rohrich R, et  al. The clinical
importance of the fat compartments in midfacial
aging. Plast Reconstr Surg Glob Open. 2014;1:e92.
6. Stella E, Petrillo AD. Injections in aesthetic medicine,
Atlas of Full-face and Full-body Treatment. Berlin:
Springer Science & Business Media; 2013. p. 33–50.
7. Pavicic T, Webb KL, Frank K, Gotkin RH, Tamura
B, Cotofana S.  Arterial Wall penetration forces
in needles versus cannulas. Plast Reconstr Surg.
2019;143(3):504e–12e.
8. JAJ VL, Humzah D, Kerscher M. Cannula ver-
sus sharp needle for placement of soft tissue fill-
ers: an observational cadaver study. Aesthet Surg J.
2018;38(1):73–88.
J. Cho and W. Lee
9. Griepentrog GJ, Lemke BN, Burkat CN Jr, JGR,
Lucarelli MJ. Anatomical position of hyaluronic acid
gel following injection to the infraorbital hollows.
Ophthal Plast Reconstr Surg. 2013;29(1):35–9.
10. Frank SG, Lalonde DH. How acidic is the lidocaine
we are injecting, and how much bicarbonate should
we add? Can J Plast Surg. 2012;20(2):71–3.
11. Wong C-H, Mendelson B.  The long-term static
and dynamic effects of surgical release of the tear
trough ligament and origins of the orbicularis oculi
in lower eyelid blepharoplasty. Plast Reconstr Surg.
2019;144(3):583–91.
 Doppler Ultrasound-Guided
Hyaluronic Acid Filler Injection
Techniques
Hyun Woo Cho and Won Lee
HA filler could have tragic complications such as
skin necrosis and ocular complications. To pre-
vent these tragic vascular complications, it is
essential to know the vascular anatomy. Doppler
ultrasound is a well-known device used in detect-
ing arteries of the face. In this chapter, we shall
discuss about Doppler ultrasound-guided HA
filler injection techniques.
7.1 Forehead Augmentation
Oriental patients tend to have a flatter forehead
but prefer to have a concave forehead. The
forehead is separated from the temple area by
the superior temporal septum. However, some-
times the injected filler crosses the superior
temporal septum because of continuity in
shape. It is important for the doctor to delimi-
tate the forehead from esthetic and anatomical
considerations.
In the anatomical aspect, the forehead has
multiple layers. These are the skin, superficial
fat, frontalis muscle, subgaleal space, and perios-
teum. Superficial fat layer is known to divide lat-
erally into a central forehead compartment and a
H. W. Cho
Ipche Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_7
7
middle forehead compartment. Clinically, fore-
head depressions are found in the central portion
and lateral portions, and these phenomena are a
consequence skull shape rather than volume of
the superficial fat. Usually, HA filler is injected
into the subgaleal space, also known as the deep
fat compartment [1].
7.1.1 Doppler Ultrasound Anatomy
There are three main arteries in the forehead.
These are the supratrochlear artery, supraorbital
artery, and frontal branch of the STA. The supra-
trochlear artery branches from the ophthalmic
artery and runs along the medial part of the orbit.
It progresses from below the deep muscles and
perforates the muscles to run superficially [2].
The supraorbital artery has a few variations in its
trajectory, but it usually runs from the deep mus-
cle layer to perforate muscles before running
superficially. The supraorbital artery tends to
form anastomoses with the frontal branch of the
STA at the lateral sides of the forehead. Therefore,
when doctors perform deep injections of HA
filler above the eyebrows (especially at a 2  cm
distance), they should proceed with it gently and
carefully.
The STA is easily detectable by Doppler ultra-
sound, just like the supratrochlear and supraor-
bital arteries which are also detectable (Fig. 7.1).
It is recommended to identify the supratrochlear
77
78 H. W. Cho and W. Lee

therefore better to inject into the subgaleal plane.

There are a lot of controversies on the choice of
the cannula. However, cannulas with diameters
smaller than 27 G are not different from needles
[7]. We therefore prefer to use 21  G cannulas.
The lateral eyebrow serves as entry point. When
the hairline is chosen as entry point, the cannula
tends to be directing toward the eye [8]. It is rec-
ommended to use large-diameter cannulas due to
forehead depression and arterial pathway [9, 10].
Puncture the entry point by needle (Fig.  7.2);
then insert cannula at supraperiosteal layer
(Fig. 7.3). Inject filler gently; then make patient
sit in an upright position for detailed injection
(Fig. 7.4).

Fig. 7.1  Doppler ultrasound evaluation before forehead

filler injection

artery and the supraorbital artery before HA filler

injection because these arteries are directly
related to the ophthalmic artery [3].

7.1.2 Techniques

For forehead augmentation, regional anesthesia

is needed as topical anesthesia cannot be enough.
When performing filler injection using a can-
nula, it is almost impossible to dissect under the Fig. 7.2  Puncture of the entry point
periosteum. Similarly, a perpendicular injection
with a needle cannot dissect under the periosteal
layer. Therefore, most of the injected fillers are
located in the supraperiosteal layer [4]. Recent
articles also confirm that it is impossible to inject
filler into the subperiosteal layer, and so, the tar-
geted layers for forehead injection should be the
subgaleal layer or the superficial fat layer [5].
There exist a central compartment and a middle
compartment in the superficial fat layer of the
forehead, and superior temporal septum is
located between the middle forehead compart-
ment and lateral temporal cheek fat compart-
ment [6]. A reason why the filler should not be
injected into the superficial fat layer is that the
septum can get interrupted, causing the injected Fig. 7.3  Cannula perforation of the frontalis muscle to
filler to spread and cause irregularities. It is enter the subgaleal plane
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 79

7.1.3 Pre- and Postoperative

Photographs (Fig. 7.5)

Fig. 7.4  Make the patient sit in an upright position, and

inject slowly to correct irregularities

a b

c d

Fig. 7.5  Forehead HA filler of 3 mL in a 23-year-old female patient. (a) Pre-op frontal view. (b) Post-op frontal view
after 2 weeks. (c) Pre-op lateral view. (d) Post-op lateral view after 2 weeks
80 H. W. Cho and W. Lee

7.2 Temple Augmentation nula can puncture the STF easily. Therefore, a
relatively safe plane is exposed. Compared to
7.2.1 Anatomy and Considerations deep injection, small amounts of HA filler can
yield better results.
The temple area is a juncture where four skull Important vessels of the temple area are the
bones (frontal, parietal, temporal, and sphenoid STA, sentinel vein, middle temporal vein, and the
bones) fuse together and is covered by a multiple-­ deep temporal artery. The pulsations of the STA
layer thick soft tissue. From the outer surface, the can be felt during palpation of the temple area
layers are the skin, subcutaneous layer, superficial [16]. The STA is a branch of the external carotid
temporal fascia (STF), deep temporal fascia artery; it runs vertically anterior to the ear. The
(DTF), temporalis muscle, and bone (Fig. 7.6). In frontal branch of the STA runs superficially in the
addition, there exists a loose areolar tissue between temple area. The STA is a relatively large vessel
the STF and DTF, and the innominate fascia and and is therefore easily detectable by Doppler
parotid temporal fascia may also be found depend- ultrasound (Fig. 7.7).
ing on the height of the temple area [11].
There are three possible layers within which
HA fillers may be injected. These include the sub- Table 7.1  Disadvantages of deep injection of the temple
cutaneous layer (for superficial injection), the area
space between the STF and DTF, and the space 1. Case report of penetration of the temporal bone by a
between the temporalis muscle and the bone (deep needle [13]
injection) [12]. The easiest technique is to inject 2. Needle should be used for deep injections, so there
is a possibility for vascular injury (superficial
deeply in a way to touch the bone with the needle temporal artery, anterior branch of deep temporal
end. However, multiple shortcomings have been artery, and middle temporal vein) to occur [14]
found recently with this technique (Table 7.1). 3. Relative larger amounts of fillers are needed
Authors like to inject between the STF and 4. Impossibility to inject into the submuscular layer, so
DTF because the STA and the temporal branch of longevity decreases due to muscle action [4]
facial nerve are shielded by the STF, and the can- 5. Difficult to eliminate when a granuloma occurs [15]

Fig. 7.6  Multiple layers of temple area

7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 81

7.2.2 Injection Techniques

Entry point: When using a cannula, the entry

Fig. 7.7  Ultrasound detection of the temple area
points are on the hairline or near the eyebrow
(Fig. 7.9).
Doppler ultrasound detection of the STA is
performed. Then local anesthesia is injected on
the hairline entry point. After needle puncture of
entry point, a 21 G cannula is inserted. The STF
is easily perforated by the cannula; however, the
DTF is hard to perforate. Therefore, the cannula
tip can easily be positioned between the STF and
DTF. Inject the HA filler when the cannula tip is
positioned. Inject gently by retrograde threading
technique (Figs. 7.10 and 7.11).
Pre- and Post-procedural Photographs
(Figs. 7.12 and 7.13).

Fig. 7.8  Arteries of temple area on Doppler ultrasound

(FBrSTA (frontal branch of the superficial temporal
artery) and deep temporal artery anterior branch)

It is usually recommended to administer the

injection perpendicularly at the site 1 cm above Fig. 7.9  Local anesthesia at entry point
and 1  cm lateral to the eyebrow end [17].
However, this technique is associated with a risk
of perforating the STA, the zygomatico-orbital
artery, or the anterior branch of deep temporal
artery. Both the STA and deep temporal artery
can be detected by Doppler ultrasound (Fig. 7.8).
In addition, this area is close to the “caution
zone,” which is the area where the sentinel vein
and the temporal branch of the facial nerve perfo-
rate superficially [18].
The middle temporal vein tends to run below
the DTF layer and at 1 cm above the zygomatic
arch level. Therefore, injection into the space
between the STF and DTF is safe as it is not Fig. 7.10  Insert the 21 G cannula between the STF and
interrupted by the middle temporal vein [19]. DTF. The STF is easily perforated
82 H. W. Cho and W. Lee

Fig. 7.11  Make the

patient sit in an upright
position and inject the
filler

a b

c d

Fig. 7.12  Bilateral injection of HA filler of 0.8 mL in a procedural three-quarter view. (d) Post-procedural three-­
29-year-old patient. (a) Pre-procedural front view. (b) quarter view after 3 months
Post-procedural front view after 3  months. (c) Pre-­
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 83

a b

c d

Fig. 7.13  Bilateral injection of HA filler of 1  mL in a procedural three-quarter view. (d) Post-procedural three-­
23-year-old patient. (a) Pre-procedural front view. (b) quarter view after 2 weeks
Post-procedural front view after 2  weeks. (c) Pre-­

7.3 Nose Augmentation 7.3.1 Anatomical Considerations

Concerning the aspect of the nose, there are little
differences between oriental patients and western
patients. Western patients usually have a higher
nasal dorsum. Thus, HA filler is mostly adminis-
tered to correct deviations and small depressions.
In addition, small amounts of the filler are usu-
ally injected, and needle is mostly used [20]. In
oriental patients however, HA injection is usually
performed because of their lower nasal dorsum
[21]. Therefore, relatively larger amounts of filler
are injected, and extreme care should be taken
about the vascular anatomy. The nose can be
divided into the radix, rhinion, supratip, and tip
area, and it is important to know vascular anat-
omy and layers of each zone of injection [22].
One of the most common filler procedures is aug-
mentation of the dorsum of the nose. There are
two possible layers for filler injection (the sub-
dermal and supraperiosteal layers). In cadaveric
studies, arteries and veins are run above the fibro-
muscular layer. Therefore, the supraperiosteal
layer could be considered to be a safe injection
plane [23]. However, when using Doppler ultra-
sound, some branches of the dorsal nasal artery
are detected in the supraperiosteal layer. One
could therefore conclude that there is no 100%
safe plane of injection [21]. We can estimate that
blood pressure in the nasal arteries is not high
because branches of external carotid artery (oph-
thalmic artery) and branches of internal carotid
84
artery (facial artery) anastomose at the nose.
Thus when performing filler injection, a low
injection pressure might affect the ophthalmic
artery (Fig. 7.14). The dorsal nasal artery can be
detected by Doppler ultrasound (Fig.  7.15).
Previous article reported the glabellar area to be
the commonest site with ocular complication
[24]. However, up-to-date articles rather report
the nose to be the commonest injection site asso-
ciated with ocular complications [25]. Therefore,
doctors should be aware that injection rhino-
plasty is a very dangerous procedure.
Fig. 7.14  Vascular anatomy of the nose
Fig. 7.15  Doppler ultrasound finding of the nose
H. W. Cho and W. Lee
7.3.2 Injection Technique
Many doctors prefer to inject using an infralob-
ule approach with a cannula (Fig.  7.16) [23].
The cannula should be located at the supraperi-
osteal layer. When performing a perpendicular
injection, the needle tip can also be positioned
at the supraperiosteal layer (Fig.  7.17).
However, the needle could encounter an artery
and/or vein while approaching to the layer [26].
Our study showed that during perpendicular
injection at radix area, even if we performed a
bone touch, the filler could still be inserted into
the dorsal nasal artery depending on the needle
bevel location [27].
Fig. 7.16  Infralobular approach
Fig. 7.17 Perpendicular needle injection. Needle tip
should be positioned at the supraperiosteal layer (an aspi-
ration test should be performed before injection)
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques
Nose injection is one of the commonest proce-
dures in the oriental population, but it is com-
monly associated with vascular accidents.
Usually, the ejection pressure is higher than
blood pressure. It is therefore very important to
a b
d e
Fig. 7.18  Pre- and post-procedure photographs: Lorient
No. 6 dorsum supraperiosteal layer 0.5 mL, Lorient No. 2
dorsum subdermal layer 0.1 mL, Lorient No. 2 tip 0.2 mL.
(a) Pre-procedure front view. (b) Day 2 post-procedure
85
inject slowly [28]. Appropriate needle and filler
should be chosen considering the filler rheology
[29]. Pre- and post-procedure photographs are
seen in Fig. 7.18.
c
f
front view. (c) Pre-procedure three-quarter view. (d) Day
2 post-procedure three-quarter view. (e) Pre-procedure
lateral view. (f) Day 2 post-procedure lateral view
86
7.4 Midface Augmentation
Filler injection at the midface is usually per-
formed on multiple locations at once. For exam-
ple, tear trough, anterior malar, and lateral cheek
are corrected concomitantly. The total amount of
filler needed should be taken into consideration
(Fig. 7.19). There are risks of provoking a delayed
hypersensitivity when large amounts are injected.
7.4.1 Tear Trough Deformity
The nasojugal groove is formed by complex
structures such as tear trough ligament and orbital
septal fat and is found between the preseptal por-
tion and the orbital portion of orbicularis oculi
muscle [30]. The orbicularis retaining ligament
can be divided into a medial and a lateral side by
the midpupillary line. The medial side is tighter
and forms a hard structure called the “tear trough
ligament.” However, its anatomical nomenclature
is not defined. The medial side has a tight struc-
ture because the orbicularis retaining ligament
and the zygomaticocutaneous ligament tend to
aggregate at the medial side [31].
In addition, the groove can become prominent
because the pretarsal or preseptal areas have a
low fat content (subcutaneous fat exists mainly in
Fig. 7.19 Midface
augmentation after
2 weeks. A total of
3.9 mL of hyaluronic
acid filler was injected
H. W. Cho and W. Lee
the orbital fat area). Sometimes, festoon forma-
tion is a consequence of the aging phenomenon
[32]. If there are only nasojugal grooves, filler
injection can yield good results. However, when
the muscle fibers extend to the orbital rim or the
tear trough ligament is tightly attached, good
esthetic results cannot be obtained. In such cases,
surgical correction would be the only solution
[33]. Thus, the tear trough is not just ligament,
but is a complex deformity, and it is important to
consider all these factors before performing filler
injection. It is quite safe when deep injections are
administered into the suborbicularis oculi fat
(SOOF), but tear trough area does not contain
SOOF (Fig.  7.20). Therefore, considering the
anatomical layers, a deep injection (between the
orbicularis oculi muscle and bone) and a superfi-
cial injection (between OOM and skin) could be
performed concomitantly.
The angular artery runs on the medial side of
the angular vein in the tear trough area and there-
fore is relatively safe. However, when the angular
artery branches from a detoured branch of the
facial artery, the facial artery runs toward the
inferior orbital artery and anastomoses with
angular artery. Consequently, the angular artery
might be located very closely to the angular vein,
and so extreme caution will need to be taken
(Fig. 7.21) [34].
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 87

Fig. 7.20  Tear trough ligament and surrounding structures

Fig. 7.21  Doppler ultrasound finding of the angular

artery at the tear trough area

7.4.1.1 Tear Trough Deformity

Correction Techniques
The Tyndall effect should be considered [35]. A
previous study reported the duration to be more
than a year [36]. Topical anesthesia is usually
administered. Cannula can be positioned at deep
layer or superficial layer depending on groove
appearance (Fig.  7.22). Pre- and postoperative
photos are seen (Fig. 7.23).
Fig. 7.22  In the upright position, direct the cannula tip to
the desired layer and inject precisely
7.4.2 Anterior Malar Augmentation
One of the biggest differences, about esthetic
opinion, between western and oriental people
might concern the malar area and the mandibular
88 H. W. Cho and W. Lee

a b

Fig. 7.23  Tear trough deformity correction, Lorient No. 2 0.3 mL. (a) Pre-injection. (b) Postinjection

Fig. 7.24 Vessel
anatomy of anterior
malar area

angle area. Some western concept, such as

Hinderer’s line, cannot explain oriental patients’
needs [37]. This area is located below the orbicu-
laris retaining ligament. Therefore, when per-
forming anterior malar augmentation, the
orbicularis retaining ligament and zygomaticocu-
taneous ligament should be considered. When
performing a deep injection behind the orbicu-
laris oculi muscle, the targets should be the
prezygomatic space and the deep malar fat pad
including the SOOF.  However, there are some
dangerous structures to avoid (always take into
consideration the inferior orbital artery and
nerve). The facial artery detoured branch should
also be considered. The angular and inferior pal-
pebral veins form anastomoses with the facial
vein in this area. They should therefore be con-
sidered (Fig. 7.24) [38]. The targets of this area
are the deep malar fat pad and the prezygomatic
space (Fig. 7.25) [39].
Fig. 7.25  Anterior malar augmentation injection

7.4.3 Lateral Cheek Correction
There are abundant fibrous bands between the
skin and the SMAS in the lateral cheek area.
Because of these fibrous bands, filler might
migrate to undesired spaces. Therefore, it is rec-
ommended to administer the injection in the
upright position. When using a cannula to inject, a
helpful tip will be to make small spaces (by feel-
ing) to cut the fibrous band (Fig. 7.26). The trans-
verse facial artery branches from the STA or
external carotid artery and runs between the zygo-
matic arch and the parotid duct. Therefore, it may
be encountered when performing lateral cheek
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 89

correction. However, since the space is not lim-

ited, the probability for vascular injury is not high.
In addition, several variations exist and should be
taken into consideration (e.g., to avoid injuring
the dorsal nasal artery). Therefore, it is recom-
mended to administer the injection gently [40].

7.4.4 Tear Trough, Anterior Malar

Augmentation, and Lateral
Cheek Correction Pre-
and Post-Procedural
Photographs (Fig. 7.27)
Fig. 7.26  Correction of lateral cheek depression

a b

c d e f

Fig. 7.27  35-year-old patient midface filler injection. (a) (d) Post-procedural three-quarter view after 2 weeks. (e)
Pre-procedural frontal view. (b) Post-procedural frontal Pre-procedural lateral view. (f) Post-procedural lateral
view after 2 weeks. (c) Pre-procedural three-quarter view. view after 2 weeks
90 H. W. Cho and W. Lee

7.5 Nasolabial Fold Correction are some variations, such as the detoured branch
that runs toward the infraorbital foramen. There
7.5.1 Anatomy and Considerations are also variations in its position with respect to
muscle layers (beneath or above the muscle) [47].
Nasolabial fold correction is one of the most Generally, the supraperiosteal layer is known to
common filler injection procedures. When a new be safe for injections. However, there exist varia-
filler is placed on the market, most authors pro- tions; so the layer is not 100% safe [48]. The
pose the use of the WSRS correction scores to facial artery is easily detected by Doppler ultra-
prove the effectiveness of the filler [41]. One of sound (Fig. 7.29).
the causes of various types of nasolabial folds is
descent of the nasolabial fat (superficial fat com-
partment) [42]. The aging process results in sag- 7.5.2 Techniques
ging of the superficial fat and decrease in dermal
elasticity [43]. Another cause is diminished vol- When performed using a cannula, the entry point
ume of the deep medial cheek fat. The aging pro- used for augmentation of the anterior malar area
cess decreases the volume of the deep fat can be used. Injection in the supraperiosteal layer
component and causes deep nasolabial folds [44]. is possible (Fig. 7.30). However, even if the deep
This is one of the main reasons why injections layer is corrected, skin indentations can appear,
are administered into the deep medial cheek fat and subdermal needle injections might be needed.
compartment. The area between the deep medial Dual-plane injection yields better results, but the
cheek fat and the periosteum is called “Ristow’s
space” [44], and from the theory of the 1  cm
space, it is the same as the deep pyriform space
[45]; however, authors think the Ristow’s space is
a kind of potential surgical space. The Ristow’s
space is the first target for the correction of naso-
labial fold. Another cause of nasolabial folds is
the repetitive movement of muscles attached to
the dermal layer of the nasolabial fold. These are
the so-called lip elevators and are made up of the
LLSAN, levator labii superioris, zygomaticus
major, and zygomaticus minor muscles [46].
The trajectory of the facial artery follows that
of the nasolabial fold (Fig. 7.28). However, there Fig. 7.29  Doppler ultrasound probe detection

Fig. 7.28 Vascular
anatomy of the
nasolabial fold. The
facial artery can be
located at the nasolabial
fold (right). The facial
artery can detour the
nasolabial fold (left)
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 91

filler should never be injected into the subcutane-

ous layer. Needle perpendicular injection tech-
nique is another good technique, unless the facial
artery is not detected by Doppler ultrasound
(Fig. 7.31).

7.5.2.1 Pre- and Post-procedural

Photographs (Fig. 7.32)

Fig. 7.30  By using the same entry point as in anterior

malar augmentation, position the cannula tip in the supra-
periosteal layer by touching the bony area, and then inject
gently

Fig. 7.31  Deep bolus

injection. Doppler
ultrasound test should be
performed before the
injection. An aspiration
test should also be
performed [49]

a b

Fig. 7.32  35-year-old female patient, 0.5 cm3 injected each. (a) Pre-procedural. (b) Post-procedural after 2 weeks
92 H. W. Cho and W. Lee

7.6 Lower Face Injection

Techniques

7.6.1 Marionette Line (Figs. 7.33

and 7.34)

The marionette line, also called labiomandibular

fold, is different from the nasolabial fold. Usually,
skin drooping occurs in the premasseteric space.
Therefore, the limitations of the procedure should
be explained to the patient before administering
the injection [50].
The facial artery usually runs lateral to the
marionette line. The inferior labial artery is usu- Fig. 7.35  Perpendicular midline needle injection after
identifying the submental artery by Doppler ultrasound
ally located deep to the muscle. Marionette line
injection is usually performed at the subcutane-
ous layer [51]. 7.6.2 Chin Augmentation

Ricketts’ line is the virtual line from the nose tip

to the chin [52]. Mouth protrusion or retraction of
Ricketts’ line is important for esthetic purposes.
The chin is a relatively safe area to inject.
However, the relationship between the mentalis
and perioral muscles should be taken into consid-
eration. The lower part of the mentalis muscle
decussates at the midline, and a submentalis fat
exists between the muscle and the mandible [53].
This is the target for HA filler injection, but con-
sidering action of mentalis muscle, highly elastic
fillers are preferred (Fig. 7.35).

Fig. 7.33  Marionette line injection

7.6.3 Lip Injection

Lip augmentation is a common filler procedure in

western countries [54]. Large lips look more
attractive in western countries. On the contrary,
in oriental countries, many patients have horizon-
tal long lips, mouth protrusion, and microgenia
[55]. So for oriental patients, appropriate filler
injection is needed depending on the harmony
between the lips and face. Understanding the vas-
culature is essential (Fig. 7.36).

7.6.3.1 Lip Border Enhancement

Fig. 7.34  Doppler ultrasound finding of the marionette The vermillion border should be prominent for
line lips to look attractive (Fig.  7.37). As the aging
7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques 93

Fig. 7.36 Nomencla-
ture of the lips

a b

Fig. 7.37  Upper lip border enhancement. (a) Start laterally. (b) Move to the medial location

process evolves, the lip borders become more

obscured. Therefore, border enhancement is
needed to restore the attractive young-looking
appearance of lips.

7.6.3.2 Lip Augmentation

Lips, especially the lower lip, look attractive when
well padded. Volume augmentation should be per-
formed for the lower lip (Fig. 7.38). For volume
augmentation, superficial injection is better than
injection in the muscle layer. The superficial labial
artery and inferior labial artery run in the mucosal
layer. Therefore, it is relatively safe to inject in the
superficial subcutaneous layer. Fig. 7.38 Lower lip augmentation. More volume is
needed compared to the upper lip
7.6.3.3 Mouth Corner Lifting
Recently, many patients have been desiring for toxin administration [56]. Filler injection tech-
mouth corner lifting. Mouth corner lifting is the niques are as follows (Figs. 7.39, 7.40, 7.41, 7.42
multiple-step procedure used to augment the lat- and 7.43):
eral part of the upper lip, to support the mario- Pre- and Post-procedural Photographs
nette line and the weak DAO muscle by botulinum (Figs. 7.44 and 7.45).
94 H. W. Cho and W. Lee

Fig. 7.39  Upper lip lateral side volume augmentation

Fig. 7.42  Upper part of the marionette line, with 0.1–
0.15  mL of HA filler injected to support the mouth
corner

Fig. 7.40  More mucosa should be exposed on the lateral

part of the upper lip

Fig. 7.43  Injection of 4 U of botulinum toxin ipsilater-

ally into two to three injection sites. The mentalis muscle
injection should also be performed

Fig. 7.41  Lower lip volume augmentation

7  Doppler Ultrasound-Guided Hyaluronic Acid Filler Injection Techniques
Fig. 7.44  Mouth corner
lifting in a 29-year-old
female patient.
Pre-procedural and
2 weeks post-procedural
front view. The upper lip
left part was depressed,
so augmentation was
also performed
Fig. 7.45  Lips pre- and post-close-up photographs
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H.  Aspiration revisited: prospective evaluation of a
physiologically pressurized model with animal cor-
relation and broader applicability to filler complica-
tions. Aesthet Surg J. 2021;41(8):NP1073–83. https://
doi.org/10.1093/asj/sjab194.
50. Braz A, Humphrey S, Weinkle S, Yee GJ, Remington
BK, Lorenc ZP, et  al. Lower face: clinical anatomy
and regional approaches with injectable fillers. Plast
Reconstr Surg. 2015;136(5 Suppl):235s–57s.
51. Lee SH, Lee M, Kim HJ. Anatomy-based image pro-
cessing analysis of the running pattern of the peri-
oral artery for minimally invasive surgery. Br J Oral
Maxillofac Surg. 2014;52(8):688–92.
52. Ricketts RM.  Perspectives in the clinical appli-
cation of cephalometrics. The first fifty years.
Angle Orthod. 1981;51(2):115–50. https://doi.
org/10.1043/0003-­3219(1981)051<0115:PITCAO>2
.0.CO;2.
53. Hur MS, Kim HJ, Choi BY, Hu KS, Kim HJ, Lee
KS. Morphology of the mentalis muscle and its rela-
tionship with the orbicularis oris and incisivus labii
inferioris muscles. J Craniofac Surg. 2013;24(2):602–
4. https://doi.org/10.1097/SCS.0b013e318267bcc5.
54. de Maio M, Wu WTL, Goodman GJ, Monheit G;
Alliance For the future of aesthetics consensus
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for botulinum toxin and injectable hyaluronic acid
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PRS.0000000000003646.
55. Peng JH, Peng HP.  Classifications and injection
strategy for lip reshaping in Asians. J Cosmet
Dermatol. 2020;19(10):2519–28. https://doi.
org/10.1111/jocd.13635.
56. Jeong TK.  Mouth corner lift with botulinum toxin
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2020;145(3):538e–41e.
 Filler Injection Complications
and Hyaluronidase 8
Won Lee

8.1 Introduction 8.2 Nonvascular Complications

Hyaluronic acid filler injections are commonly 8.2.1 Infection

used for wrinkle correction and volume augmen-
tation [1]. The knowledge of anatomy and filler
properties is essential to prevent complications.
In this chapter, we will discuss filler injection-­
associated complications and treatments.
Filler complications are of two kinds: vascu-
lar, which include skin necrosis and ocular com-
plications [2], and nonvascular, which include
inflammation, migration, Tyndall effect, granu-
loma, and delayed-type hypersensitivity. The
complications are classified according to onset
time (Table 8.1).
Aseptic procedures are essential for filler injec-
tions, as septic conditions might develop from
infections after filler injection, also triggering
any preexisting dermatitis. Skin necrosis is also
associated with an increased risk of infections.
Treatments, such as hyaluronidase injections
with antibiotics, must be initiated at the onset of
skin necrosis (Fig.  8.1). Infections rarely occur
when aseptic procedures are performed properly.
8.2.2 Migration

Fillers like to migrate to areas offering less resis-

tance after injection. Fillers can migrate by repet-
Table 8.1  Filler complications classified according to
onset time
Immediate Bruising, swelling, blindness
Early Swelling, erythema, inflammation,
(1 day–1 week) allergy, skin necrosis
Late (after Pigmentation, migration,
1 week) delayed-type hypersensitivity,
granuloma

W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea Fig. 8.1  Signs of infection after nose filler injection

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 99
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_8
100
a b
Fig. 8.2 (a) Upward filler migration. (b) Downward filler migration. (c) A second image depicting upward filler
migration
itive molding, and their properties influence the
migration [3]. Repetitive muscle action, previous
filler injections, and pre-tunneling space are pos-
sible causes of filler migration (Fig. 8.2).
The properties of fillers should be considered
when injected to the nasal area. Usually, filler
injections are recommended at the supraperios-
teal layer [4], but some hyaluronic acid fillers
tend to migrate because of compression forces.
The hardest filler should be considered for nose
injections [5].
8.2.3 Tyndall Effect
The Tyndall effect is the phenomenon when the
fillers are visible under thin skin, as light is scat-
tered by the particles in a colloid. This can be pre-
vented by injecting small amounts of fillers.
Clinicians should also consider the thickness of
the dermis.
8.2.4 Delayed-Type Hypersensitivity
Delayed-type hypersensitivity usually occurs at
least 2 weeks after filler injection. This compli-
W. Lee
cation has been highlighted recently because of
recent reports after COVID-19 vaccinations
[6], causing type IV hypersensitivity.
Hyaluronic acid filler is a foreign substance,
but since the main constituent is hyaluronic
acid, inflammation is usually minimal.
However, hyaluronic acid fillers can be recog-
nized as an antigen, and consequently an
inflammatory reaction may develop, mediated
by macrophages and T lymphocytes. If the
patient is immunosuppressed, delayed-type
hypersensitivity might develop.
Vascular complications occur through the
same mechanism across different filler products.
In addition, delayed-type hypersensitivity might
be induced by raw filler products. To fully com-
prehend the properties of a filler, the manufactur-
ing process must be known.
Hyaluronic acid fillers are composed of raw
hyaluronic acid and a crosslinker (Fig. 8.3).
The manufacturing process is complicated
because of proper pH, mixing time, mixing tem-
perature, and so on. The following images show
the manufacturing process of monophasic fillers
(Fig. 8.4).
Impurities introduced during the manufactur-
ing process can be made either by BDDE or by
8  Filler Injection Complications and Hyaluronidase 101

Fig. 8.3  Hyaluronic acid filler, which consists of raw hyaluronic acid powder and a crosslinker (BDDE 1,4-butanediol
diglycidyl ether)

Fig. 8.4 The a b c
manufacturing process
for hyaluronic acid
production. (a)
Weighing. (b)
Dissolve in NaOH. (c)
After reaction with
BDDE. (d) Cutting.
(e) After washing. (f)
Filling. (g) Autoclave

d e

f g
102 W. Lee

O O
OH H3C-C H3C-C
OH
HO NH NH
O HO O
O O O
NaOOC O HO O O HO O
NaOOC
O O OH O Epoxide group
HO HO
OH
O O O
O
a b c d
(<2ppm)*
O O O
O
OH OH
HO HO HO O

O CH2OH
COONa O COONa
O O O
O O O O O
OH HN
HN HO HO
C CH3 C CH3
O O

Fig. 8.5  Various BDDEs. (a) Well-crosslinked. (b) Pendant type. (c) BDPE (1,4-butanediol di-(propan-2,3-diolyl)
ether). (d) Native type

8.3 Vascular Complications (1):

Skin Necrosis

8.3.1 Cause

Intravascular embolisms are the most significant

Fig. 8.6  Scanning electron microscopy of hyaluronic
acid fillers, which showed multiple impurities
cause for skin necrosis, in addition to compres-
sion at dense areas. Anatomical knowledge is the
most important factor for prevention (Fig.  8.7).
Ocular complications can also significantly
impact the patient. Prevention methods are exten-
sively described in this chapter.

manufacturing defects. The residual BDDE, 8.3.2 Treatment: Hyaluronidase

which is usually minimal, is calculated for all the
products. Non-crosslinked BDDEs such as
pendant-­ type BDDE or BDPE are potential
impurities (Fig. 8.5).
The impurities introduced during the
manufacturing process can also be detected
(Fig. 8.6).
Delayed-type hypersensitivity depends on the
patient’s immunologic status. However, impuri-
ties can also cause inflammation. To minimize
the risk of complications, pure hyaluronic acid
fillers should be manufactured and used.
The most important goal in treating hyaluronic
acid filler-induced vascular complications is to
dissolve the fillers using hyaluronidase.
Intravascular dissolving is necessary when embo-
lisms occur and extravascular dissolving should
be done when compression occurs.
8.3.2.1 Mechanism
Hyaluronidase is present in the human body and
degrades hyaluronic acid at β-1,4 chain (Fig. 8.8).
(Hyaluronidase from leech degrades β-1,3 chain.)
8  Filler Injection Complications and Hyaluronidase 103

Fig. 8.7  Vasculature of the face

COO–Na+ CH2OH COO–Na+ CH2OH

O HO O O O
O O
HO O HO O
O
NH NH
HO C=O C=O
CH3 CH3
O
BDDE

O
CH3 CH3
C=O C=O
NH NH
O
O OH O OH
O O
O O O O
CH2OH COO–Na+ CH2OH COO–Na+

monomeric unit

Fig. 8.8  The location of cleavage of hyaluronic acid by hyaluronidase

The dermal layer consists of glycosaminogly-
can (which includes HA); the hyaluronidase can
degrade the HA for hypodermoclysis. Off-label
dissolved HA fillers are used here [7].
8.3.2.2 Types
Hyaluronidase is made by different manufactur-
ing processes using ovine, bovine testicular, or
human recombinant sources. The products have
varying potencies, which also differ between
countries. Hylenex and Vitrase have concentra-
tions of 150 USP (United States Pharmacopeia)
and 200 USP, respectively, and products in Korea
usually contain 1500 IU (Fig. 8.9).
8.3.2.3 Duration
Usually, hyaluronidase is injected at the subcuta-
neous layer, where its half-life is 30  min. The
104
a b
Fig. 8.9  The different brands of hyaluronidase. (a) Hylenex (150 USP). (b) Vitrase (200 USP). (c) Hyalose (1500 IU)
half-life drastically reduces to 2–3  min in the
blood, which is attributed to the antibody theory.
8.3.2.4 Hyaluronidase for Nonvascular
Complications
Low-dose hyaluronidase can be used for nonvas-
cular complications, such as nodule degradation.
Approximately 30–60 IU can be used for mouse
nodules [8]. It is also possible to reinject hyal-
uronic acid fillers 6  h after the hyaluronidase
injection [9]. A high dose of hyaluronidase can
be used for capsule formatted granuloma cases.
8.3.2.5 Hyaluronidase for Vascular
Complications
The most severe complications are vascular, like
skin necrosis and ocular complications. Despite
adequate anatomical knowledge, features vary
across individuals. How is hyaluronidase injected
to resolve vascular complications?
A previous study recommended specific dos-
ages of hyaluronidase for specific areas of treat-
ments (Fig. 8.10) [10]. However, there are some
W. Lee
c
considerations before administering different
treatments, summarized in Table 8.2.
Below, we have discussed the treatment strat-
egy for an actual skin necrosis case (Fig. 8.11). A
30-year-old patient developed skin necrosis after
nasolabial fold filler injections. The following
factors were taken into consideration:
1. Time of the filler injection: The onset is
extremely important, as within 48–72 h of the
onset, hyaluronidase should be injected.
2. Properties of the filler: It is impossible to
know all the MoD of the fillers in the market.
However, knowledge of whether the filler is
a monophasic or biphasic product is essen-
tial. Biphasic fillers usually have minimal
MoD and rapid degradation times. The dos-
age of hyaluronidase must be based on the
properties of the HA product for effective
treatment.
3. Amount of injected hyaluronidase: As
described previously, hyaluronidase products
have variable potency. Usually 1500  IU is
8  Filler Injection Complications and Hyaluronidase 105

Fig. 8.10  Dosages for

specific vascular
complications. Dosages
should be adjusted based
on the brand of
hyaluronidase used

Table 8.2  Factors to consider before administering HYAL injections to resolve vascular complications
Injected MoD Monophasic and biphasic fillers have different modification of degree (MoD) and
degradation time
Potency of HYAL Variable products have different potencies
Dosage 150 USP, 200 USP, 1500 IU
Affected vessel Subcutaneous injection nearby affected vessel
Degradation time Injected HYAL should spread to affected vessel and it should be remembered that hyaluronic
acid filler does not degrade immediately
Repetitive injection Injected HYAL subcutaneously has half-life, so repetitive injection should be performed
Among these considerations, repetitive injections are essential. A previous experiment revealed that 30  min–1  h of
repetitive HYAL injections is most effective [11]
106 W. Lee

used, so consider the dosage based on the ana-

tomical location of the necrosis.
4. Location of filler injection: The patient
(Fig. 8.11) was injected with filler at the naso-
labial fold. However, skin necrosis developed
at the supratrochlear territory. Thus, the filler
was injected inside the facial artery and
moved to occlude the angular artery and
supratrochlear artery. Hyaluronidase should
be injected at the facial artery, angular artery,
and supratrochlear artery. Although the patient
complained of pain, multiple injections at a
minimum 1 cm distance are necessary.
5. The frequency of hyaluronidase injections:
Hyaluronidase should be injected to ensure
complete degradation of the filler, for which
repetitive injections at 30 mins–1 h intervals
are needed. Hyaluronidase does not degrade
the HA filler immediately, so considering deg-
radation times and the hyaluronidase half-life,
hyaluronidase should be injected repeatedly
(Fig. 8.12).

Fig. 8.11  Skin necrosis treatment after nasolabial fold

hyaluronic acid filler injections
8  Filler Injection Complications and Hyaluronidase
a b
c d
Fig. 8.12  Repetitive hyaluronidase injections
8.4 Vascular Complications (2):
Ocular Complications
8.4.1 Incidence
As filler injection procedures increase, more ocu-
lar complications are reported. Fifty ocular com-
plications were reported till 2018 due to filler
injections without fat grafts [2]. This is most
likely underreported. The most common injec-
tion locations are the nose and glabella, where
the branches of internal carotid artery exist,
necessitating extreme caution during injections.
8.4.2 Pathophysiology
The mechanism has been previously reported
[12]. Filler embolisms develop at the supratroch-
lear artery or the dorsal nasal artery. The filler
107
then moves to the ophthalmic artery retrograde
pathway, followed by the central retinal artery
(Fig.  8.13). So extreme caution is crucial when
fillers are injected at internal carotid artery sites.
8.4.3 Preventions
There are many suggested methods of preventing
ocular complications. The author recommends
the ABC techniques described in the previous
article (Table 8.3) [13].
8.4.3.1 A: Anatomy
Anatomical knowledge, especially that of the
arterial supply, is crucial for prevention (Fig. 8.7).
The supratrochlear, supraorbital, and dorsal nasal
arteries are the branches of the internal carotid
artery and are directly associated with ocular
complications. The superficial temporal, infraor-
108
Fig. 8.13  The pathophysiology of filler-induced ocular complications
Table 8.3  The ABCs for prevention of filler-induced
ocular complications [13]
An – Anatomy (Doppler ultrasonography)
As – Aspiration with proper technique
B – Big cannulas
C – Compression
D – Direction of injection
E – Emergency kit
F – Filler technique for augmentation or wrinkle
correction
G – Gentle injection of a small amount
H – History of prior operations or injections
bital, and facial arteries are very important ves-
sels from the external carotid artery. It is
impossible to know the exact pathway as they
may vary circumstantially. Recently, detecting
arteries using the Doppler ultrasound has been
gaining importance as a preventive technique.
Doppler Ultrasonography-Guided Filler
Injections
Detailed techniques are described in Chap. 7. The
supratrochlear artery can be detected by Doppler
W. Lee
ultrasonography when injecting the glabella area
[14]. The dorsal nasal artery can also be detected
using Doppler ultrasonography when injecting
filler at the nose [5, 15]. One common site for
filler injection is the nasolabial fold, which can
be encountered through the facial artery. The
facial artery can be easily detected using Doppler
ultrasonography [16]. When filler injections are
performed for temple augmentation, the frontal
branch of superficial temporal artery can be
encountered, detected using Doppler ultrasonog-
raphy [17, 18]. The most definite prevention is to
use the Doppler ultrasonography to locate the
arteries before filler injection.
8.4.3.2 Aspiration Test
When the needle ends perforate the arteries and
syringe regurgitation is performed, blood can be
seen. This is called an “aspiration test.” The aspi-
ration test remains controversial but is theoreti-
cally an effective procedure performed by many
doctors. However, the possibility of false nega-
tives is increased when the needle end is located
8  Filler Injection Complications and Hyaluronidase
inside the arterial lumen, but no blood is seen. The
needle prime substance, retraction time, retraction
pressure, and needle lumen diameter also affect
the risk of false negatives. One experiment
assessed the aspiration test with the needle-­
priming substance [19]. Both in vitro and in vivo
tests were performed and when the needle was
filled with the filler, false negatives might occur
(Fig. 8.14). Thus, it is important to detect the nee-
dle lumen before the aspiration test is performed.
Fig. 8.14  The in vivo aspiration performed in the femo-
ral artery and central auricular vein in a rabbit
Fig. 8.15  The comparison between the diameters of arteries and cannulas
109
8.4.3.3 B: Big Cannula
Almost all doctors recommend cannulas as safer
options than needles. However, the cannula is not
100% safe. The author recommends using can-
nulas with diameters comparable to those of the
dorsal nasal or supratrochlear arteries (Fig. 8.15).
8.4.3.4 C: Compression
Compression of the periocular region can occur
during filler injections. For example, the supra-
trochlear pathway compresses during glabella
wrinkle correction using filler injections
(Fig. 8.16).
8.4.3.5 D: Direction
When filler injections are performed, injecting in
the direction toward the eye is not recommended.
For example, when filler is injected into the facial
artery, filler can reach through angular artery and
dorsal nasal artery to create an embolism at the
ophthalmic artery.
8.4.3.6 E: Emergency Kit
An emergency kit should be ready for use when
vascular or ocular complications occur, as they
110
Fig. 8.16  Compression observed during glabellar wrin-
kle correction
Fig. 8.17  Emergency kit (a Heparin. b Dexamethasone.
c Hyaluronidase. d Eglandin)
do within only a few minutes [20]. Hyaluronidase
should especially be prepared, in addition to
vasodilators, antibiotics, and so on (Fig. 8.17).
W. Lee
8.4.3.7 F: Filler Techniques
There are numerous techniques used for filler
injections, which can be classified as follows:
bolus technique, where the needle tip is located
and bolus is injected, or linear-threading tech-
nique, where a moving cannula tip is used. The
choice of technique is based on the results of the
aspiration test before procedures. The complica-
tions should be kept in mind when choosing
techniques.
8.4.3.8 G: Gentle Injection
In addition to anatomical knowledge, gentle
injections are highly recommended by doctors
as preventative measures. The author performed
an experiment to measure the actual pressure at
the needle end (Fig. 8.18). The needle tip pres-
sure is dependent on the complex viscosity of
filler, the needle diameter, and so on. However,
the most important factor is to inject as gently as
possible [21].
8.4.3.9 H: History of Prior Operations
It is important to know the patient’s history. Prior
operations can alter the preoperative vascular
locations. For example, an open rhinoplasty
would destroy the columellar artery and therefore
alter the nose vasculature. Scar formation at the
prior injection site should also be considered for
the injections.
8.4.4 Treatments
There are no definite treatments for ocular com-
plications. Suggestive treatments are described
below.
8.4.4.1 Retrobulbar Hyaluronidase
Injections
Hyaluronidase is injected at the retrobulbar area
to recanalize the central retinal artery. Previously,
retrobulbar hyaluronidase with lidocaine was
used for anesthesia (Fig. 8.19).
One experiment assessed filler-induced rabbit
blindness and retrobulbar hyaluronidase injec-
tions. The time and dosage of hyaluronidase may
8  Filler Injection Complications and Hyaluronidase 111

Fig. 8.18  The instrumental setup for the ejection force experiment. S1 denotes the filler-filled syringe, S2 denotes an
additional syringe connected to S1, and A1 denotes the internal cross-sectional area of S1

retinal artery runs into the optic nerve dura, and

hyaluronidase cannot diffuse into the dura, poten-
tially rendering the treatment ineffective. There is
a case report of retrobulbar hyaluronidase [23],
and the literature on this topic is expanding. The
most frequently used treatment is the retrobulbar
hyaluronidase injection (Fig. 8.20).

8.4.4.2 The Supratrochlear Notch

Fig. 8.19  Retrobulbar hyaluronidase
have influenced the results, but a 75% success
rate was observed [22]. However, there are differ-
ences between rabbits and humans. The central
Hyaluronidase Injection
Hyaluronidase injections at the supratrochlear
artery reportedly go to the ophthalmic artery
[24]. Hyaluronidase can reach the ophthalmic
artery through this technique but might have
issues reaching the central retinal artery.
112
Fig. 8.20  The retrobulbar injection technique
8.4.4.3 Subtenon Retrobulbar
Hyaluronidase Injection
A subtenon injection is another solution described
recently, which offers greater permeability [25].
However, the technique is relatively difficult and
there are no case reports describing it.
8.4.4.4 Intra-Arterial Thrombolysis
(IAT)
A catheter, starting from the femoral artery
extending to the ophthalmic artery, should be
used to inject hyaluronidase and urokinase. A
recent case report was published where this
approach was used for successful resolution of
complications [26]. However, there are also case
reports describing unsuccessful resolutions using
this technique [27]. As previously described,
time is one important factor when performing
this treatment. It is almost impossible to perform
within 90 min after blindness occurred.
According to the author, the most important
factors for effective treatment are as follows: (1)
the treatment should be administered as soon as
possible, (2) a high dose of hyaluronidase should
be injected, and (3) hyaluronidase cannot degrade
HA filler immediately, so repeated injections
should be performed. Soon a definite treatment
will be established.
W. Lee
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 Anatomical Considerations
for Thread Lifting
Gi Woong Hong and Won Lee
Thread lifting is one of the most performed mini-
mally invasive aesthetic procedures. Like all pro-
cedures done in the face, basic anatomical
knowledge is essential for thread lifting. In this
chapter, we will discuss the important vessels,
nerves, and retaining ligaments important for
thread lifting. We will discuss the fat components
to understanding better results for thread lifting.
Finally, we will discuss the parotid gland anatomy
to prevent thread lifting-induced complications.
9.1 Vessels
During thread lifting, the veins and arteries can be
interrupted, possibly causing bruising and swell-
ing. It is safer for the lower face because only a few
arteries run through the superficial layer at certain
areas of the lower face. Perforation of the larger
vessels at the temple area and the upper face is
likely when fixation of thread is usually performed
in the upper face. Main vessels run within the sen-
sory nerves. Thus, when a patient complains of
pain, it is recommended to pull the cannula back-
ward and then change the direction or layer.
When performing thin polydioxanone (PDO)
threads, there is a greater possibility for bruising.
G. W. Hong
SAMSKIN Plastic Surgery Clinic, Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_9
9
However, usually small vessel perforation easily
attains hemostasis by compression. However,
thick thread for lifting usually starts from hair-
lines and approaches the SMAS layers, creating
an increase for perforating bigger arteries.
The main artery at the hairline is the superfi-
cial temporal artery (STA). The STA runs through
the preauricular area and bifurcates into the ante-
rior branch and posterior branch. The bifurcation
usually occurs 64% above the supraorbital rim
and 36% below the supraorbital rim. The frontal
branch of the STA is usually at the superomedial
60.8° and runs toward the lateral border of the
frontalis muscle. It is wrapped by a superficial
temporal fascia and then runs superficially at the
lateral forehead area (Fig. 9.1) [1].
Despite anatomical knowledge of the STA,
perforations could occur due to anatomic varia-
tions. A temporal needle is used for the fixation
method. When the STA is perforated, a high
blood volume is regurgitated through the needle
puncture area within 1–2 s. When this phenome-
non occurs, compression should be done for
>5 min, followed by making another entry point.
When hemostasis does not occur, sutures are
required with the adjacent tissue [2].
The superficial temporal vein (STV) also might
be perforated at the temple area and might cause
severe bruising, necessitating a gentle approach [3].
Severe bleeding might also be caused by the
facial artery. The facial artery usually runs between
the mid-mandibular inferior border and the ante-
rior border of the masseter muscle (Fig. 9.2) [4].
115
116 G. W. Hong and W. Lee

Anterior branch
of superficial
temporal artery
Poterior branch
of superficial
temporal artery
Line of superior
orbital rim

Zygomatico-
orbital artery
Auriculotemporal
nerve

Transverse
facial artery Greater auricular nerve

Fig. 9.1  The anterior and posterior branches of the superficial temporal artery

Fig. 9.2  The vessels on

the antegonial notch of
the mandibular border

Premasseteric branch
of facial artery
Facial artery

Facial vein
9  Anatomical Considerations for Thread Lifting
When the facial artery runs near the mandible
area, it mostly runs in the deep layer. Thus, thread
lifting at the superficial layer can be safe. The
facial artery runs deep in the medial direction and
superficial at the mimetic muscles and branches
arteries at the nose and lips [5].
The angular artery is the terminal portion of
the facial artery and runs through variable layers,
necessitating extra caution for risks of perfora-
tion. The STA is located at the temporal bone,
making compression possible. However, when
the facial artery is lacerated, a hematoma occurs
through the buccal area, and the patient could
experience severe bruising and swelling [6].
9.2 Nerves
Thread lifting is usually performed by a cannula,
causing minimal nerve damage. However, the
temporal branch of the facial nerve at the temple
area, usually located 0.5 cm below the tragus and
1.5  cm lateral to the eyebrow by the Pitanguy
line, requires gentle procedures to be performed
near this area (Fig. 9.3) [7].
Fig. 9.3  The temporal branch of the facial nerve on the
Pitanguy line
117
The nerve location is important. However, the
layer location is also significant to determine the
depth of thread lifting. Fortunately, the temporal
branch of the facial nerve does not exist as only
one, but as two to three branches. Therefore, con-
comitant damage does not occur [8].
The actual disturbance associated with nerve
damage is the perioral sensory disturbance
when opening the mouth. When a cogged thread
is inserted at the perioral muscles, it likely
causes disturbance or pain, which is most
severe at 1 week and improves after 1–2 weeks
[9]. This phenomenon is usually not attributed
to nerve damage itself but is sensorily
uncomfortable.
9.3 Retaining Ligaments
The retaining ligaments of the face can be classi-
fied as follows: true retaining ligaments, which
start from the bone and attach to the skin, and
false retaining ligaments, which start from the
muscle or soft tissue layers. The true retaining
ligaments are the orbital, zygomatic, maxillary,
and mandibular ligaments (Fig. 9.4) [10].
However, the retaining ligaments are useful as
fixation structures rather than ligaments. The
ligament-­like structure is needed to make variable
expressions while preventing sagging. Whether
this structure is a true ligament or only ligament-
like, this hard tissue is useful for the cogged
thread to hold the soft tissues of the face [11].
The most important two ligaments are the
zygomatic and masseteric cutaneous ligaments.
They decussate a “T” shape and display hard-­
bearing power for the skin and soft tissues. These
ligaments act as hard fixation structures when
multidirectional cogged threads are used
(Fig. 9.5) [12].
In contrast, when too many forces are applied
at the retaining ligaments, it is hard to release the
threads and form dimples. This should be noticed
at the location of maxillary ligament and man-
dibular ligament area, and massage should be
immediately performed to necessitate immediate
release when dimples occur [13].
118 G. W. Hong and W. Lee

Fig. 9.4  True and false retaining ligaments of the face

Fig. 9.5  The positions

of the zygomatic and
masseteric cutaneous
ligaments
9  Anatomical Considerations for Thread Lifting
9.4 Fat Compartments
The aging process decreases the skin’s elasticity
and gravity causes soft tissue descent. An ana-
tomical study showed that fat cell descent occurs
inside the fat compartment and is likely to occur
at the superficial and deep fat layers [14]. The
superficial fat compartment should therefore be
the target for lifting by threads. For example, the
nasolabial fat near the nasolabial fold and the
superior and inferior jowl fat near the marionette
line are the most common superficial fat com-
partments to be lifted (Fig. 9.6) [15].
The nasolabial fold occurs due to multiple
causes, and considerations should be made for
the fat compartment volume reduction. The
superficial fat compartment increases in volume
because of the aging process, but the deep fat
compartments decrease in volume. This means
that the nasolabial fat increases the volume and
descent, and the deep medial cheek fat (DMCF)
decreases the volume and descent [16]. Thus,
nasolabial folds deepen by DMCF volume reduc-
tion and the DMCF support ability decreases. To
solve this problem, filler injections at the DMCF
area are recommended to increase the support,
combined with thread lifting at the superficial fat
compartment [17]. The marionette line has simi-
lar problems. At the medial side, labiomandibular
fat is located, and the aging process induces
Fig. 9.6  The location of
nasolabial and jowl fat
119
labiomandibular fat reduction, and at the lateral
side, jowl fat is located, and the volume increases
(Fig. 9.7) [18].
Therefore, a combination treatment is recom-
mended such that thread lifting targets jowl fat
and filler targets labiomandibular fat.
Thread lifting of the buccal fat is controversial
because the volume of fat is around 10 mL and it
extends to the temple area, which is called the
deep temporal fat pad [19]. Buccal fat usually
decreases the friction around perioral structures
by sucking or pouring. When patients age, the
masseter muscle strength increases and the action
of buccal fat is reduced. Buccal fat increases in
volume until 50  years of age and then starts to
decrease like the deep fat compartment. This
structure supports soft tissue above the ­zygomatic
arch and the decreases in fat can result in a sunken
cheek appearance [20]. While one may think that
lifting the buccal fat may solve the sunken cheek
appearance and descent, buccal fat exists deep, at
the SMAS layer and the facial nerve branches.
The parotid ducts are located inside these sites,
so thread lifting directly for the buccal fat is not
recommended. Perforating a parotid duct can
induce severe inflammation. Buccal fat has a very
soft structure, and cogged thread might be ade-
quately powerful for lifting. Therefore, the cap-
sule around buccal fat is an alternative target for
lifting [21].
120
Fig. 9.7  Fat tissue around the marionette line
9.5 Spaces
The facial spaces are located between the fat lay-
ers, SMAS, muscle, and retaining ligaments.
Surrounding structures like the capsule do not
exist at the facial spaces. They usually exist
between the superficial fascia and deep fascia and
make the facial expression muscle move alone,
without adjacent structures. For example, lifting
by the zygomaticus major and minor contraction
does not affect the adjacent muscle or structures.
The vessels and nerves also like to run through the
borders of the spaces, so there are no important
structures inside spaces. These can therefore be
used for surgical dissection of structures and as
safe pathways for cannula. So thick cogged threads
can move safely through these spaces [22].
However, the cogged threads once inserted
can induce pain because it is gliding through the
space and irritating the adjacent expression mus-
cle. The premasseteric space requires extreme
caution. Here, the masseteric cutaneous ligament
is located anterior, the platysma muscle is located
superficially, while the masseteric muscle is
located at a deep location, and the mandibular
ligament is located below these structures [23].
G. W. Hong and W. Lee
When performing thread insertions at the
space, cannula insertion can be easily performed.
While the procedure is usually easily performed,
when the thread is located near masseter muscle,
the patient might feel pain when opening their
mouth or chewing [24]. Therefore, this space
should be avoided for thread insertion. The target
should be the SMAS layer or deep portion of
superior and the inferior jowl fat [25].
However, we cannot see the exact layer during
the procedure. The SMAS can be identified
through its typical structure of multiple fibers and
the upper layer can be felt during the process [26].
9.6 Parotid and Submandibular
Gland
The parotid and submandibular glands require
greater precaution than the vessels and nerves.
Perforated vessels can be resolved with compres-
sion, and motor nerve disturbances are rare.
However, if the thread perforates the parotid or
submandibular glands, a sialocele or inflamma-
tion could occur.
The parotid gland is located below the zygo-
matic arch, anterior from the earlobe, usually above
9  Anatomical Considerations for Thread Lifting 121

Fig. 9.8  The position of

the parotid gland and
five branches of the
facial nerve

the mandibular border, but can also be located over

the mandibular ramus border and form a huge
lump-like structure under the ear. As described in
Chap. 2, the facial nerve runs between the superfi-
cial and deep lobes of the parotid gland, and some-
times, by the accessory parotid gland [27]. The
parotid capsule is located deeper than the SMAS
and deep fascia (Figs. 9.8 and 9.9) [28].
Therefore, the parotid capsule should not be
perforated during thread lifting. It is a relatively
tough structure, so gentle parallel insertion from
the skin is recommended. But when a patient
crunch during operation and/or the parotid gland
moves upward, the cannula might perforate it.
Therefore, deep insertions are not recommended
[29]. The submandibular gland is located poste-
rior to the lateral third and medial part of the
mandible bone. It is not grossly noticeable, but
the submandibular gland can be palpated after the
patient is made to swallow (Fig. 9.10) [30].
When performing a double chin lift, it is Fig. 9.9  Parotid and submandibular glands
advisable to not insert the cannula deep portion.
Thread lifting can be performed at a double chin
deformity. However, a misdiagnosis can be made, botulinum toxin injection can be performed
i.e., submandibular gland hypertrophy. Thus, a instead of thread lifting [31].
122
Fig. 9.10  The position of the submandibular gland
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 History, Principles, and Adjuvant
Therapy for Thread Lifting 10
Young Dae Kweon and Won Lee

Thread lifting is one frequently performed mini-

mally invasive aesthetic procedure. In this chap-
ter, we will discuss the history, principles,
mechanisms, and adjuvant techniques for maxi-
mizing thread lifting.

10.1 History and Background

Thread lifting is an innovative technique using

the structural modification of preexisting suture
material. It is one of the most frequently per-
formed minimally invasive procedures, based on
suturing without ligation. Surgeons developed
the lifting material and non-ligation suture mate-
rial inspired by porcupines (Fig. 10.1), or Spanish
needles.
In the 1950s, J.H.  Alcamo, a US doctor and
inventor, developed cogged threads using
Prolene, which has high tensile strength. He sub-
mitted a patent for the cogged thread in 1956,
which was granted in 1964 [1], but did not pub-
lish his production process. Nowadays, his design
is considered variable and basic for thread lifting
(Fig. 10.2).
Y. D. Kweon
Kang Nam Plastic Surgery Clinic, Osan, Kyonggi-do,
Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
Fig. 10.1  A porcupine (purchased from Utoimage)
Since then, many doctors have developed
suture materials which work without ligation, for
use in noninvasive techniques. Sulamanidze
developed the APTOS, now produced worldwide
[2]. In Korea, Lee developed the primary thick
PDO thread for lifting. The PDO thread is the
most used, in addition to PCL- and PLLA-based
threads, also used for absorbable thread lifting.
Many patients desired for less invasive proce-
dures and a procedure called “petit surgery”
including the botulinum toxin injection, filler
injection, and thread lifting which have gained
more popularity [3]. Previously patients were
focused on effectiveness and longevity. However,
recently the focus has shifted to less invasive
procedures and minimizing the time to resume
daily activities. To cater to these demands, vari-
ous kinds of laser and energy-based devices,
short but effective results using botulinum toxin,

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 123
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_10
124
Fig. 10.2  The cogged thread design (Courtesy from
original drawings for barbed sutures. Reproduced from
Alcamo J.H. [1])
immediate and safe filler injections, and effec-
tive techniques for thread lifting have been used
widely.
In Korea, few doctors are focused on simple
PDO threads for embedding. Based on oriental
medicine, these absorbable sutures were embed-
ded at the subcutaneous layer for skin tightening
[4, 5]. Various kinds of suture material, such as
chromic, PGA, and PDO, were used, but the
PDO thread became more effective and less com-
plicated over time. Thin threads provide a lattice
shape for collagen production and support the
structures against gravity. Thus, it affects the
physical and chemical reaction resorption at
6–8 months. These are made at 5-0 or 6-0 thick-
ness and are used for applications other than the
face, like upper arm laxities and abdomen
tightening.
Y. D. Kweon and W. Lee
They were modified as spring type and multi-
ple type and developed for maximizing the effec-
tiveness. Adjuvants were also used for thicker
cogged threads.
10.2 Developments
The initial cogged threads were made from
Prolene (polypropylene), which gradually
changed to absorbable PDO threads. Techniques
also developed over time. Previously, threads
were inserted after minimal incision at the temple
area for fixation into the deep temporal fascia.
The process has developed such that non-­
incisional temporal fixation technique or floating
techniques can be utilized.
The process of fabricating the cog also devel-
oped from cutting by knife to being automated.
When tension was applied for cutting, the thread
splits from the main thread, thereby reducing sup-
port such that a stronger thread was developed.
Prolene threads were usually made by techniques
involving cutting, and PDO threads were devel-
oped by press molding method, making anchoring
easy between the tissues and threads. The press
molding method produced heat during the manu-
facturing. The press cutting method also developed
to overcome this. Stronger anchoring manufactur-
ing methods are used nowadays (Fig. 10.3).
Recently, PLLA- and PCL-based threads have
been developed to circumvent the 6–8-month
resorption period of PDO threads. PCL threads are
soft; thus, cutting methods are used for manufac-
turing. PLLA, being relatively hard, requires one or
a few threads for embedded use. PCL has an estab-
lished absorption duration of 24 months and PLLA
20  months. Threads with even higher absorption
times will be developed. Structure-­ memorizing
threads and structure restoration threads using
high-frequency devices are also in development.
More complex structural threads are also man-
ufactured and used. The silhouette thread was
also changed to become absorbable, which was
renamed the Silhouette Soft. It has a relatively
high power for lifting using cone-shaped knots
(Fig. 10.4).
10  History, Principles, and Adjuvant Therapy for Thread Lifting
Fig. 10.3  Various press molding threads
Fig. 10.4  The silhouette thread
The embedded thread also developed from
plain thread to screw, tornado, and spring types
and was developed for volumizing threads.
Volumizing threads are made in different shapes,
like the cylindrical shape and the multiple-thread
twisted shape.
PDO threads are known for a 50% decrease
of tensile strength at 6  weeks and soften at
8–12  weeks, followed by resorption at 6–8
months. Therefore, thread lifting usually effec-
tively lasts for 1 year.
10.3 Mechanism
The goal of thread lifting is to reposition the soft
tissue to compensate for descent by gravity. It is
like meat is hanging on an iron hook. However,
since the thread needs to be adequately thin, mul-
tiple cogs are made.
125
10.3.1 Soft Tissue Repositioning
The desired result of lifting for every patient
resembles the face when using the hands to lift
the face in a lateral and upward position
(Fig. 10.5a, b). It should resemble photos taken at
supine position (Fig.  10.5c). Thread lifting is
usually performed at the supine position, ­ensuring
even lifting forces being applied. Relatively hard
tissues such as the preauricular or temporal area
should be fixated to ensure adequate lifting at the
upright position.
10.3.2 Fixation (Internal Splinting
for Remodeling)
When in supine position, the descent tissue relo-
cates to the lateral upward position. Wrinkles,
senile eyelid, bulging low eyelid fat, and nasola-
bial fold reduce in appearance in the supine posi-
tion. The low face borderline due to jowl descent
also improves (Fig. 10.5c).
Lifting can be performed by inserting 4–8
threads ipsilaterally using threads of variable
thicknesses (2, 1, 0, 2-0). Several doctors pre-
fer patients with neck extension state at −10°
to −15°.
10.3.3 Collagen Replacement
of Absorbable Material
The PDO thread is most used in recent times. It
degrades by hydrolysis in the body. The thread
usually softens by hydrolysis at 8  weeks after
insertion in the body [6]. But even when the
thread softens, the tissue is not likely to descent
because of the subsequent inflammatory phase,
proliferative phase, and maturation phase after
the thread insertion. Repetitive stimuli from
inserted thread induce an inflammatory and pro-
liferative phase. Even during hydrolysis, a wound
healing process occurs [7], and the inflammatory
process extends to 6–8 months. Neocollagenesis
also occurs for about a year as a part of the thread
126
a b
Fig. 10.5  Differences in facial structure by position. (a) Upright position. (b) Patient’s desire. (c) Photographs taken at
upright and supine positions
lifting maturation process. The lifting effect is
visible for 1–1.5-year duration. During this time,
neocollagenesis occurs and matures, and fixation
by the thread loses strength because of muscle
activity for expressions and descent due to grav-
ity. The duration is variable based on the patient’s
condition but can be prolonged by adjuvant
therapy.
10.4 Classification of Threads
Threads can be classified based on the following
techniques:
10.4.1 Anchoring vs Floating
Fixation at the deep temporal fascia technique is
done using anchoring-type thread lifting. Non-­
fixation thread lifting is known as the floating
type. Previously, the anchoring type was per-
Y. D. Kweon and W. Lee
formed within the incision at temple area and fix-
ated at the deep temporal fascia. Later,
non-incisional deep temporal fascia fixation was
performed.
10.4.2 Cogged Thread vs Plain Thread
Cogged threads are relatively thick threads such
as 2, 1, 0, and 2-0 used for tissue lifting. Plain
thread is absorbable thread and made 5-0 to 7-0.
It is embedded at the dermal and/or subdermal
layer as a meshed type. Usually, the improvement
of fine wrinkles is seen.
10.4.3 Absorbable vs Nonabsorbable
Prolene has been used previously. It has been
replaced to absorbable threads such as PDO,
PLLA, and PCL.  However, nonabsorbable
threads are still also used.
10  History, Principles, and Adjuvant Therapy for Thread Lifting 127

10.5 Adjuvant Therapy for Thread 10.5.2 Botulinum Toxin Injection

Lifting
The aging process causes significant wrinkle for-
Thread lifting can be used alone for lifting tissue, mation and loss of skin elasticity. Fine wrinkles
or in combination for better results. The widely by muscle action can be resolved by botulinum
used adjuvant therapies are listed below toxin, and thread can be used concomitantly to
(Table 10.1): lift the skin. One of the locations where this con-
comitant strategy is used is the low face. To
reduce the masseter muscle volume, botulinum
10.5.1 Fat Graft toxin can be injected, and thread lifting can be
performed for the lift jowl area. At frontal view of
The aging process causes facial soft tissue reduc- the patient, the posterior third can be corrected by
tion and decreases skin elasticity. Fat grafts can be the botulinum toxin, and middle third can be
performed at the forehead, anterior malar area, improved by cogged threads. Plain embedded
nasolabial fold area, cheek, and lateral sub-­ thread can also be inserted at the lateral canthal
zygomatic depression. Increasing volume also has area, forehead, and upper lip area after botulinum
lifting effects. However, the lower face fat graft toxin injection.
must also be considered, which can show increased
descent in the appearance. Therefore, lower face
lifting should be performed by thread lifting. At 10.5.3 Filler Injection
the perioral area, micro fat injection can be per-
formed with absorbable embedded plain threads. Hyaluronic acid filler injection is one common
Thread lifting with fat graft might have the aesthetic procedure. It is controversial to use con-
advantages of structural support of the thread and comitantly with thread lifting because the HA
antigravity effects. The survival rate is important filler absorbs adjacent water and thread under-
for fat graft and might affect structural stability. goes easy hydrolysis. However, thread insertion
External taping is used for increased stability, but can support the structural stability and might
taping cannot be performed for more than 5 days. limit the migration of filler injections.
Plain thread such as 5-0 absorbable thread can be Filler longevity is dependent on the extent of
used for stability. At the perioral area, thread can absorption and migration. Thus, thread insertion
be used for wrinkle correction, structural support, might prolong filler longevity by providing struc-
and neocollagenesis. tural support. At the glabellar wrinkle area, botu-
Thread also can be used with large-volume fat linum toxin can be used for the corrugator
grafts. A large-volume fat graft is performed at muscle, filler injections can be performed for pre-
the breasts and buttocks. Structural instability existing groove correction, and thread can be
can result in a low survival rate. Thread can be used for structural stability. At the nasolabial fold
used for greater stability. area, threads and fillers can be used as a combina-
tion therapy.
Table 10.1  Various methods for combined thread lifting
1. Fat graft
2. Botulinum toxin injection 10.5.4 Interstitial Laser
3. Fillers
4. Interstitial laser Usually, laser irradiates the skin surface.
5. Liposuction Sometimes fibers are inserted into the subcuta-
6. Combination of different kinds of threads
7. HIFU neous tissue to irradiate light, which is called
8. Fractional laser interstitial laser. It is used for fat reduction or
9. Fractional RF (multi-needle RF), RF skin tightening. Using 1444 or 1470 nm, laser is
10. Petit rhinoplasty used for fat reduction at the jowl fat and double
128
chin. Lipolysis with laser and thread lifting can
be used simultaneously. The author likes to use a
980-nm laser for inducing fibrosis before thread
lifting. Irradiation can induce inflammation and
fibrosis. Wound healing and scar maturation pro-
cess might induce tighter tissues for thread lift-
ing. The longevity of the thread lifting might be
prolonged using laser. The author also uses the
980-­ nm laser for breast ptosis with thread
lifting.
10.5.5 Liposuction
The face is the area where concomitant therapy
by thread lifting and liposuction is frequently
done. Other places also can use both thread and
liposuction. After liposuction, the skin tends to
loosen, and thread can provide structural support.
Inflammatory processes can improve the
­appearance of wrinkles and skin loosening by
regeneration and fibroblast activation.
10.5.6 Different Kinds of Threads
As previously described, threads can be used for
several different reasons. For lifting, cogged
threads are used, while plain threads are used for
structural support and to facilitate neocollagene-
sis. Thus, various threads can be simultaneously
used for better results.
10.5.7 High-Intensity Focused
Ultrasonography (HIFU)
Energy-based devices, such as HIFU, are used
for mechanisms like those of the interstitial laser.
Thread lifting can be used to achieve an immedi-
ate lifting effect. HIFU is additionally used for
increased tightening and effectiveness of threads.
HIFU is a noninvasive procedure. Effective pro-
cedures are performed with the combined use of
thread and HIFU.
Y. D. Kweon and W. Lee
10.5.8 Fractional Laser
Laser can be classified as ablative and non-­
ablative. Fractional laser is used for reduced heal-
ing time and at fine wrinkles, acne scars, and
pores. Absorbable plain thread can be concomi-
tantly used for better results.
10.5.9 Radiofrequency Devices
Energy-based devices, such as radiofrequency
devices, are used for skin tightening and lifting.
Multiple types are used, such as monopolar and
bipolar energy devices. Microneedle radiofre-
quency devices are popularly used for tightening,
so combination therapy with thread lifting is used
to obtain better results.
10.5.10 Petit Rhinoplasty
Nose augmentation using noninvasive proce-
dures is commonly used. Filler injections at the
dorsum are commonly used. Cogged thread has
been used for nasal tip elongation and will be
discussed in depth in Chap. 13. Thread insertion
in the nose is like solid filler in the nose but soft-
ens after few months because of the thread
mechanism. Therefore, after 3 months, second-
ary procedure is commonly performed.
Additional fillers can be injected for structural
support.
10.6 Considerations for Effective
Thread Lifting
10.6.1 Limitations of Minimally
Invasive Procedures
Thread lifting has limited effectiveness compared
to traditional face lifting. It is used to plicate soft
tissue, limiting the results. The sum of linear trac-
tion can be explained for thread lifting.
10  History, Principles, and Adjuvant Therapy for Thread Lifting
10.6.2 Understanding of Thread
PDO absorbs within 6–8 months. However, trac-
tion forces start decreasing only a few weeks
after insertion. As previously described, the PDO
hydrolyses 8 weeks after insertion. Some patients
complain of painful sensations, nearly extrusion,
but these complications disappear by 2–3 months
after as the thread softens and loses strength.
Thus, the patient should exercise precaution for
2–3  months while performing certain activities
like opening the mouth wide, facial massages,
etc.
10.6.3 Understanding
Manufacturing Process
Absorption depends on the manufacturing pro-
cess because PDO thread is prone to hydrolysis
by the environment. High humidity can increase
the thread’s fragility. Packing is also important.
Nitrogen gas is usually filled inside the package.
Vacuum packing seems to maintain the thread
properties better.
When the package has been opened, the thread
inside should be used as soon as possible.
Re-sterilization should not be performed after
opening the package. Once the package is
opened, external humidity causes hydrolysis of
129
the thread. The delivery time from the raw thread
company to manufacturing company is also cru-
cial. Even though they are similar in shape, the
exposure time of humidity is different, which is
an important factor affecting effectivity and lon-
gevity. Therefore, using freshly manufactured
thread is recommended.
References
1. Alcamo JH.  Surgical suture. US Patent 3,123,077.
1964.
2. Sulamanidze MA, Fournier PF, Paikidze TG,
Sulamanidze G.  Removal of facial soft tissue ptosis
with special threads. Dermatol Surg. 2000;28:367–71.
3. The Korea Herald. Petit’ surgery promises ‘natural’
look. In: Demand on rise for non-invasive cosmetic
treatments that promise instant rejuvenation. Seoul:
The Korea Herald; 2013.
4. Yun Y-H, et  al. Narrative review and propose of
thread embedding acupuncture procedure for facial
wrinkles and facial laxity. J Korean Med Ophthalmol
Otolaryngol Dermatol. 2015;28(1):119–33.
5. Yun Y, Choi I.  Effect of thread embedding acu-
puncture for facial wrinkles and laxity: a single-­
arm, prospective, open-label study. Integr Med Res.
2017;6(4):418–26.
6. Vieira AC, et al. Degradation and viscoelastic proper-
ties of PLA–PCL, PGA–PCL, PDO and PGA fibres.
In: Materials science forum, vol. 636. Bach: Trans
Tech Publications Ltd; 2010.
7. Lee CG, et  al. Histological evaluation of biore-
sorbable threads in rats. Korean J Clin Lab Sci.
2018;50(3):217–24.
 The Basic Techniques for Thread
Lifting 11
Bong-il Rho, Chang Woon Yun, Soo Yeon Park,
and Won Lee

Thread lifting is a commonly used technique in
minimal aesthetic fields. However, the proce-
dures are not standardized, resulting in technical
variations. In this chapter we will discuss several
types of threads and basic procedures of thread
lifting.
11.1 Introduction
Thread lifting is a relatively easy, frequently per-
formed technique resulting in minimally invasive
lifting effects. However, it is also disadvanta-
geous in terms of its short-lived, minimal lifting
effects [1]. Several types of cogged threads have
been developed to increase the lifting effect and
longevity of the technique.
The cogged threads can be classified into a
few categories based on certain properties. First,
based on the direction of the cogs, the threads can
be unidirectional, bidirectional, and multidirec-
tional. Based on the technique types, thread lift-
ing can be floating or anchoring type. APTOS
thread is a well-known floating thread made from
polypropylene (PP), made for gathering tissue
[2], usually 7–10  cm long and bidirectional.
Recently, comparable products have been manu-
factured by polydioxanone (PDO) threads.
However, for patients of Asian origin, the zygoma
is relatively wide and prominent. The use of bidi-
rectional threads for gathering tissue can make
the zygoma look more prominent [3].
Multidirectional cogged threads have been devel-
oped to overcome these issues. Multidirectional
cogged threads are suitable for fixation, but not
tissue gathering at one point. Therefore, adjuvant
fixation with bidirectional thread lifting is recom-
mended [4].

11.2 Characteristics of Threads

B.-i. Rho
Glovi Plastic Surgery Clinic,
Seoul, Republic of Korea 11.2.1 Bidirectional Cogged Thread
C. W. Yun
View Plastic Surgery Clinic, These threads are usually 7–14  cm long, with
Seoul, Republic of Korea cogged areas of 4–9 cm. Directionally, the cogs
S. Y. Park face away from each other across each end of the
MadeYoung Plastic Surgery Clinic, Seoul, Republic thread and meet at the center. It is used for gath-
of Korea ering tissue but, as previously described, is disad-
W. Lee (*) vantageous for gathering tissue at the zygoma
Yonsei E1 Plastic Surgery Clinic, area. The basic mechanism involves pulling the
Anyang, Kyonggi-do, Republic of Korea

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 131
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_11
132
Fig. 11.1  Bidirectional cogged thread
Fig. 11.2  Multidirectional cogged thread
loose tissue such that it tightens. The lower
medial face typically accumulates loose tissue,
while temple area is typically tight. Therefore,
lifting can be performed (Fig. 11.1).
11.2.2 Multidirectional Cogged
Thread
This thread type is typically 7–14 cm long, with a
cogged area of 4–9 cm. A consecutive set of three
to four cogs faces one direction, while the adja-
cent set faces the opposite direction. It is used for
fixation rather than gathering and is therefore
useful for adjuvant fixation after floating bidirec-
tional thread lifting (Fig. 11.2).
11.3 Thread Lifting Techniques:
The Anchoring Technique
The anchoring technique is performed to attain a
strong lifting effect. The threads are typically
anchored at the temple area. Threads can be
anchored at the deep temporal fascia (DTF),
which is a fixed structure. Alternatively, ties can
be made at the subcutaneous layer.
B.-i. Rho et al.
Fig. 11.3 A suitable candidate for thread lifting.
Patients with a nasolabial fold, jowl laxity, marionette’s
line, low face contour, and perioral wrinkles are good
candidates
Dr. Gordon Sasaki successfully used Gore-­
Tex thread for the anchoring technique and pub-
lished at PRS2002. However, the technique did
not gain popularity [1]. Various non-cogged
threads were also used, but did not become
popular.
Anchoring at the DTF technique is one of
the most effective thread lifting techniques
which necessitates the need for anatomical
knowledge to prevent complications. When
the thread is anchored to movable structures
like the superficial temporal fascia or subcuta-
neous layer (as opposed to immovable struc-
tures like the DTF), reduced lifting effect is
observed.
11.3.1 Indications
The nasolabial fold, marionette line, and low face
skin laxity are indications of thread lifting
(Fig. 11.3).
11.3.2 Materials
A 41-cm-long absorbable cogged thread
(Fig.  11.4) and the apparatus required for local
anesthesia are prepared. Awl is used to puncture
the temporal skin and a temporal needle (hooked
needle) is used to anchor at the DTF.
11  The Basic Techniques for Thread Lifting 133

Fig. 11.4  The unilateral 41 cm cogged thread

Fig. 11.6  Deep temporal fascia (DTF) fixation by tem-

poral needle

Fig. 11.5  Anchoring-type design

11.3.4 Techniques

11.3.3 Basic Design 1. Anesthesia, using 2% lidocaine and 1:100,000

The basic designs are described below (Fig. 11.5):
1. A safe borderline (red line) depicting the
expected thread protrusion during facial
expressions or mastication is drawn. The hori-
zontal line begins at the mouth corner to the
mandible angle and the vertical line is perpen-
dicular to the lateral canthal line.
2. The temple area, which is 1–1.5  cm above
the eyebrow, serves as an entry point, result-
ing in relatively easy fixation at the DTF and
cannula insertion. The exit points for the
cannula can vary but should be within the
red line.
3. More than two threads should be inserted to
draw the virtual thread’s pathway to account
for sagging skin and the patient’s desire.
epinephrine, is injected at the entry point. The
tumescent solution is injected along the can-
nula pathway. A wait time of 5–10 min is rec-
ommended post-local anesthesia injections.
2. An entry point hole is made using an 18  G
needle or awl inside the hairline. The hairline
should be prepared such that no other inser-
tions are made at the entry point during the
process.
3. A temporal needle is used for deep fixation at
the DTF.  During the needle insertion, the
semicircular temporal needle end should feel
deep to the periosteum or DTF (Fig. 11.6). If
the temporal fixation is performed superficial
to the DTF, thread migration and extrusion
might occur. Alopecia is a potential side effect
during the temporal needle-induced temporal
loop descent.
134
a b
Fig. 11.7  Fixation at the deep temporal fascia (DTF). (a) Thread insertion at the temporal needle end. (b) Pulling the
same length to locate the center at the DTF
4. The thread is inserted to the end hole of the
temporal needle and rewound for thread fix-
ation (Fig.  11.7a). Two threads can be
inserted concomitantly, but considering the
directionality, more than two entry points
may be necessary. The two ends of the
thread are pulled by the same length to
locate the center of the thread at the DTF
(Fig. 11.7b).
5. The cannula is inserted at the entry point. The
cannula is maneuvered such that the end is at
the deep subcutaneous layer of the lower face
and penetrates the exit site (Fig.  11.8). The
cannula must not be located at the dermal
layer. This can be tested by shaking the can-
nula end.
6. The thread is inserted through the cannula.
When the thread is visible at cannula exit,
the cannula is removed from the exit site,
thus leaving only the thread. It must be
ensured that hair does not enter the entry
point (Fig. 11.9). The remaining half of the
thread is inserted using the same methods
(Fig. 11.10).
7. When both ends of the thread are inserted, the
skin is stretched for face lifting (Fig. 11.11a).
The excess threads are cut. Notably cutting
B.-i. Rho et al.
should be performed only after pulling the
thread to prevent thread extrusion
(Fig. 11.11b).
8. After removing the excess thread, dimples
might occur at the exit site. Gentle massage is
performed to resolve these dimples
(Fig. 11.11c).
9. The patient is made to sit in an upright posi-
tion and examined for symmetry and
dimples.
11.3.5 Considerations
1. The patient might experience postoperative
pain after 1–2  weeks. Overexpression or
opening the mouth too wide should be
avoided.
2. Postoperative swelling might be observed at
the zygoma area until 2–3  weeks after the
procedure.
3. Discomfort during opening the eyes in the
perioral area might occur for 1 day due to the
local anesthesia. Preoperative explanations
regarding the same are recommended.
4. Exit site dimples are a common complication
requiring early intervention. If the dimples
11  The Basic Techniques for Thread Lifting 135

Fig. 11.8  Cannula insertion and penetration to the exit point

Fig. 11.9  Thread insertion through the cannula and subsequent removal of cannula

Fig. 11.10  Insertion of the remaining half of thread

136 B.-i. Rho et al.

a b c

Fig. 11.11  Thread cutting. (a) Skin lifting. (b) Cutting remaining threads. (c) Gentle massage

Fig. 11.12  Thread lifting using anchoring cogged thread techniques. Patient images taken preoperatively (Lt) and
1 month postoperatively (Rt)

persist for 4 weeks, a permanent dimple might 11.4 Thread Lifting Technique:
occur. To avoid these cases, follow-up visits The Floating Technique
are recommended 3–4  weeks after the
operation. The floating technique involves multidirec-
tional thread insertions and is relatively easy.
However minimal immediate lifting is seen,
11.3.6 Pre- and Postoperative Photo and the effects are short-lived. The APTOS
(Figs. 11.12 and 11.13) thread is a well-­known floating thread. Recently,
numerous cog-­ shaped PDO threads have
Case 1 been manufactured for different purposes.
See Fig. 11.12. Bidirectional cogged threads are commonly
used, specifically for gathering soft tissue at the
Case 2 center area. A lifting effect is achieved because
See Fig. 11.13. the lower face is relatively mobile. Compared
11  The Basic Techniques for Thread Lifting
Fig. 11.13  Anchoring fixation cogged thread lifting. Patient images taken preoperatively (Lt) and 1 month postopera-
tively (Rt)
to the fixed-type techniques, multiple threads
can be inserted at once using easy procedures,
and there is negligible pain at the temple area.
Multiple types of thread can also be used for
floating-type techniques, like bidirectional and
multidirectional threads.
11.4.1 Indications
The clinical indications are described
below
1. Jowl.
2. Nasolabial fold.
3. Lower face V shape contour.
4. Double chin.
5. Eyebrow.
11.4.2 Materials
1. An absorbable bidirectional thread and absorb-
able multidirectional thread (Fig. 11.14).
2. Anesthesia
A topical cream does not suffice because of the
cannula insertion. Epinephrine containing lido-
caine is usually used to reduce bruising. Lidocaine
137
Fig. 11.14  Bidirectional and multidirectional threads
used in floating techniques
(1–2%) with 1:100,000 epinephrine is adminis-
tered at the entry point. Bicarbonate is used as an
analgesic. The tumescent solution is made with
0.2–0.3% lidocaine and 1:250,000–500,000 epi-
nephrine. A tumescent solution infiltration is per-
formed using a 26–30-G-long needle or cannula.
A minimum wait time of 5 min is recommended
after the administration of anesthesia.
3. Cannula
A blunt cannula is used for less traumatic pro-
cedures. Recently many products have been man-
ufactured such that the blunt cannula includes
thread. The cannula usually has a bigger diameter
than the thread. For example, a 19 G cannula is
used for 2-0 thread.
11.4.3 Basic Design (Figs. 11.15
and 11.16)
138 B.-i. Rho et al.

Fig. 11.17  The entry point

Fig. 11.15  Targeting the nasolabial fold

Fig. 11.18  The cannula insertion

11.4.4 Techniques

1. The entry point is made using either an 18 G

needle, awl, or knife (Fig. 11.17). One or mul-
tiple entry points are made.
2. The cannula is inserted vertically, followed by
a direction change along the skin vector. The
inserted layer can be the deep subcutaneous
layer or SMAS layer (Fig. 11.18). When the
cannula is held by the right hand, the left hand
is used to perform the pinch technique so that
the proper insertion layer is estimated.
Fig. 11.16  Targeting the jowl line When the cannula is inserted too deep,
there is a risk of parotid gland perforations or
11  The Basic Techniques for Thread Lifting
Fig. 11.19  Removal of the cannula while holding the
thread in the left hand
oral cavity perforations. In contrast, insertions
that are too superficial can create dimples or
skin irregularities. The deep subcutaneous
layer or SMAS is the ideal target for lifting.
When the cannula is fully inserted, the tip
should be raised to estimate the inserted layer.
If the cannula tip is located too superficially,
the cannula should be pulled backwards and
reinserted to a deeper layer. Recently, thick
molding-­type threads have been used, wherein
targeting the sub-SMAS layer can provide
safer results.
3. The cannula is removed after the thread is
fully inserted. The thread within the cannula
can be held by the left hand followed by can-
nula removal (Figs. 11.19 and 11.20).
4. If five to six threads are inserted bilaterally,
the patient must be made to sit in an upright
position for the assessment of symmetry.
Additional threads can be inserted.
5. When the lifting is performed symmetrically,
excess thread can be cut. Dimples can form at
the entry point. To prevent this, cuts should be
made only at the edge of the skin and gentle
massages should be performed at the dimple
location.
139
Fig. 11.20  Another thread insertion using a different
approach vector
11.4.5 Considerations
1. Mild pain may last for 1–2 weeks, specially at
the dermal attached areas, like the entry point.
The overuse of facial expressions must be
avoided.
2. Zygoma swelling might occur, subsiding at
2–3 weeks post-procedure.
3. Dimples require immediate interventions.
11.4.6 The Author’s Latest Technique
The author used thread from 2003. Various
threads and altered techniques were used. Thread
lifting has limitations when compared to tradi-
tional incisional face-lift operations. The author’s
experiences can be summarized as follows:
First, nonabsorbable and absorbable provide lim-
ited longevity. So, the procedure needs to be
performed periodically. Absorbable thread is
safer and more useful in these cases.
Second, molding-type thread provides superior
of traction force as compared to cutting-type
thread.
Third, the fixed type was most frequently used
previously. However, some patients develop
temporal pain and discomfort. Recently,
floating-­type lifting has also shown significant
140 B.-i. Rho et al.

effects as compared to the fixed type. Case 2

Therefore, molding-type floating thread lift- See Fig. 11.22.
ing has recently gained popularity.
Case 3
See Fig. 11.23.
11.4.7 Case Photos (Figs. 11.21, 11.22,
11.23, 11.24 and 11.25) Case 4
See Fig. 11.24.
Case 1
See Fig. 11.21. Case 5
See Fig. 11.25.

Fig. 11.21  55-year-old woman. Photographs taken preoperatively (Lt), 2 weeks postoperatively (center), and 3 months
postoperatively (Rt)
11  The Basic Techniques for Thread Lifting 141

Fig. 11.22  The floating-type technique. Images were taken preoperatively (Lt) and 1 month postoperatively (Rt)

Fig. 11.23  A 56-year-old woman. Images taken preoperatively (Lt), 1 week postoperatively (center), and 3 months
postoperatively (Rt)
142 B.-i. Rho et al.

Fig. 11.24  A 62-year-old woman. Photographs taken at pre-op (Lt), 1 week post-op (center), 3 months post-op (Rt)

Fig. 11.25  A 53-year-old woman. Images were taken preoperatively (Lt), 2  weeks postoperatively (center), and
3 months postoperatively (Rt)
11  The Basic Techniques for Thread Lifting 143

References sue ptosis with special threads. Dermatol Surg.

2002;28(5):367–71.
3. Wu WTL.  Commentary on: effectiveness, longevity,
1. Sasaki GH, Cohen AT. Meloplication of the malar fat
and complications of facelift by barbed suture inser-
pads by percutaneous cable-suture technique for mid-
tion. Aesthet Surg J. 2019;39(3):248–53.
face rejuvenation: outcome study (392 cases, 6 years’
4. Kang SH, Rho BI, Yoon SJ.  Textbook of absorbable
experience). Plast Reconstr Surg. 2002;110(2):635–54.
thread lifting. Gyeonggi: Koonja Publishing, Inc.;
2. Sulamanidze MA, Fournier PF, Paikidze TG,
2018.
Sulamanidze GM.  Removal of facial soft tis-
 The Techniques
and Considerations
for Thread Lifting
Won Lee and Chang Woon Yun
The results of thread lifting are dependent on the
doctor’s expertise, vectors, and the patient’s con-
dition. Thread lifting can be done by either
cogged thread or plain thread, dependent on the
required mechanical traction force and chemical
effects. The cogged threads can be further divided
into the fixed type and floating type. In this chap-
ter, we will discuss the crucial factors and various
techniques for thread lifting.
12.1 Thread Thickness
The thread thickness is a crucial factor to be con-
sidered for thread lifting, in addition to the thread
length, thread count, shape, and the insertion
layer. Thread thickness is a basic component for
physical strength. The considerations for choos-
ing the appropriate thickness includes the
patient’s skin thickness, degree of soft tissue
descent, prior operations, the desired lifting vec-
tor, and so on.
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
C. W. Yun
View Plastic Surgery Clinic,
Seoul, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_12
12
A thick thread provides a more significant lift
in the tissue but might leave the patient with an
increased foreign body sensation-associated dis-
comfort. Thick threads also require cannulas with
larger diameters, resulting in increased pain and
tissue damage. Thin threads provide compara-
tively inferior lifting effects.
Considering the thickness of thread, thicker
thread should be inserted deeper. The insertion of
thick threads near the facial retaining ligaments is
not recommended, as doing so can cause compli-
cations like dimple formation.
Every thread is labeled by the United States
Pharmacopeia (USP). The criteria vary between
the synthetic absorbable surgical sutures and
nonabsorbable surgical sutures [1]. There are dif-
ferences between the USP and European
Pharmacopoeia (EP). Here, we summarize the
thread thicknesses based on the USP labeling
system (Fig. 12.1).
145
146 W. Lee and C. W. Yun

USP METRIC Sutures Diamater in mm effect early phase and chemical effect late phase.
Thread lifting techniques are developed using
3 6 effective cogged designs and better packing pro-
0.600-0.699
cesses. The thread insertion layer is important to
ensure the best results.
When the thread is inserted near the dermal
2 5 layer, the chemical effect will be superior.
0.500-0.599 However, thread visibility and dimples can occur
as unwanted side effects. The threads are there-
fore inserted into the deep subcutaneous layer,
1 4
but unfortunately, unintentional thread insertion
0.400-0.499
can occur at the SMAS and sub-SMAS layers.
0 3.5
0.350-0.399
12.2.1 Uni-Layer Insertion
2/0 3
0.200-0.249
From the entry point to exit, thread is inserted at
3/0 2 a uni-layer, like the subcutaneous layer. Facial
0.150-0.199 soft tissue contains the septum, fascia, and
lubricating layer. Lifting is more effective when
4/0 1.5
0.100-0.149 these components are less interrupted
(Fig. 12.2). More lifting can be performed using
5/0 1
0.070-0.099 the uni-layer insertion as compared to multi-
layer insertions.
6/0 0.7
0.050-0.069

7/0 0.5
0.040-0.049 12.2.2 Multilayer Insertion
8/0 0.4
0.030-0.039
Inserting thread into a unilateral layer such as the
9/0 0.3 subcutaneous fat layer or SMAS layer can be
0.030-0.039
challenging (Fig. 12.3). When a multilayer inser-
10/0 0.2
0.020-0.029
tion is performed, the effective lubricating layer
mobility can be interrupted. Also, multiple septa
Fig. 12.1  Thread thicknesses based on the United States can interrupt the mobility and cause soft tissue
pharmacopeia system accumulation (Fig.  12.4). Doctors are typically
experienced in dealing with zygoma area protru-
12.2 Different Layer, Different sions, also called the “bumping effect.” Patients
Results with breast or hip augmentations are good candi-
dates for bumping effect.
The facial layer is a crucial factor to be consid- Therefore, multilayer insertions result in facial
ered for thread lifting. Appropriate lifting must lifting and volume augmentation. The difference
be evaluated early and satisfy the patient, fol- caused by the choice of insertion layers can pro-
lowed by evaluations for longevity. The thread vide drastically better results and prevent
lifting effects can be classified by the traction complications.
12  The Techniques and Considerations for Thread Lifting 147

Fig. 12.2  The layers of

the face. Uni-layer
lifting results in more
significant lifting effects

12.3 Crisscross Technique

and Mattress Pattern
Technique

Multiple-vector lifting using numerous traction

Fig. 12.3  A cadaveric subcutaneous fat layer of the face
forces can give better results [2]. Using a limited
number of threads for multiple vectors can result
in better lifting results. The mattress pattern tech-
nique involves inserting a cogged thread to the
desired vector and the perpendicular insertion of
plain thread for fixation. This technique can pro-
vide greater physical traction forces and chemi-
cal elastic effects. This technique is used for the
lower face, eyebrow lift, and improvement of the
forehead contours (Fig.  12.8d). Increasing the
number of threads can induce stronger physical
traction. However, when using the same number
of threads, the crisscross technique is better, con-
sidering the anatomical soft tissue and retaining
ligaments (Fig. 12.5).

Fig. 12.4  Cadaveric thread lifting. A thread has been

inserted to the subcutaneous layer, SMAS, and sub-SMAS
layer
148 W. Lee and C. W. Yun

Fig. 12.5  Crisscross techniques. (a) Design. (b) Retaining ligaments

12  The Techniques and Considerations for Thread Lifting 149

a b c

d e

Fig. 12.6  The vertical lifting technique. (a) The vertical lifting vector estimation. (b) Thread insertion after the cannula
insertion. (c) Another vector for the thread. (d) Soft tissue lifting. (e) Massage after cutting

12.4 Vertical Lifting 12.4.1 Surgical Technique (Fig. 12.6)

The basic vector for lifting opposes gravity.
This vector lifting cannot be applied to all
faces due to factors like scars, depression, and
possible damages of the nerves and vessels.
Thus, the recommended direction for lifting
vectors is usually oblique, toward the upper
lateral. Vertical lifting can be performed at the
periocular area using short-length cogged
threads [3]. Similar techniques are described as
follows:
Thread lifting can result in zygoma protrusions and
unnatural expressions when done in the upper lat-
eral direction. Vertical lifting directly opposes the
force of gravity using a small number of threads.
12.5 Reverse Insertion
Thread lifting is usually recommended at the
upper area, like the temple area for anchoring a
fixed point and the lower face lifting, which is a
150 W. Lee and C. W. Yun

Fig. 12.7  Multidirectional cogged thread

Fig. 12.8 Reverse a b
technique. (a) Thread
insertion for the reverse
technique for eyebrow
lifting. (b) Four threads
are used for one side.
(c) Four thread reverse
insertions to improve
the nasolabial fold and
anterior malar
augmentation. (d) Plain
threads are used for the
mattress-type fixation

c d

movable area. The reverse insertion technique is
to insert thread from the lower to the upper area
of the face. It is a relatively easy procedure but
soft tissue dimples might occur. Preoperative and
postoperative treatments, such as deep insertions
at the entry point or postoperative massages, are
essential to prevent dimples. Short cogged
­ idirectional or multidirectional threads are usu-
b
ally recommended (Fig. 12.7).
First, four to five multidirectional thread inser-
tions are performed and plain threads are used for
the mattress pattern (Fig. 12.8).
12  The Techniques and Considerations for Thread Lifting 151

Fig. 12.9  The frontal branch of the superficial temporal artery pathway can be detected by Doppler ultrasound. Thread
lifting should be performed detecting the superficial temporal artery

Second is locating the depth of the inserted

cannula. Usually, thread lifting is performed with
the doctor’s left-hand estimation. Ultrasound can
detect specific layers of insertion (Fig.  12.10).
The Doppler ultrasound can detect the cannula as
a white line, and the thread can be inserted to the
specific layer desired.

12.7 Volumizing Thread

PDO threads are known to provide mechanical

Fig. 12.10  The ultrasound can detect the cannula as a traction and chemical effect supporting neocol-
white line in subcutaneous layer. When ultrasound probe
is detecting along cannula, the technique is called “in-­ lagenesis [5]. Various threads are designed to
plane technique” stimulate neocollagenesis and fibroblast activa-
tion, resulting in tissue growth and volumizing at
multiple places such as the nose, tear trough, and
nasolabial folds.
12.6 Ultrasound-Assisted Thread Multiple types of volumizing threads are used,
Lifting like the meshed type and spring type. Multiple
threads can be used to achieve volume, followed
The thread lifting technique is also a procedure by soft tissue infiltration into the threads to main-
wherein the inside of the face cannot be visual- tain the volume. Hyaluronic filler is very simple
ized. To overcome this, ultrasound can be used, procedure and easy to augment but can have dras-
mainly for two purposes. First is the detection of tic complications like skin necrosis or ocular
the superficial temporal artery pathway, located complications. Volumizing threads provide safer
at the temple area [4]. When using the fixed-type augmentation (Fig.  12.11). Filler injections are
(anchoring-type) thread lifting, Doppler ultra- superior for augmenting the shape, and numerous
sound is an extremely useful device (Fig. 12.9). studies have investigated the concurrent use of
152 W. Lee and C. W. Yun

Fig. 12.11 Volumizing
threads

12.8 Combination Treatment

Using High-Intensity
Focused Ultrasound
(HIFU) Device

Numerous studies have been performed using

Fig. 12.12  Nasojugal groove correction using volumiz-
ing threads
filler and thread. Three or five volumizing threads
are inserted at once to achieve good results
(Fig. 12.12) [6].
threads and HIFU concomitantly. Both the tech-
niques are used for their antiaging effects.
Threads are used for physical traction and chemi-
cal neocollagenesis, while HIFU is used for the
thermal stimulation of neocollagenesis and con-
tractures (Fig. 12.13) [7].
HIFU can induce an inflammatory reaction
after thread lifting, thereby reducing the traction
effect and increasing neocollagenesis. The vari-
ous advantages and disadvantages of adjuvant
therapy must be kept in mind while choosing the
treatment regimen. To maximize the traction
force, thread lifting is recommended 3  weeks
after HIFU use.
12  The Techniques and Considerations for Thread Lifting
Fig. 12.13  Micro-focused ultrasound technology gener-
ates thermal coagulation in the musculocutaneous layer
for skin tightening or destroys fat cells in the subcutane-
12.9 Thread Material Storage
The low deformity of PDO at room temperature
is well-established. When PDO threads are used
for suture material, traction force should be
maintained as much as possible.
To maintain the traction force, refrigeration of
the thread is recommended to prevent deforma-
tion by the central tunneling effect. Thread stabil-
ity is affected by storage method and storage
time. Deformed threads can cause complications
like thread protrusions.
Threads exposed to air should not be used.
Additionally, saline-exposed or alcohol-exposed
threads are also not suitable for use. PDO threads
become fragile upon exposure to air and heat,
which decreases their tensile strength. Excessive
exposure to blood also decreases the thread’s ten-
sile strength.
Using the thread at the earliest after opening
the package is recommended, after checking the
tensile strength before insertions.
153
ous layer for face contouring. Ultrasound energy at 7 MHz
reaches a shallower depth than at 4  MHz, and thus, a
higher intensity is needed to reach the same depth
12.10 The Present and Future
of Thread Lifting
Numerous kinds of threads are manufactured.
Threads are typically made of PDO with various
cogged designs and modifications [8]. Poly-l-­
lactic acid (PLLA) threads are also used [9].
Nonabsorbable threads such as PP are also fre-
quently used. The literature focuses on the tech-
niques [10–12] and associated complications [13,
14]. However, compared to botulinum toxin and
fillers, the literature on thread lifting is limited. In
the future, comparisons of the tensile strength of
face soft tissues and thread products will be
reported, in addition to the novel components of
manufactured threads.
Future products will ideally be designed con-
sidering the patient’s immunological reactions,
prolonged longevity, reduced patient discomfort,
and easier removal.
Many threads are approved as suture materi-
als, but a limited number are approved for thread
154
lifting purposes. Therefore, these can be improved
to develop novel techniques and more varieties of
cogged designs. Inefficient products with short-­
lived results need to be optimized for better
results.
References
1. http://ftp.uspbpep.com/v29240/usp29nf24s0_c861.
2. Song JK, Chang J, Cho KW, Choi CY.  Favorable
crisscrossing pattern with polydioxanone: barbed
thread lifting in constructing fibrous architecture.
Aesthet Surg J. 2021;41(7):NP875–86. https://doi.
org/10.1093/asj/sjab153.
3. Kang SH, Byun EJ, Kim HS. Vertical lifting: a new
optimal thread lifting technique for Asians. Dermatol
Surg. 2017;43(10):1263–70.
4. Lee W, Moon HJ, Kim JS, Chan BL, Yang EJ. Doppler
ultrasound-guided thread lifting. J Cosmet Dermatol.
2020;19(8):1921–7.
5. Yoon JH, Kim SS, Oh SM, Kim BC, Jung W. Tissue
changes over time after polydioxanone thread inser-
tion: an animal study with pigs. J Cosmet Dermatol.
2019;18(3):885–91.
6. Lee W, Oh W, Kim HM, Chan BL, Yang EJ.  Novel
technique for infraorbital groove correction using
multiple twisted polydioxanone thread. J Cosmet
Dermatol. 2020;19(8):1928–35.
W. Lee and C. W. Yun
7. Fabi SG.  Noninvasive skin tightening: focus on
new ultrasound techniques. Clin Cosmet Investig
Dermatol. 2015;8:47–52.
8. Moon HJ, Chang D, Lee W. Short-term treatment out-
comes of facial rejuvenation using the mint lift fine.
Plast Reconstr Surg Glob Open. 2020;8(4):e2775.
9. Rezaee Khiabanloo S, Jebreili R, Aalipour E,
Saljoughi N, Shahidi A.  Outcomes in thread lift for
face and neck: a study performed with Silhouette
soft and promo happy lift double needle, innova-
tive and classic techniques. J Cosmet Dermatol.
2019;18(1):84–93.
10. Kim J, Kim HS, Seo JM, Nam KA, Chung
KY. Evaluation of a novel thread-lift for the improve-
ment of nasolabial folds and cheek laxity. J Eur Acad
Dermatol Venereol. 2017;31(3):e136–79.
11. Suh DH, Jang HW, Lee SJ, Lee WS, Ryu HJ. Outcomes
of polydioxanone knotless thread lifting for facial
rejuvenation. Dermatol Surg. 2015;41(6):720–5.
12. Lee H, Yoon K, Lee M. Outcome of facial rejuvena-
tion with polydioxanone thread for Asians. J Cosmet
Laser Ther. 2018;20(3):189–92.
13. Tong LX, Rieder EA.  Thread-lifts: a double-edged
suture? A comprehensive review of the literature.
Dermatol Surg. 2019;45(7):931–40.
14. Sarigul Guduk S, Karaca N.  Safety and complica-
tions of absorbable threads made of poly-l-lactic
acid and poly lactide/glycolide: experience with
148 consecutive patients. J Cosmet Dermatol.
2018;17(6):1189–93.
 Minimally Invasive Rhinoplasty:
Augmentation Rhinoplasty
with Cogged Threads
Hyun Jin Yang and Won Lee
Rhinoplasties are very frequently performed pro-
cedures on patients of Asian origin due to their
relatively low dorsum of the nose. Filler and
thread can also be used for augmentation of the
nose. In this chapter, we will discuss the applica-
tion of short, cogged threads for nose augmenta-
tion using numerous techniques.
13.1 Introduction
Patients of Asian descent commonly have a rela-
tively low dorsum, low nasal tip, short nose,
wide alar, and short columella. The nasal tip skin
is relatively thick and has dense fibroadipose tis-
sue. The cartilage in the alar is small and fragile,
making the results of invasive rhinoplasties
unsatisfactory and with complications like
implant deviations or protrusions. Autologous
rib cartilage can also be used as an alternative,
but insufficient skin results in unsatisfactory
results. Therefore, the elongation of skin elastic-
ity and hard structures should be performed. In
this chapter we discuss the applications of PP
and PDO threads in embedded structures
H. J. Yang
BaroYL Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_13
13
between the nasal soft tissue. Cogged threads are
used for immediate and efficient fixation. PP and
PDO threads are superior for exerting restoration
forces as compared to nylon or polycaprolac-
tone. The author used thread in conjunction with
a micro fat transfer, first reported in 2003.
Multiple applications were available for this
procedure.
The author uses PP and PDO threads because
of their high elasticity and restoration forces. Both
threads can be used individually or together. The
use of two to three USP threads together is highly
effective. A 19 G needle (outer diameter, 1.10 mm;
inner diameter, 0.9 mm) is typically suitable for
these threads. A thread labelled USP 0 can be
inserted into a 21 G (OD, 0.8 mm; ID, 0.6 mm)
needle. In contrast, thermal molded cogged
threads are typically already solidified, such that
even USP 0 thread requires 12 G needles.
The thread strength is dependent on the thread
thickness, cog angle, and cog length. The author
usually uses threads that are ~0.4–0.7 mm thick.
The thread end is bifurcated at a ~ 2–4 mm dis-
tance, with cogs located in the opposite direction.
The thread axis is typically anti-compressive and
155
156 H. J. Yang and W. Lee

Fig. 13.1  The mechanism of anti-compressive barbs within tissues

a b

Fig. 13.2  The types of anti-compressive barbed threads. (a) Three threads pushing each other between the nasal tip and
maxilla. (b) Multiple types of push-type barbed threads

not anti-tension (Fig. 13.1). The bifurcated thread
end is key to attain the anti-compression effect
(Fig. 13.2).
The advantages for cogged thread rhino-
plasties as compared to conventional rhino-
plasties are described below
1. Major prominence of the tip is attained using
a minimally invasive technique.
2. The ideal ratio of columella and infra-tip lob-
ule (2:1) can be achieved using thread lifting
(Fig. 13.3).
3. Soft tissue changes develop after tip plasties
and cause irregularities of the lobule and ala.
Cogged threads can be inserted in the alar
extension direction.
4. The nasal tip area elasticity can be main-
tained when compared to conventional
rhinoplasties.
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads
a b
Fig. 13.3  Base changes using cogged threads. Photographs were taken: (a) preoperatively. (b) Immediately postopera-
tively. (c) 2 months postoperatively
13.2 Patient Selection
and Informed Consent
The appropriate indications should be performed.
The best candidates are those with (1) no prior
history of surgeries, (2) sufficient soft tissue and
skin mobility, and (3) a loose tip area, which can
be stretched enough by pinching.
Preoperative evaluations and informed con-
sent are essential. The end of the thread can be
protruded when the thread resistance is higher
than the nose tip resistance. However, the thread
extrusion is relatively easy for treatment. When
using lesser amounts of thread or absorbable
thread, the effectiveness is reduced. Additional
procedures like fat grafts or filler injections might
be needed for volume restoration. The patient
should be warned for pricking pains and tooth-
aches, and immediate clinic visits should be rec-
ommended if thread protrusions occur.
Preoperative photographs must be taken at the
frontal view, bilateral view, three-quarter view,
and worm’s-eye view.
157
c
13.3 Materials
Disposable needles with cogged PDO and PP
thread at the tips are used (Fig.  13.4a). The
injector is used for pushing the thread after
injecting into the nose (Fig.  13.4b). All-in-one
disposable needles and injectors can also be
used (Fig. 13.4c).
The tip end should be in the opposite direction
of decussation when attached to the periosteum,
to provide adequate supportive strength. The
author prefers threads with cogs heading upward
except the lowest portion of the thread
(Fig.  13.2b). When the periosteum is unstable,
the lower 1/3 of the thread can be heading in the
direction of the periosteum (Fig. 13.2b). The sec-
ond characteristic of the thread is relatively long
cogs. The thread design is such that the cogs are
made by back cutting the thread. When the cogs
are long, more supportive tissue can be trapped
(Fig. 13.5).
158 H. J. Yang and W. Lee

b c

Fig. 13.4  The materials required for the operation. (a) The thread inserted at the disposable needle. (b) The injector.
(c) Disposable all-in-one needle and injector

Fig. 13.5 The a Manually cut b Machine cut

characteristics of cogged
threads. (a) Manually
cut (author use). (b)
Machine cut Patented back cut Ordinary simple cut

Longer barb length Shorter barb length

Higher tissue holding volume Less tissue holding volume

13.4 Method grafts or filler injections concomitantly

(Fig. 13.6).
13.4.1 Design

Mark the entry point at upright position. 13.4.2 Draping

The entry point can be made ~1–4 points at the
tip and ~1–2 points at the alar area. The dor- When the patient is in the supine position, ben-
sum area must be drawn when performing fat zalkonium chloride can be applied for aseptic
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 159

a b

Fig. 13.6  The design. (a) The pre-op design. (b) Post-op results

conditions. Betadine or benzalkonium can be lower end upper end

applied to the inner nostrils.

26mm
13.4.3 Anesthesia
28mm
Epinephrine (1:100,000) with lidocaine is
used at the ala, columella, anterior spine, max-
30mm
illa, and nose dorsum area. Approximately
4–7  cc is used. The epinephrine is used for
32mm
vasoconstriction.

34mm
13.4.4 Thread Size Selection
Fig. 13.7  The length of the threads
and Injector Assembly

The thread is made of PP and PDO. PDO is used author usually uses threads that are 30 and 32 mm
for (1) increased length, (2) increased thickness long (Fig. 13.7).
(USP 2) resulting in immediate effects, and (3)
increased number of threads. PP is used for (1)
shorter lengths, (2) thinner threads (USP 0), and 13.4.5 The Locations of Thread
(3) a smaller number of threads. PP is used for and Direction of the Cogs
the elongation of the nasal tip, for which four to
six threads are inserted. The thread type and The insertion directions are as follows (Fig. 13.8)
length (usually around 26–34  mm) must be
decided based on the intended application. The 1. Tip projection direction.
160 H. J. Yang and W. Lee

a b

Fig. 13.8  The insertion direction. (a) Green arrows indicate the tip projection direction, blue arrows indicate the nose
length elongation, and yellow arrows indicate the alar extension direction. (b) The postoperative view

a b

Fig. 13.9  The insertion direction. (a) Supratip depression. (b) Postoperative results

2. Nose length elongation.

3. Alar extension direction. 13.4.7 Skin Stretching and Skin
4. Augmentation of the columella base. Advancing Over the Thread
5. Supratip depression (Fig. 13.9). End Indicator Band

The thread can be inserted multi-directionally
for preoperative evaluations (Fig. 13.10).
13.4.6 Searching the Dense Tissues
(Periosteum, Perichondrium,
Cartilage, and Scar)
and Thread Tucking
The cannula is inserted and approached until the
periosteum area by pinching with the left hand.
The fourth finger is used to feel the end of the
cannula (Fig. 13.11).
When the cannula reaches the periosteum, the
nasal tip must be pulled using the pinching hand.
The left hand is usually recommended to feel the
cannula end (Fig. 13.12).
13.4.8 Thread Implantation
The plunger is approached to the thread end
and the injector pulled posteriorly for thread
implantation. When the thread is implanted at
approximately 12 mm, the plunger is released.
The tip should be pulled using the left hand,
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 161

13.4.9 Multiple Implantation

Multiple threads are inserted for increased sup-

port. The insertions of threads while considering
vectors are recommended. The author uses two to
eight threads for tip projections, two to six threads
for nose length elongations, and two to three
threads for alar extensions. When a tip projection
is performed, 8–12 threads can be inserted for
nose lengthening. The recommendations suggest
that the thick PDO be inserted first, followed by
PP. A distance of 5–6 mm from the skin to thread
end is recommended (Fig. 13.14).
The use of additional soft tissue is recom-
mended due to the additional support of the
threads. The author used squeezed fat grafts and
mechanically micronized fat tissue [1].

13.4.10 Alar Extension

An increase in the nostril size and alar retraction

can occur after tip projections. The alar extension
can be performed by pulling alar tissue and by
cogged thread insertion (Fig. 13.15).
Alar asymmetry can also be corrected using
alar extension technique (Fig. 13.16).

13.4.11 Adjunctive Procedures
Fig. 13.10  Preoperative evaluations using the pinching
technique
13.4.11.1 Fat Grafts (Fig. 13.17)
Fat grafts performed after tip projection using
threads can supplement the results. The nose dor-
sum soft tissue is relatively thin, making a multi-
layer graft challenging. The author prefers using
crushed fat injections at the superficial layer so
that multilayer grafts are easier to perform. These
grafts can be performed at the tip and columella
area after thread insertions (Fig. 13.18).

13.4.11.2 Hyaluronic Acid Filler

Fig. 13.11  Thread implantation techniques for dorsal Hyaluronic acid (HA) filler can be injected con-
lengthening currently with thread insertions for augmentation
(Fig.  13.19). It is a relatively easier procedure
while the injector is pulled posteriorly than fat grafts. Typically, 0.5–1 mL of HA filler is
(Fig. 13.13). used.
162 H. J. Yang and W. Lee

Fig. 13.12 Thread
implantation techniques
for tip projection

5~10mm

Right Periosteum Left

oblique oblique

Central

3 different location of foot plates

2. Thread is implanted while cylinder is

draw-back with plunger and thumb
level are fixed

3. 2nd, 3rd fingers and

wrist are all raised

12mm

1. Strong tip raising with 4. Tip is still raised strongly

holding columella

Fig. 13.13  The skills required to operate the injector

13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 163

Fig. 13.14  A tip plasty using cogged threads. (a) Preoperative images. (b) Immediate after the procedure. (c) At
1 month post-procedure. (d) At 1 year post-procedure
164 H. J. Yang and W. Lee

Fig. 13.15  Alar extension

a b c

Fig. 13.16  Alar asymmetry correction. (a) Preoperative. (b) At 2 days post-operation. (c) At 10 weeks post-op

Fig. 13.17  Cogged thread tip projection and alar extension with fat graft. (a) Preoperative; retracted alar. (b)
Postoperative 6 weeks. (c) Postoperative 6 months
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 165

Fig. 13.17 (continued)

a b c

Fig. 13.18  Cogged thread tip projections and fat grafts. (a) Preoperative image, which also shows excessive hyaluronic
acid filler use. (b) At 2 weeks post-operation. (c) At 8 months post-operation
166 H. J. Yang and W. Lee

a b c

Fig. 13.19  Cogged thread tip projection performed concurrently with HA filler injection. (a) Preoperative image. (b)
Immediately after the procedure. (c) At 4 months post-procedure

a b

Fig. 13.20  The ejection pressure. (a) 1 mL. (b) 10 mL

The author recommends using hard fillers at 13.4.11.3 Minimally Incisional

the nose. Embolisms can occur if the filler is
injected into the vessels. High-pressure injec-
tions can be dangerous. The ejection pressure
when using a 1 mL syringe can be 200 times of
the arterial pressure (Fig. 13.20). When an embo-
lism occurs, the filler prefers movement into an
adjacent normal vessel over the embolized vessel
(Fig. 13.21).
Undermining Procedure
When correcting a contracted nose, the removal
of implants, small nose correction, dense tip tis-
sue, minimal incisions for release helps cogged
thread results. A stab incision 5–8  mm long is
made, and weakening the scar tissue can
increase the effectiveness of a cogged thread
rhinoplasty.
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 167

Lymphoid System
Fillers
Micro canal

vein flow

Cells

lymphvessel
wall

artery flow Filler injected

Filler rectrograde flow into
lymphvessel

Fig. 13.21  The possible mechanism of embolisms

a b c

Fig. 13.22  Dressing. (a) Preoperative image. (b) Hydrocolloid applied post-procedure. (c) Taping

13.4.11.4 Dorsum Augmentation 13.4.13 Repeated Procedure

Dorsum augmentation using a fat graft or allo-
plastic implants can be performed using cogged
threads.
13.4.12 Dressing
Hydrocolloids can be applied at the entry point
post-procedure (Fig. 13.22b). When performing a
minimal incision technique or fat graft, taping
can be done (Fig. 13.22c).
Cogged thread procedures can be repeated. The
combination of fat grafts with repeated thread
procedures can improve the results. The skin typ-
ically becomes thinner and harder during the sec-
ond thread insertion, decreasing the extent of the
projection possible, which can be overcome
using adjuvant fat grafts (Fig. 13.23). Secondary
procedures are recommended 6 months after the
first procedure.
168 H. J. Yang and W. Lee

Fig. 13.23  A repeated procedure. (a) Preoperative image. (b) At 5  days post-procedure. (c) At 11  months post-­
procedure. (d) Immediately after the secondary procedure. (e) At 4 months after the secondary procedure
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads
Fig. 13.23 (continued)
13.4.14 Cogged Threads
for Secondary Rhinoplasties
Cogged threads can be used for secondary rhino-
plasties. Preoperative evaluations are needed
because of previous scar tissues, deformities, and
functional problems. In the absence of severe
scars, cogged threads can be effective. In the pres-
3. Alloplastic implant-associated infections
ence of scar tissue, minimally incisional dissec-
tions are helpful for cogged threads. Preoperative
conditions can be classified as follows:
1. Alloplastic implants at the dorsum and mini-
mal scarring at the tip. For this condition, a tip
plasty using cogged threads can be performed
as the first operation (Fig. 13.24).
2. An alloplastic implant removal and cogged
thread procedures can be performed concomi-
tantly. The implant can be removed through
169
an 8–10-mm-long incision intranasally and
minimal dissection can be performed. After
compressing for 3–5 mins for hemostasis, a
tip plasty is performed using cogged threads.
The wound is closed using 6-0 Nylon. An
additional fat graft can be performed after
closing the wound (Fig. 13.25).
are usually treated with implant removal,
antibiotics, and wound treatment. Then sec-
ondary operation is usually performed
3–12 months after the treatment. Nose skin
has sebaceous glands and hard skin, result-
ing in scarring. Revisional rhinoplasties are
difficult because of difficult dissections and
poor vascularity. Implant removal and con-
comitant fat grafts and tip plasties using
thread can reduce scars and deformities
(Fig. 13.26).
170 H. J. Yang and W. Lee

Fig. 13.24  Alloplastic implant at the dorsum. (a) Preoperative image. (b) At 4 months post-procedure. (c) At 6 years
and 4 months post-procedure
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 171

Fig. 13.25  Implant removal and fat graft with cogged thread insertion. (a) Preoperative image. (b) At 1 month post-­
procedure. (c) At 6 years post-procedure
172 H. J. Yang and W. Lee

Fig. 13.26 Revisional
a
rhinoplasties because of
dorsum swelling and
implant visibility at the
right nostril rim. (a)
Preoperative image. (b)
At 1 day post-operation.
(c) At 6 months
post-operation

c
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 173

Fig. 13.27  Patient undergoing implant removal. (a) Preoperative. (b) At 3 weeks post-procedure. (c) At 12 months
post-procedure
174 H. J. Yang and W. Lee

Fig. 13.28  Dissection. A scar tension band (red line) should be noticed and cutting (blue line) should performed
accordingly

4. Soft tissue scar contractures can occur, to (Fig.  13.30), for which minimal incisions and
varying degrees, at 4–6  months post-­ dissections are needed (Fig. 13.31).
procedure, usually performed with minimal
incision–dissection and thread insertions. Fat 6. Unsatisfactory results in the nose.
grafts are effective in the reduction of contrac-
tures (Fig. 13.27). There are multiple cases where the revisional
5. Implants like bone or rib cartilage, Medpor, or rhinoplasty might give unsatisfactory results.
Gore-Tex are typically used, using minimal Usually, the patient is informed, the operation is
incisions and dissections (Fig.  13.28). The delayed by 1  year, and autologous implants are
extent of dissection is dependent on the exten- used, in addition to minimal dissection. ADSVF
sion and vascularity due to the tip plasty. are used for treatment (Fig. 13.32).

Slow arterial refill and venous congestion are
indicators of ischemia. Accurate comparisons
should be made before local anesthesia, immedi-
ately after, and 20 min after. At 20 min after the
administration of local anesthesia injections, arte-
rial refill can be an indicator to judge the extent of
the dissection. When the capillary refill slows, dis-
sections should be minimal, followed by few min-
utes of waiting. Tip plasties using cogged threads
are performed at the localized area increasing the
extent of the ischemia, necessitating well-distrib-
uted pressure. Dissections should be performed
lower than the dermal layer. Dissections using
sharp Metzenbaum scissors are preferred
(Fig. 13.28). Fat grafts or adipose derived stromal
vascular fractions (ADSVF) could be done to
reduce the risk of necrosis (Fig. 13.29).
When the implant extends to the tip area, a
partial removal needs to be performed
1. Liposuction and centrifugation are done to
extract the ADSVF by enzyme treatment.
2. The ADSVF is injected for improved vascu-
larity. This treatment is recommended three to
eight times for 3–8 months.
3. The contracture is minimally dissected. If vas-
cular insufficiency is encountered, ADSVF is
injected.
4. ADSVF injections are recommended two to
three times post-operation.
Tip plasties have advanced, especially for the
patient of Asian descent, who typically has weak
tip cartilages. Procedures can be performed
using alloplastic implants, which can cause com-
plications. To avoid this, the author prefers to
perform ADSVF injections and tip plasties using
cogged threads instead of revisional incisional
rhinoplasties.
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 175

Fig. 13.29  Gore-Tex implant removal and fat graft with a tip plasty using cogged threads. (a) Preoperative image. (b)
Immediately post-procedure. (c) At 16 months post-procedure
176 H. J. Yang and W. Lee

Fig. 13.30  A partial removal of the implant with cogged thread insertions
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 177

Fig. 13.31  A partial removal of the implant and fat graft with thread insertion. (a) An L-shaped silicone implant. (b)
At 5 days post-op. (c) At 6 months post-op
178 H. J. Yang and W. Lee

Fig. 13.32  Secondary rhinoplasty. (a) Contracted nose. Minimally incisional dissections with fat grafts. (f) At
(b) ADSVF injection. (c) At 19-days post-ADSVF injec- 5 days post-op. (g) At 7 months post-op. (h) At 32 months
tions. (d) At 10  months post-ADSVF injections. (e) post-op
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 179

Fig. 13.32 (continued)

13.5 Education and Follow-Up
Periods
The patient needs follow-ups at postoperative
day 1 and day 5, followed by self-stretching mas-
sages. If the threads are visible, the patient must
visit the clinic. Postoperative photographs must
be taken on postoperative day 1 and 5; week 2;
months 1, 2, 4, and 6; and 1 year to monitor and
document the progress.
180 H. J. Yang and W. Lee

13.6 Self-Stretching Massages pressure and reduce the chance of thread expo-
sure (Fig. 13.33).
The skin should be manually stretched for skin
elongation, followed by a 1-min hold. This should
be done one to two times a day to redistribute the 13.7 Methods for Photometric
Evaluation

Regular photometric evaluations are recom-

mended [2].

13.7.1 The TC/TP Ratio Measurement

The posterior tragus (tp: tragion posterior border)

and cornea (ca: cornea anterior border) is not
altered after a rhinoplasty. The TP, which is the
length from the posterior tragus to pronasale,
increases after the tip plasty. TN, the length
between the tragus and nasion, increases due to
the dorsum augmentation. The TC/TP ratio
should be calculated because they can vary
depending on the photographer. Photoshop can
be successfully used to draw the TC and TP and
calculate the ratio (Fig. 13.34).
Fig. 13.33  The recommended self-massages for patients

a b c

Fig. 13.34  True lateral photos for the TC/TP ratio measurement. (a) 2’ inward rotated. (b) optimal. (c) 2’ outward rotated
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 181

Fig. 13.35  Barbed thread tip implantation in a 29-year-old woman. The TC/TP increased by 5% of the original ratio

Fig. 13.36  Tip implantation using barbed threads and an autologous micronized fat graft in a 54-year-old woman. The
TC/TP increased by 3.6% of the original ratio

If the head is axially rotated 10° inwardly or (a) At 2° inward axially rotated, TC/TP ratio
outwardly, the errors would be less than 2%. would increase 2%, which was not optimal.
The stars indicate the key structures to decide
(b) A neutral true lateral view, which was
the axial head rotation: the external auditory optimal.
canal, eyebrows, eyelashes, and the Cupid’s (c) At a 2° outward axial rotation, the TC/TP ratio
bow. would decrease 2%, which is not optimal.
182 H. J. Yang and W. Lee

Fig. 13.37  A barbed thread tip implantation and autologous micronized fat graft in a 43-year-old woman. The TC/TP
increased by 1.9% of the original ratio

a b c

Fig. 13.38  Thread extrusion. (a) At 5 weeks post-op. (b) At 1 day pot-removal. (c) At 10 months post-removal

The preoperative, immediately post-­procedure, Postoperative bleeding is minimal and

and follow-up photographs are evaluated using
the TC/TP ratio (Figs. 13.35, 13.36 and 13.37).
13.8 Complications
The possible complications are bleeding, thread
extrusions, infections, foreign body reactions,
granulomas, hematomas, bruising, and sensory
neuropathy.
1. Bleeding
transient. Compression can be used for reso-
lution, followed by thread insertions.
2. Pain
The patient might experience toothaches,
which might subside after a few days.
3. Infection
A localized infection could occur, which
could be resolved by the removal of the thread.
4. Thread Extrusion
Thread extrusion at the skin or mucosa is
possible, resolved by complete or partial
cutting (Fig.  13.38). A patient with preop-
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 183

a b c d

Fig. 13.39  Thread extrusion. (a) Preoperative. (b) Immediately post-procedure. (c) PDO thread extrusion at 7 weeks
post-op. (d) PP thread extrusion at 9 months post-op

a b c

Fig. 13.40  Thread extrusion-induced depressive scars. (a) The scars. (b) At 5 days post-op. (c) At 1 year post-op

erative ­ columella asymmetry tends to
develop extrusions at the mucosa. It is eas-
ier to remove the mucosa because of the cog
direction.
PDO threads might protrude for 2  months,
after which it is absorbed. PP threads are
shorter, and hence do not extrude during the
initial period. When the skin is thinner, protru-
sions can occur (Fig.  13.39). If thread extru-
sions occur, a 21  G needle is used to make a
hole, followed by removal using forceps.
Prolonged extrusions might develop infections
or depressed scars. Postoperative depression
scars can be cured by micro fat transfers
(Fig. 13.40).
184
13.9 Conclusion
Immediate postoperative tip augmentations peak
at 10 mm and subsequently reduce. Filler injec-
tions or fat grafts can concomitantly be per-
formed for dorsal augmentation. The rates of
complications depend on the patient’s condition
and doctor’s expertise. Irreversible or severe
complications are rare.
13.10 Discussion
Tip plasties are challenging procedures. Severe
complications like contractures can occur
because the tip area consists of weak structures.
The author has used fat grafts at the dorsum area
since 1997. PP and PDO threads were used for
the tip area since 2003. Thread insertion is an
easy procedure and easy to perform along the
desired vector, as alar extensions or corrections
of the nostril show. In USP2 PDO, although
absorbable 3–4  months post-procedure, tissue
scarring occurs. The scarring was observed in
histology as well (Fig. 13.41).
Early relapse can occur when using only
PDO threads. The thread is not adequate vol-
ume-wise to support the pressure. The pressure
due to wound contracture can reduce the cog
Fig. 13.41  The histology of a tissue biopsy sample taken
4  months after using polydioxanone (PDO) threads. (a)
Hematoxylin–eosin stain for infiltrated cells, seen as
H. J. Yang and W. Lee
structure. The wound healing process can there-
fore be supported using an additional fat graft.
The use of squeezed fat was recommended [3],
which contains mesenchymal stromal cells.
Alternatively, fat grafts containing ADSVF can
be used [4].
Cogged threads are effective and have short
recovery times. Even when thread extrusions
develop, the treatment is relatively easy.
Immediate stretching and fixation techniques for
cogged thread insertions are recommended. Cogs
are made by sharp cutting. During the insertion it
is small-diameter threads that should be used. For
example, a 19  G needle can be used for USP2
thread.
The lateral view should be recorded and eval-
uated for the TC/TP ratio. When the axial rota-
tion exceeds 5′, it is noticeable in photographs.
Therefore, the lateral view photograph should be
taken multiple times. As described previously,
calculating the TC/TP ratio is more important
than the TC length. This parameter can be useful
for the evaluation of postoperative results.
The author uses cogged threads with bifurca-
tion thread ends, which act as an internal splint. It
is effective when used in conjunction with fat
grafts or filler injections. Cogged threads, useful
for minimally invasive tip plasties, stand the tests
of long-term evaluations.
small dots with navy color. (b) Masson trichrome stain for
collagen shows a cobblestone matrix with blue color
13  Minimally Invasive Rhinoplasty: Augmentation Rhinoplasty with Cogged Threads 185

References matrix (ECM) powders for injectable cell delivery

and adipose tissue engineering. J Control Release.
2009;139(1):2–7.
1. Yang H, Lee H. Successful use of squeezed-fat grafts
4. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda
to correct a breast affected by Poland syndrome.
K, Harii K, Yoshimura K. Influences of centrifugation
Aesthet Plast Surg. 2011;35(3):418–25.
on cells and tissues in liposuction aspirates: optimized
2. Lee HY, Yang HJ.  Rhinoplasty with barbed threads.
centrifugation for lipotransfer and cell isolation. Plast
Plast Reconstr Surg Glob Open. 2018;6(11):e1967.
Reconstr Surg. 2008;121(3):1033–41.
3. Choi JS, Yang HJ, Kim BS, Kim JD, Kim JY, Yoo
B, Park K, Lee HY, Cho YW.  Human extracellular
 Submental Contouring Using
Elastic Threads 14
Jin Young Kim, Jeongmok Cho, and Won Lee

14.1 Introduction

Cervical contour is an important factor for facial

contour. Cervical contours such as double chins
do not conform to good aesthetic lines and can
seem unattractive.
A previous article by Ellenbogen et  al.
made recommendations to sustain the appear-
ance of a youthful neck [1], such as a distinct
inferior mandibular border, sub-hyoid depres-
sion, visible thyroid cartilage, visible anterior
border of sternocleidomastoid muscle (SCM),
and a cervicomental angle between 105° and
120° (Fig. 14.1).
The cervicomental angle is affected by double
chins. In this chapter we will discuss the causes
of double chin and minimally invasive proce-
dures that can improve the neck contour.

J. Y. Kim Fig. 14.1  Criteria for a youthful neck: distinct inferior

OhKims Oh Plastic Surgery Clinic, mandibular border from the mentum to angle, sub-hyoid
Goyang-si, Gyeonggi-do, Republic of Korea depression, visible thyroid cartilage, visible anterior bor-
der of SCM, and a cervicomental angle between 105° and
J. Cho 120°
Incline Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 187
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_14
188
Table 14.1  The causes of double chin deformities
1 Submental fat
2 Platysma laxity
3 Skeletal malformation
4 Location of hyoid bone
14.2 Causes of a Double Chin
Double chins can be caused by multiple factors.
The first cause is excessive fat tissue located at
the submental area, wherein subcutaneous fat or
subplatysmal fat accumulation occurs. The sec-
ond cause is laxity of the platysma muscle, often
attributed to aging but also reported in young
patients. The third cause is skeletal underdevel-
opment. Microgenia causes decreased submental
deepening, resulting in a double chin. Fourth, the
hyoid bone is located beneath or anterior from
the normal levels [2–4]. The hyoid bone is usu-
ally located at the level of the fourth cervical
bone, horizontal from the menton line. When the
hyoid bone is located below, a double chin defor-
mity is apparent. It is impossible to operate upon
the hyoid bone for aesthetic results. Patients
should be informed of the same. The causes for
double chins are complex and require treatments
specific to the cause (Table 14.1).
14.3 Anatomical Considerations
of Submental Fat
The recent literature has made the nomenclature
confusing [5–8]. There are three layers in the
neck muscle. Starting from the superficial layer,
the layers are as follows: supraplatysmal fat,
subplatysmal fat, and very deep fat. The supra-
platysmal fat is located between the skin and pla-
tysma. It is located posterior to the submental
crease, anterior from the cervicomandibular
angle, and medial from the labiomental creases.
This surface anatomy can be compared with the
subcutaneous anatomy, and the supraplatysmal
fat is located posterior to the submental septum,
anterior from the suprahyoid septum, and medial
from the digastric septum. Larson et al. described
J. Y. Kim et al.
the supraplatysmal fat compartment as the supra-
hyoid sub-compartment and infrahyoid sub-­
compartment. The suprahyoid sub-compartment
is from the submental crease to the hyoid bone,
while the infrahyoid sub-compartment is from
the hyoid bone to thyroid cartilage. The second
layer is the subplatysmal fat compartment,
located between the platysma and submental
muscle (digastric muscle and mylohyoid mus-
cle). Rohrich et  al. made their classifications
according to the central, medial, and lateral com-
partments. The central compartment, located
between the bilateral digastric muscle, should
not be removed because of depressive deformi-
ties. Larson et  al. describes the lateral sub-­
compartment same as the medial and lateral
sub-­compartments as described by Rohrich et al.
This approach divides the lateral sub-compart-
ment into upper and lower based on the hyoid
bone. The deepest fat layer is located deeper
than the digastric and submandibular glands and
consists of small amounts, making it clinically
insignificant.
The neck fat compartment (Rohrich et al.)
1. Supraplatysmal compartment.
2. Subplatysmal compartment: central, bilateral
medial, and bilateral lateral sub-compartments.
The neck fat compartment (Larson et al.)
1. Supraplatysmal fat compartment: suprahyoid
and infrahyoid sub-compartment.
2. Subplatysmal fat compartment: central supra-
hyoid and central infrahyoid bilateral lateral
suprahyoid and bilateral lateral infrahyoid.
3. Very deep compartment.
While there are multiple sub-compartments,
fat-dissolving injections or liposuctions are usu-
ally performed at the supraplatysmal fat and sub-
platysmal central sub-compartment. The other
sub-compartments are not clinically significant.
Based on the quantity of fat, the supraplatysmal
compartment and subplatysmal central sub-­
compartment are important.
14  Submental Contouring Using Elastic Threads
14.4 Techniques for Double Chin
Deformity
There are multiple methods for the correction of
double chin deformities, such as lipo-dissolving
solution injections, liposuctions, and submental
fat excisions with neck lifting. Thread lifting and
corset platysma plasties are used to correct mus-
cle laxity. Fillers and fat injections, implant inser-
tions, and sliding genioplasties are used to correct
skeletal deformities. In this chapter, we discuss
the minimally invasive techniques.
The first step is the estimation of the quantity
of fat, done by pinching. Liporeductions usually
give good results when the quantity and thickness
of fat are high. The injection of deoxycholic acid
is another recently developed technique [9–11].
The Food and Drug Administration approved the
use of deoxycholic acid for fat reduction in 2015.
Deoxycholic acid destroys the adipose cell walls
without affecting the skin and muscle. Therefore,
it destroys adipose tissue rather than decreasing
volume and stimulates neocollagenesis by fibro-
blast activation.
Liposuction is the traditional technique for fat
reduction [12, 13]. It is more invasive, and the
results are also better, compared to those with
injections. Using a small entry point, liposuction
can be performed using the tumescent solution.
Usually, the supraplatysmal fat compartment is
targeted for liposuction. However, the technique
should be performed at the diffuse area for skin
contracture and smooth contour lines in addition
to the specific fat compartment. The technique
can be performed using one single entry point at
the submental crease, but bilateral entry points
are recommended to perform even liposuction.
Concomitant liposuction for the lower face can
be performed for mandible borderline and super-
ficial jowl fat reduction. Laser-assisted fat reduc-
tion is another option for lower face contouring.
Fig. 14.3 Schematic
depicting the elastic
thread needle end
189
Thread lifting for neck contouring supports
the platysma muscle [14, 15]. Absorbable threads
have gained popularity recently. As described
previously, the aim of thread lifting should be
supporting the muscles, for which elastic thread
is better, especially for double chin deformities
[16].
Elastic thread lifts are performed such that
silicone thread is surrounded by a polyester
thread, and the consequent elasticity results in
more natural facial expressions after insertion.
The needle is shaped such that the thread is
located at the center of the needle (Fig. 14.2). A
long length of the thread can be inserted without
protruding from the skin. The needle is bilater-
ally maneuvered such that the thread can locate
the subcutaneous layer, and the needle half end
can then be rotated to continue the thread inser-
tion inside the subcutaneous layer. Needle ends
have indicators to locate the same depth of the
needle (Fig.  14.3). Usually, the last indicating
mark can be used for confirmation that the needle
can be turned in the other direction.
Thread insertions performed at the neck area
should be done along the cervicomental angle. A
slit incision should be made at the posterior ear-
lobe and the needle inserted. Precaution should
be taken to avoid the lobular branch of the great
auricular nerve pathway (Fig. 14.4). The starting
point should be near the platysma-auricular liga-
Fig. 14.2 Schematic depicting the elastic thread
structure
190 J. Y. Kim et al.

Fig. 14.4  Intraoperative markings indicating the surgical

caution zone, which is the lobular branch location, repre-
sented by two vertical lines from the tragus and the anti-
tragus to the McKinney point [17]

Fig. 14.6  Lore’s fascia [19]

Fig. 14.5  The platysma-auricular ligament (PAL) [18]

ment (PAL) area (Fig. 14.5) and the needle extru-

sion at Lore’s fascia (Fig. 14.6). The needle end
should be inserted along the cervicomental angle
line and prolonged until the opposite side where
the Lore’s fascia is located. Two strings of thread
should support the platysma area (Fig. 14.7). An
alternate method involves just holding at the PAL
without Lore’s fascia (Fig.  14.8). This method
might be simpler, without complications such as
dimple formation at the pretragus area. When the
Fig. 14.7  The elastic thread lift strategy for the neck area
thread is finally pulled, it might migrate posteri-
[16]
14  Submental Contouring Using Elastic Threads 191

chin. The survival rate is a consideration when

using laser-assisted liposuctions.

14.5 Cases (Figs. 14.9, 14.10, 14.11,

14.12, 14.13, 14.14, 14.15,
14.16, 14.17, 14.18 and 14.19)

Case 1
See Fig. 14.10

Case 2
See Fig. 14.11

Case 3
See Fig. 14.12

Case 4
See Fig. 14.13

Case 5
See Fig. 14.14
Fig. 14.8  Alternate strategy for an elastic thread lift for
the neck Case 6
See Fig. 14.15
orly; therefore, a 3–5 mm anterior location at the
desired cervicomental line is needed during the
operation. The insertion layer is the deep
­subcutaneous layer because a superficial layer
can cause dimples, while a layer too deep to the
platysma can render the process ineffective.
When the elastic thread is used at the cheek area,
there are increased occurrences of dimple forma-
tion. However, when used at the neck area, dim-
ples subside after a few days.
Microgenia is also associated with double
chin deformities, which can be improved using
chin augmentations. Fat grafts or filler injections
are simple methods for chin augmentation. The
injection layers are the supraperiosteal layer and
subcutaneous layer. When liposuction of the dou- Fig. 14.9  Preoperative pattern of the thread insertion
strategy. The desired cervicomental line (dotted). Two
ble chin area is performed, fat graft at the chin
parallel lines depict the elastic thread insertion. After
area can also be performed concomitantly after inserting the threads, they are pulled and located at the
centrifuging to harvest the fat from the double desired cervicomental lines
192 J. Y. Kim et al.

a b

Fig. 14.10  A 43-year-old woman. (a) Pre-procedure image. (b) Image taken 3 months after liposuction and elastic
thread lifting

a b

Fig. 14.11  A 49-year-old woman. (a) Pre-procedure image. (b) Image taken 3 months after laser-assisted liposuction
and elastic thread lifting

a b

Fig. 14.12  A 53-year-old woman with double chin and jowl laxity. (a) Preoperation image. (b) Image taken 3 months
after laser-assisted liposuction and elastic thread lifting
14  Submental Contouring Using Elastic Threads 193

a b

Fig. 14.13  A 30-year-old woman with microgenia and double chin deformity. (a) Preoperation image. (b) Image at
3 months after liposuction, elastic thread lifting, and chin augmentation using a fat graft

a b

Fig. 14.14  A 29-year-old woman with a double chin and microgenia. (a) Preoperation image. (b) Image at 3 months
after liposuction, elastic thread lifting, and chin augmentation using fat graft

a b

Fig. 14.15  A 41-year-old woman with excessive fat at the neck. (a) Image at preoperation. (b) Image taken 3 months
after liposuction, elastic thread lifting, and fat graft on the chin
194 J. Y. Kim et al.

a b

Fig. 14.16  A 51-year-old female with excessive fat at the neck area and an obtuse cervicomental angle. (a) Image at
preoperation. (b) Image taken 6 months after liposuction and elastic thread lifting

a b

Fig. 14.17  A 22-year-old female with excessive fat at the neck. (a) Image at preoperation. (b) Image taken 1 week after
liposuction and elastic thread lifting
14  Submental Contouring Using Elastic Threads 195

a b c d

Fig. 14.18  A 26-year-old woman with microgenia and thread lifting. Additional images taken at (c) postopera-
excess fat at the neck area. (a) Image at preoperation. (b) tion day 1. (d) Postoperation week 1
Image taken immediately after liposuction and elastic

2. Marino H, Galeano EJ, Gandolfo EA. Plastic correc-

a b tion of double chin. Importance of the position of the
hyoid bone. Plast Reconstr Surg. 1963;31:45–50.
3. Guyuron B. Problem neck, hyoid bone, and submen-
tal myotomy. Plast Reconstr Surg. 1992;90:830–7.
4. Sykes JM.  Rejuvenation of the aging neck. Facial
Plast Surg. 2001;17:99–107.
5. Hatef DA, Koshy JC, Sandoval SE, Echo AP, Izaddoost
SA, Hollier LH.  The submental fat compartment of
the neck. Semin Plast Surg. 2009;23:288–91.
6. Pilsl U, Anderhuber F. The chin and adjacent fat com-
partments. Dermatol Surg. 2010;36:214–8.
7. Rohrich RJ, Pessa JE. The subplatysmal supramylo-
hyoid fat. Plast Reconstr Surg. 2010;126:589–95.
8. Larson JD, Tierney WS, Ozturk CN, Zins JE. Defining
the fat compartments in the neck: a cadaver study.
Fig. 14.19  Same patient as in Fig.  14.18. (a) Image at
Aesthet Surg J. 2014;34:499–506.
preoperation. (b) Image taken 15 months postoperation, in
9. Jones DH, Carruthers J, Joseph JH, et al. REFINE-1,
the lateral view. The patient underwent a chin augmenta-
a multicenter, randomized, double-blind, placebo-­
tion using filler
controlled, phase 3 trial with ATX-101, an injectable
drug for submental fat reduction. Dermatol Surg.
Case 7 2016;42:38–49.
10. Dayan SH, Schlessinger J, Beer K, et al. Efficacy and
See Fig. 14.16 safety of ATX-101 by treatment session: pooled anal-
ysis of data from the phase 3 REFINE trials. Aesthet
Case 8 Surg J. 2018;38:998–1010.
See Fig. 14.17 11. Shridharani SM, Chandawarkar AA.  Novel
expanded safe zone for reduction of submental full-
ness with ATX-101 injection. Plast Reconstr Surg.
Case 9 2019;144:995e–1001e.
See Figs. 14.18 and 14.19 12. Avelar J.  Fat-suction of the submental and subman-
dibular regions. Aesthetic Plast Surg. 1985;9:257.
13. Stebbins WG, Hanke CW.  Rejuvenation of the neck
with liposuction and ancillary techniques. Dermatol
References Ther. 2011;24:28–40.
14. Savoia A, Accardo C, Vannini F, Di Pasquale B,
1. Ellenbogen R, Karlin JV.  Visual criteria for success Baldi A. Outcomes in thread lift for facial rejuvena-
in restoring the youthful neck. Plast Reconstr Surg. tion: a study performed with happy lift™ revitalizing.
1980;66:826–37. Dermatol Ther. 2014;4(1):103–14.
196
15. Tiryaki KT, Aksungur E, Grotting JC.  Micro-shuttle
lifting of the neck: a percutaneous loop suspension
method using a novel double-ended needle. Aesthet
Surg J. 2016;36:629–38.
16. Kang MS, Kim SH, Nam SM, et  al. Evaluation of
elastic lift for neck rejuvenation. Arch Aesthet Plast
Surg. 2016;22(2):68–73.
17. Sharma VS, Stephens RE, Wright BW, Surek CC. What
is the lobular branch of the great auricular nerve?
J. Y. Kim et al.
Anatomical description and significance in rhytidec-
tomy. Plast Reconstr Surg. 2017;139(2):371e–8e.
18. Seo YS, Song JK, Oh TS, Kwon SI, Tansatit T, Lee
JH. Review of the nomenclature of the retaining liga-
ments of the cheek: frequently confused terminology.
Arch Plast Surg. 2017;44(4):266–75.
19. Rozen WM, Whitaker IS, Ashton MW. Lore’s fascia
and the platysma-auricular ligament are distinct struc-
tures. Br J Plast Surg. 2012;65(9):e241–5.
 Submental Liposuction
and Thread Lifting 15
Won Kyung Kang and Won Lee

15.1 Introduction
Neck shape varies across individuals. Neck laxity
is most commonly a by-product of aging but is
also observed in young patients. A sagging neck
ages an individual. In contrast, a tight neck makes
one look young. Submental liposuction is one of
the best minimally invasive procedures for neck
contouring.
15.2 Anatomical Considerations
Liposuction can be performed at multiple loca-
tions on the face. It is relatively simple and mini-
mally invasive and therefore a commonly
performed procedure in plastic surgery [1]. The
neck area is one of the places where liposuction
can be performed. The anatomical considerations
for the central submental unit are its location
below the inferior border of the mandible, lateral
from the anterior border of the sternocleidomas-
toid muscle, and anterior from the hyoid bone
(Fig. 15.1) [2].
Previous literature has established the
following criteria for aesthetic neck contour
[3, 4]
1. Distinct inferior mandibular border from the
mentum to angle.
2. Subhyoid depression.
3. Visible thyroid cartilage.
4. Visible anterior border of SCM.
5. Cervicomental angle between 105° and 120°
[2, 4].
Apart from these five requirements, two addi-
tional points related to the hyoid bone have to be
added: (1) when the hyoid bone is located higher
and (2) when the posterior cervicomental angle is
acute [3]. This makes the neck look more
attractive.

W. K. Kang
BORA Plastic Surgery Clinic,
Ansan-si, Kyonggi-do, Republic of Korea
e-mail: kangwk@paran.com
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 197
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_15
198 W. K. Kang and W. Lee

Submandibular triangle
Diagastric muscle,
anterior belly
Submental triangle

Carotid triangle Hyoid bone

Sternocleido-
mastoid

Lateral cervical region,

posterior cervical triangle Trapezius

Lesser supra-
clavicular fossa

Fig. 15.1  Central submental unit is located posterior from the mandible border and anterior from the hyoid bone

These criteria are effective for the operation

design and are guidelines for effective results
(Fig. 15.2).

15.3 Preoperative Evaluation

Preoperative evaluations should be performed

Fig. 15.2  Criteria for a youthful neck. 1. Distinct inferior
mandibular border from the mentum to angle. 2. Subhyoid
depression. 3. Visible thyroid cartilage. 4. Visible anterior
border of SCM. 5. Cervicomental angle between 105° and
120° [2]
carefully, assessing the patient’s anatomical fea-
tures and desired results. Patients with thin or
sagging skin are poor candidates for liposuction
[5, 6]. Previous literature reported that skin elas-
ticity heavily influences the surgical outcomes in
patients older than 40 years. Other studies have
reported that only liposuction without incisional
rhytidectomies would give unsatisfactory results
[5, 6]. In the presence of platysmal bands, platys-
maplasties give better results when compared to
liposuction or thread lifting [9, 10].
Huge submandibular glands are also consider-
ations for liposuctions, which can make the sub-
mandibular gland appear more prominent [7, 8].
15  Submental Liposuction and Thread Lifting
The author has also experienced this issue in
cases and recommends evaluating the subman-
dibular gland preoperatively.
When the adipose tissues are dense or hard,
the outcome is not predictable. Dense or hard
adipose tissue can occur due to large amounts of
fat tissue at the subplatysmal muscle and is hard
to remove by liposuction. Liposuction can also
induce bleeding or nerve damage [7].
The patients should also be warned about the
limitations of minimally invasive procedures as
compared to incisional operations.
15.4 Operative Techniques
Photographs of patients showing the preoperative
anatomical features and the operative strategy
design are taken at an upright position. Local
anesthesia can be used for liposuctions and thread
lifting. Preoperative informed consent of the
patients is essential and local infiltration can be
applied. The entry point area is injected with
lidocaine. The entry point is used for the injection
of tumescent solution (followed by a 20-min
wait) and can also be used for thread lifting. At
the lateral sides of the neck, a 3 mm incision is
made for the entry point using a number 11 or 15
knife. The tumescent solution is formulated using
saline, lidocaine, and epinephrine. The tumescent
Fig. 15.3  Preoperative frontal view and lateral view
199
solution can be injected using a 25G needle or
cannula.
Lipo-aspiration can be performed using 2 mm
cannulas. Irregularity must be considered during
the process. A bilateral entry point is
­recommended. An additional entry point can be
made at the center of the neck, which is useful as
a thread lifting tunnel.
Lipo-aspirated fat should be collected for
additional possible fat grafts at the chin area.
At least 20-mm-long cogged threads should
be used. When the center entry point is made
during liposuction, it should be used for thread
lifting. A relatively thick thread, such as the
number 1 or 0 thread, should be used. The thread
should be inserted at the center entry point and
pulled out through the lateral entry point. When
one site of surgery is finished, the opposite site
should be managed using the same method.
When the bilateral-­side surgery is finished, both
threads should be gently pulled laterally. The
laterally extruded thread should fixate at the
mastoid periosteum or the subcutaneous layer
by needle sutures. Dimples should not occur at
the center entry point when the bilateral thread
is pulled laterally. If a depression occurs, use
forceps to release the dermal layer. The entry
points are not sutured so that blood or exudates
can be drained (Figs. 15.3, 15.4, 15.5, 15.5, 15.6
and 15.7).
200 W. K. Kang and W. Lee

Fig. 15.4  Pre-procedure strategy design for liposuction Fig. 15.5  Immediately after the procedure. The neck
and thread lifting contour is improved and the entry point wound is not
closed

Fig. 15.6  At postoperative day 2. Mild bruising and tap- noticeable. Swelling is frequently observed without high
ing marks are visible. The central entry point is not notice- compression
able without sutures. The lateral entry point is also not

Fig. 15.7  Images taken 3 years postoperatively (frontal and lateral view). Sunken and senile eyelid correction was
performed 2 years prior using sub-brow lift and orbicularis oculi muscle turndown transposition technique
15  Submental Liposuction and Thread Lifting
15.5 Postoperative Care
Immediately post-operation, the entry points are
opened for blood and exudate drainage. Mild tap-
ing is performed, along with the use of gauze.
Compressive garment tape can be applied.
Follow-up appointment is made 2–3  days after
the procedure to apply dressing and hydrocolloid.
No taping is needed after 2–3 days.
15.6 Complications
Postoperative bruising might occur. Partial bruis-
ing is common and resolves after 1–2  weeks.
Swelling also disappears by that time. When
swelling disappears, minimal irregularities or
asymmetries might be visible, which disappear
after some time. Gentle and careful liposuction is
required to avoid these side effects. Hematomas
or seromas are the most common complications
associated with liposuctions and can be prevented
using appropriate dressings. Entry point scars are
typically not noticeable.
The post-liposuction area tends to initially
harden and soften again after 2–3  months. The
author believes that the cannula thickness also influ-
ences the postoperative subcutaneous layer hard-
ness. The use of thicker cannula to remove large
volumes of fat at once causes increased hardness.
The possibility of nerve damage is very low
and resolves within a few weeks [10, 11].
Thread lifting performed immediately after
liposuction has advantages and disadvantages.
One of the main advantages is that the thread can
eliminate the possible spaces after liposuction
a b
Fig. 15.8  Submental liposuction and thread lifting. (a) Preoperation image. (b) Image taken at postoperative month 18.
(c) Image taken 2 weeks post-HIFU. Adjuvant therapy can be applied for additional thickness
201
due to the thread and subcutaneous tissue adher-
ing to each other. Thus, complications such as
bruising, swelling, hematoma, or seroma are rare.
Increased patient satisfaction is usually observed
due to the immediate results attributed to thread
lifting. The disadvantage is the increased pain
associated with thread cogs when the neck rotates
to the right and left sides. However, the pain sub-
sides after 1 week or 10 days.
A preoperative platysmal band, called the
“pseudo-cobra neck deformity,” might be visible
after liposuction, typically corrected by platys-
maplasties. Poorly performed liposuctions can
induce dermal scar contracture, which are diffi-
cult to resolve [12].
Previous literature describes additional sec-
ondary liposuctions, but based on the author’s
experience, this does not occur frequently, as the
patient is usually satisfied with their results com-
pared to the preoperative condition [6].
15.7 Adjunctive Procedures
Preoperative informed consent from the patients
should be obtained regarding the hardness of the
postoperative subcutaneous layer. However, if the
patients still complain, low-dose injections of triam-
cinolone and hyaluronidase can be helpful. This can
be also used to resolve postoperative irregularities.
At 1-month post-operation, high-frequency
radiofrequency devices can also be used.
When the fat removal is under-corrected,
high-intensity focused ultrasound (HIFU) can be
useful 2–3 months after. HIFU can also be applied
after 1–2 years (Fig. 15.8).
c
202
Many patients who opt for neck liposuctions
tend to have microgenia, for which immediate fat
grafts performed using the fat harvested from the
neck area can be helpful. Microgenia can also be
corrected by fat grafts, filler injections, or implant
insertions performed later to achieve an acute
cervicomental angle.
15.8 Conclusion
Liposuction is a commonly performed technique
in the field of plastic surgery, which can be per-
formed at the neck area to increase the attractive-
ness and youthfulness of the neck. Neck area
liposuction results are comparable to those of
incisional operation, mostly because of skin
accommodation and skin contracture effects [13].
The author has performed neck liposuctions in
mid-1990s, followed by the use of cogged threads
in 2015, which has improved the results.
References
1. American Society for Aesthetic Plastic Surgery
Statistics, 2020.
2. Chung JH, Williams EF.  Facial suction lipectomy.
In: Babak A, et  al., editors. Master techniques in
W. K. Kang and W. Lee
facial rejuvenation. Philadelphia: Saunders; 2007.
p. 229–30.
3. Chung JH, Williams EF. Facial suction lipectomy. In:
Babak A, et  al., editors. Master techniques in facial
rejuvenation. Philadelphia: Saunders; 2007. p. 231–2.
4. Ellenbogen R, Karlin JV.  Visual criteria for success
in restoring the youthful neck. Plast Reconstr Surg.
1980;66(6):826–37.
5. Hetter GP.  Improved results with closed facial suc-
tion. Clin Plast Surg. 1989;2:319–32.
6. Dedo DD.  Management of platysma muscle after
open and closed liposuction of the neck in face lift
surgery. Facial Plast Surg. 1986;4(1):45–6.
7. Gryskiewicz JM.  Submental suction-assisted lipec-
tomy without platysmaplasty: pushing the (skin)
envelope to avoid a face lift for unsuitable candidates.
Plast Reconstr Surg. 2003;112(5):1393–405.
8. Morrison W, Salisbury M, Beckham P, Schaeferle III
M, Mladick R, & Ersek R. A. The minimal facelift:
liposuction of the neck and jowls. Aesthetic plastic
surgery. 2001;25(2):94–99. https://doi.org/10.1007/
s002660010103.
9. Fattahi TT.  Management of isolated neck defor-
mity. Atlas Oral Maxillofac Surg Clin N Am.
2004;12(2):261–70.
10. Knize DM.  Limited incision submental lipec-
tomy and platysmaplasty. Plast Reconstr Surg.
2004;113(4):1275–8.
11. Tapia A, Ferreira B, Eng R.  Liposuction in cervical
rejuvenation. Aesthetic Plast Surg. 1987;11(2):95–100.
12. Chung JH, Williams EF. Facial suction lipectomy. In:
Babak A, et  al., editors. Master techniques in facial
rejuvenation. Philadelphia: Saunders; 2007. p. 243.
13. Joel JF.  Neck lift. Saint Louis: Quality Medical
Publishing, Inc.; 2006. p. 29–31.
 Short Scar Rhytidectomy
Combined with PDO Threads
Soo Yeon Park, Kyu Hwa Jung, and Won Lee
Thread lifting has recently become one of the
most performed minimally invasive procedures.
However, it might have relative short longevity
and less effectiveness as compared to conven-
tional facelifts. However, conventional facelifts
frequently result in surgical scars. Here we intro-
duce short scar rhytidectomies with thread lift-
ing, which result in minimal scars and increased
effectiveness.
16.1 Introduction
Skin loosening, fat compartment descent, defla-
tion, and bony absorption are the features of face
aging. Bony absorption can be reinforced using
implant insertions; deflation can be corrected
using fat grafts or filer injections. Loose skin can
be tightened by performing direct skin excisions
such as conventional facelifts. Facelift techniques
are developed from subcutaneous face lifting,
which involves the excision of subcutaneous tis-
sue, superficial musculoaponeurotic system
(SMAS) plication, and MACS lift, in addition to
S. Y. Park
MadeYoung Plastic Surgery Clinic, Seoul, Republic
of Korea
K. H. Jung
Liting Plastic Surgery Clinic, Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_16
16
more specific operations of SMAS such as dual
plane and deep plane techniques [1]. The supe-
rior technique for operating on the SMAS layer
has been long questioned. However, the SMAS
operation is evidently superior to subcutaneous
skin excision techniques. In contrast, skin-based
facelifts are advantageous in terms of short oper-
ation times and fast recovery times.
There are differences between conventional
facelifts and thread lifting. Incisional facelifts can
remove excessive skin. The main purpose of
thread lifting is the repositioning of descended fat
tissue, accompanied by skin tightening. Thus, to
maximize the effects of thread lifting, fat reposi-
tioning should be performed effectively. The pre-
vious literature has described that thread lifting
has relatively short longevity and is less effective,
and possible complications such as dimples occur.
Short scar rhytidectomies are the combination
of traditional facelifts and thread lifting. It can be
performed in patients who have already under-
gone conventional facelifts. Limited literature
exists describing the relevant techniques. The
pure suture suspension technique is minimally
invasive technique but has decreased long-term
efficiency because of soft tissue stress relaxation
[2]. Mesh-type thread suspension has been
described by another study [3]. Threads should
be easy to use effectively for doctors. Thus, the
author uses floating-type bidirectional cogged
threads. The author made dissections for
increased tissue mobility and used threads for
203
204
distal part lifting, which can result in volume dis-
tribution and quick facial tightening. Minimal
incisions combined with well-designed thread
lifting are advantageous in terms of subcutaneous
dissection locking effect, which can be explained
by supporting, anchoring, and tissue reaction
using threads.
16.2 Operation Technique
16.2.1 A Schematic Depicting
the Preoperative Procedure
Design for Short Scar
Rhytidectomies (Fig. 16.1)
Preoperative evaluations are imperative. Mild
skin laxity and/or mild to moderate fat sagging in
patients is/are indication(s) for this procedure.
Fig. 16.1  A schematic depicting the preoperative design.
The virtual line moves from the lateral canthus to the
mandible angle (lateral canthus-mandible (LM) line, pur-
ple color); x, zygomatic ligament; 1, arcus marginalis; 2,
3, the most prominent pinching point between the arcus
marginalis and zygomatic ligament; 4, parallel to the
Frankfurt line from the otobasion inferius (O) the crossing
point with LM line; 5, the longest projection between x
and point 4; 6, 7, 1/3 and 2/3 from otobasion inferius to
point 4
S. Y. Park et al.
Conventional facelifts should be used to address
prominent skin laxity. Patients with prominent
zygoma should also avoid this procedure.
The patients should be evaluated in the upright
position. The fat compartments such as the malar
fat pads, jowl fat pads, and cheek fats should be
considered for lifting. Incisions should be made
at the hairline horizontal line from the eyebrow
for thread fixation. Ascertaining the sagging
areas and tissue mobility should be done manu-
ally. A virtual line is typically drawn from the
lateral canthus to mandibular angle. Two points,
most prominent by pinching, are made between
the arcus marginalis and zygomatic ligament,
considered for the malar fat pad. A line parallel to
the Frankfurt line from the otobasion inferius is
made, followed by cross points between the line
and LM line. The most prominent area is ascer-
tained by pinching, to decide the need for jowl fat
lifting. Two points are marked between the oto-
basion inferius and the LM line point 4, which is
the lateral cheek fat. Reverse techniques are per-
formed in which the threads are directed to the
temple area, such that the gathered tissues accu-
mulate at the temporal fossa rather than the
zygoma area. Increased fixation can be done at
the temporal fascia.
16.2.2 Anesthesia
Local anesthesia can be administered intrave-
nously, depending on the patient’s pain tolerance.
Local anesthesia usually contains 2% lidocaine
combined with 1:100,000 epinephrine. It is
administered at the entry points and thread desti-
nations. A volume of 10 mL is typically injected,
followed by waiting for 10–15  min. The author
does not recommend using the tumescent solu-
tion due to disturbed cog abilities attributed to
hydro-dissection and initial swelling.
16.2.3 Procedure
The operative design is drawn on the patient’s
face (Fig. 16.2). Petrolatum gauze is inserted into
the auricular meatus. A hairline incision is made,
16  Short Scar Rhytidectomy Combined with PDO Threads 205

postoperatively, keeping the patient in an upright

position. Usually, six to eight threads are inserted
ipsilaterally. Since the properties of threads vary
based on manufacturing, the thread lengths
should be estimated before insertion. Vectors
should be more vertical when performing the
procedure laterally. Two threads should be used
together as pairs for making suture ties and mak-
ing loops.
The procedure should be performed at a
depth adequate for holding the SMAS below the
zygomatic arch (Fig. 16.3). Sufficient fat tissue
should be held by the thread cogs to prevent
irregularities or dimples. The cannula end
should be rotated when passing dense areas
such as the zygoma area for easy penetration.
When penetration is not easy through a liga-
ment, the cannula should be pulled backward
slightly, and an alternate approach should be
attempted.
Temple incisions are sutured using No. 4
Nylon. Thread remnants at the entry point should
Fig. 16.2  The operative design: a line drawn from the
lateral canthus to mandible angle (dotted, LM line); x,
be cut, followed by a gentle massage. Massages
zygomatic ligament are not required at the temple area, despite skin
accumulation.
Additional thread lifting can be performed for
followed by a 2 cm dissection between the super- the nasolabial fold. Entry points should be posi-
ficial temporal fascia and subcutaneous layer. tioned at the lateral orbital rim and thread fixated
The deep temporal fascia layer can be exposed to at the periosteal layer, and subsequently the
ensure a successful procedure. Honeycomb-­ thread should approach at the nasolabial fat com-
shaped dissections and optional partial release of partment [4].
the zygomatic cutaneous ligaments are achieved
using Metzenbaum scissors at the zygomatic
area. Preoperative marking points are used as the 16.2.4 Postoperative Care
entry point of threads. Threads manufactured
inside cannulas are used. The author prefers a Mild compressive dressing such as taping is rec-
150  mm bidirectional thread reverse technique, ommended, removed 2 days post-procedure. Ice
which results in an exposed thread distal point at packs can alleviate swelling and pain. The upright
the incision area. The cannula is gently removed position is recommended for minimizing facial
and the thread ends checked by holding at the swelling. Opening the mouth wide, heavy laugh-
temporal incision area. The cogs should suffi- ter, facial massages, and hard chewing are not
ciently hold the soft tissue. Threads are then tied recommended. Prophylactic antibiotics and anti-­
to each other to make loops, using 3-0 vicryl to inflammatory drugs are recommended for 3 days
suture between the deep temporal fascia and post-procedure. Hair dying is not recommended
loop. Suture knots should not be palpable at the at the incision site for 1-month post-procedure.
external skin. Two other fat compartment reposi- Hydrocolloid dressings are recommended for the
tioning thread lifting techniques also utilize the entry points. Temple area sutures are removed at
same techniques. Additional thread can be added 10 days post-op.
206 S. Y. Park et al.

Fig. 16.3  A schematic

diagram of short scar
rhytidectomies.
Bidirectional cogged
thread is typically used
from the entry point
(blue arrow) to hold the
SMAS layer using cogs
(red arrow), followed by Skin
locating the zygomatic
arch thread at the
superficial temporal SQ
fascia and subcutaneous
layer
SMAS

temporal medial

Fig. 16.4 Preoperative a b
and postoperative views
in a 59-year-old woman.
(a) The preoperative
frontal view. (b) The
frontal view at 2 weeks
postoperatively. (c) The
preoperative lateral view.
(d) The lateral view at
2 weeks postoperatively
c d

16.2.5 Postoperative Results 16.3 Cases

(Figs. 16.4 and 16.5)
Case 1
The nasolabial fold and marionette line improve- See Fig. 16.6
ments should be evaluated at the frontal view.
Mandibular borderline improvements should be Case 2
checked at the lateral view. Lower facial contour See Fig. 16.7
improvement can be assessed at the mandible
borderline and the higher points of the most
prominent malar area.
16  Short Scar Rhytidectomy Combined with PDO Threads 207

a b

c d

Fig. 16.5  Operative evaluation in a 65-year-old woman. (a) The preoperative frontal view. (b) The frontal view at
2 weeks postoperatively. (c) The preoperative lateral view. (d) The lateral view at 2 weeks postoperatively

a b c

d e f

Fig. 16.6  A 47-year-old woman who underwent short postoperatively. (d) The preoperative lateral view. (e) The
scar rhytidectomy using polydioxanone (PDO) threads. lateral view at 2  weeks postoperatively. (f) The lateral
(a) The preoperative frontal view. (b) The frontal view at view at 1 month postoperatively
2 weeks postoperatively. (c) The frontal view at 1 month
208
a b
d e
Fig. 16.7  A 42-year-old woman who underwent short
scar rhytidectomy with PDO threads. (a) A preoperative
frontal view. (b) A frontal view at 2  weeks postopera-
tively. (c) A frontal view at 6 months postoperatively. (d)
16.4 Complications
Swelling, dimple formation, paresthesia, thread
visibility or palpability, infections, and thread
extrusions are the general complications associ-
ated with threads. The complication rate has
declined after increasing the use of absorbable
threads. However, dimple formation and infec-
tions are still common in older patients [5]. The
authors also experienced similar complications.
Usually, the complications were not serious and
could be resolved easily.
16.4.1 Infections and Granuloma
Formation
Infections can occur in the temporal incision
area, mainly attributed to hair. When hair is mis-
takenly inserted with thread into the subcutane-
ous layer of the scalp, inflammation occurs. Short
scar rhytidectomies usually don’t require hair
shaving due to the short recovery times, necessi-
tating extra precaution. When the thread is
located near the dermal layer, granulomas can
occur. Pulling and cutting the remnant threads is
an effective preventive technique. Antibiotics
should be administered for infections. If the
S. Y. Park et al.
c
f
A preoperative three-quarter view. (e) A three-quarter
view at 2 weeks postoperatively. (f) A three-quarter view
at 6 months postoperatively
symptoms exist 1–2  weeks, thread removal
should be performed.
16.4.2 Temporal Pain
As described previously, the thread loop is fixated
at the deep temporal fascia using vicryl 3-0, which
might suture the temporalis muscle, which is a
masticatory muscle. Hence, pain might occur when
opening mouth or chewing. Usually, the pain sub-
sides by refraining from opening the mouth and
taking pain killers. Sufficient preoperative warning
should be given to the patients. Botulinum toxin
injections might relieve prolonged symptoms.
16.4.3 Malar Prominence and/or
Worsening of Mid-Cheek
Groove
Malar prominence usually occurs due to tissue
gathering at the malar area. It is likely to subside
over time, but the patients should be warned of
the symptoms 2–4  weeks prior to surgery
(Figs. 16.8 and 16.9). Thread lifting focused on
sub-zygoma depression correction is likely when
the zygoma is prominent before surgery.
16  Short Scar Rhytidectomy Combined with PDO Threads 209

a b

c d

Fig. 16.8  Prominent zygoma in a 48-year-old woman. (a) A preoperative frontal view. (b) A frontal view at 2 weeks
postoperatively. (c) A preoperative three-quarter view. (d) A three-quarter view at 2 weeks postoperatively

a b c

d e f

Fig. 16.9  Prominent zygoma in a 66-year-old woman. (d) A preoperative three-quarter view. (e) A three-quarter
(a) A preoperative frontal view. (b) A frontal view at view at 2 weeks postoperatively. (f) A three-quarter view
2 weeks postoperatively showing the prominent zygoma. at 2 months postoperatively
(c) The prominence subsided at 2 months postoperatively.
210
16.4.4 Thread Migration/Protrusion
Thread must be checked for appropriate burying,
as it can protrude when thread is cut very shortly.
At the temple area, thread loop fixation should be
performed at the deep temporal fascia unless
there is a possibility of migration. When the
thread is palpable or protruded, immediate
removal is required. If migration occurs, com-
plete removal is recommended.
16.4.4.1 Dimple Formation
Postoperative skin irregularities can
­spontaneously resolve. However, dimples can
occur at the entry point (Fig.  16.10). When
­dimples occur minimally, spontaneous resolu-
tion is likely. However, severe dimples should
be removed immediately, except for consequent
fibrosis-­
associated scars. Relative large cogs
tend to have higher possibilities of dimple
formation.
Fig. 16.10  Dimple formation
S. Y. Park et al.
16.4.5 Swelling/Bruising/Ecchymosis
This is the most frequently observed complica-
tion. The superficial temporal artery can detour
by palpation or Doppler ultrasound. Due to the
numerous blood vessels in the face, hematomas
or bruising might occur. Compressions must be
commenced immediately.
16.4.6 Parotitis
Parotid gland injuries are rare but can occur, usu-
ally identifiable through pin-like sensations dur-
ing eating and swelling after eating. When the
symptoms are prolonged, skin fistulas can
develop. Conservative treatment strategies such
as antibiotic and anti-inflammatory drugs are
needed for 2–3 weeks.
16.4.7 Neuropraxia
Direct nerve injuries are rare. Temporary decline
in sensations can occur because of swelling and/
or hematomas. Local anesthesia can induce dis-
comfort, especially in the periocular area, but
subsides after 4–8 h.
16.4.8 Relapse
Skin laxity relapse is the primary problem associ-
ated with all thread lifting procedures, using both
absorbable or nonabsorbable threads. The effec-
tiveness of the procedure does not exceed 2 years.
The patient should be informed of the same.
16.5 Limitation and Discussion
The recently developed techniques are predomi-
nantly minimally invasive. Successful results
should align with the patient’s expectations and
demands. For example, when the patient’s expec-
tations are high, a short scar rhytidectomy would
16  Short Scar Rhytidectomy Combined with PDO Threads
not suffice. Excessive double chin fat should also
be treated with additional procedures such as
liposuction. A dissatisfied patient might need
additional thread lifting after 1–2  months. The
efficiency depends on the techniques of choice,
the patient’s condition, and the properties of the
threads. The patient’s condition is determined by
the skin thickness, elasticity, and volume of the
thread. The thread condition depends on thread
thickness, length, and the cog intervals. An
understanding of the thread’s properties is
essential.
The author recently performed temporal exci-
sions rather than incisions to improve the skin
laxity and hammock effect. Inserted threads
diminish skin tension, reducing scar formation.
Short scar rhytidectomies have limitations which
need to be improved. However, numerous tech-
niques are rapidly developing these days.
211
References
1. Kim BJ, Choi JH, Lee Y. Development of facial reju-
venation procedures: thirty years of clinical experience
with face lifts. Arch Plast Surg. 2015;42(5):521–31.
2. Paul MD. Barbed sutures in aesthetic plastic surgery:
evolution of thought and process. Aesthet Surg J.
2013;33(3 Suppl):17S–31S.
3. Wattanakrai K, Chiemchaisri N, Wattanakrai P. Mesh
suspension thread for facial rejuvenation. Aesthet
Plast Surg. 2020;44(3):766–74.
4. Myung Y, Jung C. Mini-midface lift using polydioxa-
none cog threads. Plast Reconstr Surg Glob Open.
2020;8(6):e2920.
5. Niu Z, Zhang K, Yao W, Li Y, Jiang W, Zhang Q,
Troulis MJ, August M, Chen Y, Han Y.  A meta-­
analysis and systematic review of the incidences of
complications following facial thread-lifting. Aesthet
Plast Surg. 2021;45(5):2148–58.
 Complications of Thread Lifting
and Treatments
Yongwoo Lee and Won Lee
Thread lifting is a popular minimally invasive
procedure to achieve antiaging effects. However,
the procedure is associated with several compli-
cations, which will be discussed in this chapter,
in addition to methods of prevention and effec-
tive treatments.
17.1 Introduction
Prevention is the most important factor for com-
plications associated with thread lifting. It is
important to evaluate the contraindications for
every patient. For example, excess skin laxity
patient is a contraindication of thread lifting.
Excessive fat on the face also renders the proce-
dure ineffective [1]. Who is the best candidate of
thread lifting? The author has established an
algorithm to evaluate the patient before the pro-
cedure (Fig. 17.1).
Y. Lee
LIKE Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_17
17
When the patients have excess skin, conven-
tional rhytidectomies are recommended. When
patients have excess fat at the lower face, liposuc-
tion is recommended. In patients with volume
deficiencies, fat grafts or filler injections are rec-
ommended [2]. Patients with sub-zygoma depres-
sions are also treated with fat grafts or filler
injections because the jowl fat reposition is usu-
ally not sufficient to fulfill the sub-zygoma
depression. Patients with prominent zygoma
should exercise caution for thread lifting. Skin
thickness is also a consideration. Patients with
irregularities after previous operations or thread
lifting should opt for thin threads rather than
thick threads.
Dissatisfaction, bruising, sensory changes,
and irregularities are the complications most fre-
quently associated with thread lifting complica-
tions [3]. The incidences are also dependent on
the expertise of the person performing the proce-
213
214 Y. Lee and W. Lee

Liposuction

high Laser
lipolysis

Soft tissue
volume
Thick thread
average thick

low yes
Filler or fat Skin
injection thickness
yes

no refuse thin
Subzygoma
depression Thin thread

no

yes

Malar
protrusion

Fig. 17.1  Algorithm for selecting the optimal thread lifting procedure

Table 17.1  Thread lifting complications

Common Rare reduce bruising. Vasoconstrictors or ice packs are
Hematoma, bruising Infection also effective for the reduction of bruises. The
Swelling Protrusion pathway of superficial temporal artery must be
Dimple Gland penetration ascertained by palpation or Doppler ultrasound.
Motor and sensory dysfunction Granuloma The important veins are ­visible through thin skin.
Pain Alternately, vein detectors can be used to prevent
Relapse vein disruptions. Cannula use is preferred over
needles to minimize bruising [4].
Entry point bleeding can be resolved by com-
dure. The author has classified the complications pression. However, bleeding in the buccal area is
as common and rare (Table 17.1). difficult to resolve (Fig.  17.2). Lacerations and
thread perforations cannot be resolved using
compression. The thread should be finished at the
17.2 Common Complications earliest, followed by external. Thread tightening
can minimize bleeding by tightening. When buc-
17.2.1 Hematoma and Bruising cal bleeding occurs, the buccal mucosa should
also be checked.
Bruising is one of the most common complica- Fast recovery is impossible from bruising and
tions, due to the numerous blood vessels on the hematoma. Anatomical knowledge is essential in
face. Reduced thread insertions can prevent or addition to the recommended use of cannulas.
minimize bruising. While increased thread inser- Most importantly, gentle injections are
tions can increase the lifting effect, less insertions recommended.
17  Complications of Thread Lifting and Treatments 215

a b

Fig. 17.2  Left buccal hematoma after thread lifting. (a) Immediately after thread lifting. (b) 7  days after thread
lifting

a b c d

Fig. 17.3  Zygoma prominence and swelling after thread lifting. (a) Preoperatively. (b) At 3 days postoperatively. (c)
At 2 weeks postoperatively. (d) At 5 months postoperatively

17.2.2 Swelling show prominence [5]. This is commonly observed

Swelling is one of the common complications,
due to causes like tissue swelling or migration of
the tissue. Minimal local anesthesia infiltration is
helpful to minimize swelling. Local anesthesia
injection is essential for thick threads. Temporary
swelling can last for 3–5 days. Patients are usu-
ally most dissatisfied by swelling after zygoma
prominence after thread lifting (Fig. 17.3).
Tissue repositioning is often observed after
thread lifting because the elevated tissues like to
when fixation is performed at the temple area. In
floating-type techniques, bidirectional thread
causes this effect more frequently than
­multidirectional threads, necessitating preopera-
tive evaluations to optimize the procedure. This
complication lasts between 2 weeks and 1 month.
Filling the sub-zygoma depression must be tar-
geted. Preoperative evaluation of the patients for
zygoma prominence is essential to ascertain
whether multidirectional or bidirectional cogged
threads be used (Fig. 17.4).
216 Y. Lee and W. Lee

17.2.3 Dimple Formation patient dissatisfaction and complaints. In the cases

of superficial insertion of thread or thin skin, thick
Bruising and swelling are expected complications, threads and thread contour are visible (Fig. 17.5).
usually subsiding with minimal interventions. Dimple formations can be attributed to multi-
However, when dimple formations occur, the ple causes, such as thick threads, volumizing
patients should be concerned. Irregularities per- threads, and entry points (Fig. 17.6).
sisting for more than 2–4  weeks also result in When using cogged threads, the cogs can cause
mild dimples. Big cogs or threads with cones can
cause dimples. Therefore, the thread must not be
inserted too superficially. It is also crucial to pull
the thread when cogged thread is inserted.
If the cogged thread is inserted too deeply, the
lifting effect can be obscure. Thus, insertions
near the SMAS layer or deep subcutaneous layer
are recommended if the subcutaneous layer is not
Center cog Zigzag cog
thin. The recommended is depicted in Fig. 17.7.
: good holding power : low holding power
but, center elevation but, balanced elevation When the thread is inserted too superficially
(Fig.  17.7 red dot line), dimple formations are
Fig. 17.4  Bidirectional thread (center cog) and multidi- likely. However, deep insertions are not recom-
rectional thread (zigzag)

a b

Fig. 17.5  Irregularities at the thread pathway. (a) Preoperatively. (b) Immediately postoperatively

a b

Fig. 17.6  Dimple formation at the entry point of volumizing thread insertion. (a) Preoperatively. (b) At 7  days
postoperatively
17  Complications of Thread Lifting and Treatments
Ear
Useless
2nd recommended
Best
High irregularity risk
Fig. 17.7  Recommended layer for avoiding dimples
mended. The mechanism should lift jowl fat or
nasolabial fat which is superficial fat compart-
ments, and when the thread is inserted in the deep
layer, the effectiveness is minimized (Fig.  17.7
blue dot line). The ideal layer is near the SMAS
layer. However, insertions in the same layer con-
stantly is difficult and the relationship with facial
structure should also be considered. The thread
should be near the skin at the entry point and
should be inserted deeply when passing the zygo-
matic arch area to prevent dimples. Finally, the
thread end should be located at the superficial fat
compartment, which is the main target for lifting.
The fixation portion of the thread is defined as
the anchoring portion, and the lifting portion of
the thread can be defined as the soft tissue hold-
ing portion (Fig.  17.8). The lifting effect and
complications are dependent on the balance
between these two portions. The anchoring por-
tion should be less than the soft tissue holding
portion because it is usually a harder structure,
providing support and strength. In contrast, the
holding portion is usually near the skin, so large
amounts of thread should be at this portion.
217
Zygomatic arch
Posterior cheek sunken
Jowl
Deep
fat
OO
GW
ON
EY
LE Deep fascia
SMAS
Skin
When the thread is pulled hard to increase the
lifting effect, dimples can occur, requiring mas-
sages. Appropriate pulling is preferred, i.e., pull
until massage is not needed.
Mild dimples, frequently observed immedi-
ately after the procedure, tend to resolve after
the swelling subsides because of facial
expressions.
17.2.4 Nerve Dysfunction
When nerve dysfunction occurs, both the patient
and doctor tend to panic. Nerve dysfunction due
to the thread can exceed a month and might
require the removal of the inserted threads [6].
However, cogged threads are not easy to remove,
necessitating extreme precautions to prevent this
side effect. When thread insertion is performed at
the sub-SMAS layer, the insertion should be done
more gently because the motor nerves tend to run
through the sub-SMAS layer. However, as previ-
ously mentioned, insertions done too superfi-
cially might result in dimples.
218 Y. Lee and W. Lee

Ear

Best 2nd recommended

Zygomatic arch
Anchoring
portion

Anchoring
portion

Soft
tissue
holding
portion Soft
tissue
Jowl holding
Deep portion
fat

OO
GW
ON
LE
EY Deep fascia
SMAS

Skin

Fig. 17.8  Balance between the anchoring portion and soft tissue holding portion of the thread

For anesthesia, lidocaine is injected, and con-
sequent sensory dysfunction might occur.
However, sometimes motor dysfunction might
occur and should resolve within a day. The
­possibility of motor dysfunction increases with
increasing concentrations of lidocaine. Therefore,
the use of tumescent solution rather than the 2%
lidocaine alone is recommended. Motor dysfunc-
tion occurs at the ipsilateral face. When the fron-
tal branch of the facial nerve is involved, the
eyebrows cannot move and eye opening could be
impacted. When the zygomatic or buccal branch
is involved, an unnatural facial appearance could
occur during smile or opening the mouth.
17.2.5 Pain
Pain can occur immediately pot-procedure but
also persist afterward. Pain is more likely in the
procedures where multiple and thick cogged
threads are used. Pain is reported in the perioral
area and neck area, lasting between 1  day to
2 weeks post-procedure. Increased pain is associ-
ated with thread insertion into the premasseteric
space because it is a gliding plane during masti-
cation or opening the mouth. Thus, thread inser-
tion is recommended in the SMAS area near the
premassteric space.
In thread lifting at the neck area for double
chin deformities, pulling the bilateral thread
tightly can tighten the center of the neck area,
resulting in a tight sensation [7]. Precaution
should be exercised around the great auricular
nerve, located in the sternocleidomastoid muscle
fascia (Fig. 17.9) [8].
Pain killer prescriptions and refraining from
opening the mouth too widely can help reduce
pain. Over time, the thread tends to harmonize
with tissue and reduce pain symptoms.
17  Complications of Thread Lifting and Treatments 219

should be performed as aseptically as possible,

a
with minimal contact of the thread.
Infections can occur despite the use of asep-
tic technique, necessitating the use antibiotics
and careful observation. If the infection does
not subside, thread removal should be consid-
ered. Removal is not easy and can often be
painful.

b
17.3.2 Thread Protrusion

Thread protrusion can be seen in cogged threads

and volume threads due to multiple possible
causes. Unstable or weak thread can cause this.
Polydioxanone (PDO) thread, one of the most
used threads, hydrolyzes when inserted in the
Fig. 17.9  Great auricular nerve located at the sternoclei- face. However, it is also degradable at the atmo-
domastoid muscle fascia. (a) Cadaveric anatomy. (b) sphere because of humidity. The thread starts to
Schematic diagram
hydrolyze immediately after the package is
opened. So the use of opened packages is not rec-
ommended. Old manufacturing dates might
17.2.6 Relapse cause the thread to weaken over time. The thread
strength must be evaluated before inserting into
One of the disadvantages of thread lifting is inef- the face.
fectiveness and relapse [9]. The effects of thread Bidirectional thread has bidirectional cogs,
lifting do not exceed 2 years, and are most promi- minimizing the migration. Multidirectional
nent immediately post-procedure to 6  months thread has an even lower possibility of migration.
after. Tissues tend to revert to their preoperative However, when the bidirectional thread is weak-
states when the thread cogs are absorbed and ten- ened at the center, the thread can migrate to the
sile strength decreases. Patients must be informed cog direction. When the thread migrates, it can be
of the temporary effectiveness of the procedure. felt by palpation. When thread protrusion occurs,
Periodical tightening is needed using energy-­ 8 G needles or stab incisions are used for thread
based devices. removal (Fig. 17.10).
Volumizing threads can also protrude
(Fig.  17.11). Thread removal is performed with
17.3 Unusual Complications stab incisions. However, prevention is the most
important, by inserting adequate thread from the
17.3.1 Infection skin entry point.
Unwanted extents of fibrosis, usually at the
Aseptic conditions are essential for these proce- nose, are also a cause for concern. Threads that
dures. Infections, while rare, can occur, necessi- are used at the nose are usually thick to provide
tating the immediate removal of the thread. Hair structural support (Fig. 17.12). Prior thread inser-
should be not inserted into entry point during the tions are not recommended for the patients under-
procedure. When using cogged threads, the cogs going this procedure. Preinserted threads can
must be free of foreign bodies. The procedure disturb the procedure.
220 Y. Lee and W. Lee

a b

Fig. 17.10  Thread protrusion. (a) Protrusion is noticeable when smiling (blue circle). (b) Partially removed threads

a b c

Fig. 17.11  Thread protrusion. (a) Protrusion when expressed. (b) Minimal stab incision for removal. (c) Removed
threads

a b c

Fig. 17.12  Patient with thread insertions. (a) Wide dorsum after thread insertion. (b) Thread removal during rhino-
plasty. (c) Removed threads

17.3.3 Penetration of Glands
The penetration of glands is one of the most seri-
ous complications associated with thread lifting.
The parotid gland can be perforated during face
lifting, and the submandibular gland can be per-
forated during double chin correction using
thread insertion (Figs. 17.13 and 17.14).
These glands are covered with deep fascia,
making them difficult to penetrate. Sharp needles
or cannulas can effectively penetrate the glands.
Additionally, when the patient feels pain, they are
likely to clench the masticatory muscle, causing
gland penetration (Fig. 17.15).
Swelling occurs for 2–7  days in addition to
localized infections. Symptoms are likely to
17  Complications of Thread Lifting and Treatments 221

Fig. 17.15  Parotid gland penetration using thread in a

cadaveric view

worsen after eating, so the patient’s history is

needed [10].
A sialogram can be a diagnostic tool, but clini-
cal signs can show parotitis, requiring immediate
treatment [11]. Compression is a good treatment
modality, so facial bandage is recommended. A
facial drain also should be considered if the
symptoms are serious. Antibiotics and steroids
are recommended in addition to anticholinergic
drugs such as scopolamine or atropine [12].
Botulinum toxin is also recommended to reduce
the gland function [13].
When proper treatment is provided, symptoms
subside within 2 weeks.
Fig. 17.13  Parotid gland location. (a) A cadaveric view
of the parotid gland and Stensen’s duct. (b) A schematic
diagram of the parotid gland and submandibular gland
17.3.4 Granuloma and Soft Tissue
Benign Tumor

While extremely rare, surgical operation is

needed when soft tissue tumors such as granulo-
mas or epidermal cysts occur. Mycobacterium
[13] and epidermis components can be inserted
to perform epidermal cyst [14]. While PDO
threads eventually absorb in the face, permanent
thread does not and reportedly forms granulomas
after 2 years [15]. Aseptic, clean procedure is key
for thread lifting.

Fig. 17.14  Submandibular gland

222 Y. Lee and W. Lee

References 9. Rachel JD, Lack EB, Larson B. Incidence of compli-

cations and early recurrence in 29 patients after facial
rejuvenation with barbed suture lifting. Dermatol
1. Ruff G.  Technique and uses for absorbable barbed
Surg. 2010;36(3):348–54.
sutures. Aesthet Surg J. 2006;26(5):620–8.
10. Winkler E, Goldan O, Regev E, Mendes D, Orenstein
2. Rohrich RJ, Ghavami A, Constantine FC, Unger
A, Haik J. Stensen duct rupture (sialocele) and other
J, Mojallal A.  Lift-and-fill face lift: integrat-
complications of the Aptos thread technique. Plast
ing the fat compartments. Plast Reconstr Surg.
Reconstr Surg. 2006;118(6):1468–71.
2014;133(6):756e–67e.
11. Nahlieli O, Abramson A, Shacham R, Puterman
3. Chen Y, Niu Z, Jin R, Lei Y, Han Y.  Treatment of
MB, Baruchin AM. Endoscopic treatment of salivary
complications following facial thread-lifting. Plast
gland injuries due to facial rejuvenation procedures.
Reconstr Surg. 2021;148(1):159e–61e.
Laryngoscope. 2008;118(5):763–7.
4. Lee W, Moon HJ, Kim JS, Chan BL, Yang EJ. Doppler
12. White PF, Tang J, Song D, et al. Transdermal scopol-
ultrasound-guided thread lifting. J Cosmet Dermatol.
amine: an alternative to ondansetron and droperidol
2020;19(8):1921–7.
for the prevention of postoperative and postdischarge
5. Han HH, Kim JM, Kim NH, Park RH, Park JB, Ahn
emetic symptoms. Anesth Analg. 2007;104(1):92–6.
TJ. Combined, minimally invasive, thread-based face-
13. Lovato A, Restivo DA, Ottaviano G, Marioni G,
lift. Arch Aesthet Plast Surg. 2014;20(3):160–5.
Marchese-Ragona R.  Botulinum toxin therapy:
6. Lee CJ, Park JH, You SH, Hwang JH, Choi SH, Kim
functional silencing of salivary disorders. Terapia
CH. Dysesthesia and fasciculation: unusual complica-
con tossina botulinica: silenziamento funzionale
tions following face-lift with cog threads. Dermatol
dei disordini salivari. Acta Otorhinolaryngol Ital.
Surg. 2007;33(2):253–5.
2017;37(2):168–71.
7. Tiryaki KT, Aksungur E, Grotting JC.  Micro-shuttle
14. Baek SO, Shin J, Lee JY.  Epidermal inclusion cyst
lifting of the neck: a percutaneous loop suspension
formation after barbed thread lifting. J Craniofac
method using a novel double-ended needle. Aesthet
Surg. 2020;31(5):e493–4.
Surg J. 2016;36(6):629–38.
15. Beer K.  Delayed complications from thread-lifting:
8. Cruz RS, O'Reilly EB, Rohrich RJ.  The platysma
report of a case, discussion of treatment options, and
window: an anatomically safe, efficient, and easily
consideration of implications for future technology.
reproducible approach to neck contour in the face lift.
Dermatol Surg. 2008;34(8):1120–3.
Plast Reconstr Surg. 2012;129(5):1169–72.
 Body Contouring Using Threads
and Fat Graft 18
Young Choon Jung and Won Lee

Body contouring is an important field of plastic
surgery. Thread lifting is commonly used for
facial lifting but also can be used for body con-
touring. In this chapter, we will discuss hip lifting
using threads and fat grafts. We will also discuss
the anatomy and esthetic unit of the gluteal area.
18.1 Introduction
The criteria defining beauty have changed over the
decades. It also varies across countries, cultures,
race, and so on. However, the buttock is one of the
most important contributors to a person’s overall
beauty, and gluteal surgery is one of the most rap-
idly growing fields of plastic surgery. A total of
17,245 surgeries were performed in the United
States alone in 2015, which were a 29% increase
compared to 2014 [1]. The International Society of
Aesthetic Plastic Surgery reported more than
30,000 cases were performed in 2018 [2].
What is an esthetically beautiful buttock?
A beautiful buttock should fulfill the
following criteria (Fig. 18.1) [3]
1. Bilateral prominent dimples, one on each
side of the medial crest, which is a part of
the posterior superior iliac spine.
2. A V-shaped sacral triangle starting from the
end of the gluteal crease toward the dimples.
3. Infragluteal fold not exceeding two-thirds
of the medial posterior thigh.
4. Two shallow depressions caused by the
great trochanter.
Furthermore, the “ideal” waist-to-hip ratio for
women is considered 0.67–0.7%. The waist-to-­
hip ratio and lumbosacral curvature also contrib-
ute to the overall esthetics for beauty.

Y. C. Jung
Hershe Plastic Surgery Clinic,
Seoul, Republic of Korea
W. Lee (*)
Yonsei E1 Plastic Surgery Clinic,
Anyang, Kyonggi-do, Republic of Korea Fig. 18.1  Criteria for a beautiful buttock

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 223
W. Lee (ed.), Minimally Invasive Aesthetic Surgery Techniques,
https://doi.org/10.1007/978-981-19-5829-8_18
224 Y. C. Jung and W. Lee

Fig. 18.2 The
important ligaments of
buttock lifting

18.2 Anatomical Considerations

The aging process results in gluteus maximus

atrophy, laxity of the superficial fascia system, fat
atrophy, loss of skin elasticity, and lateral down-
ward drooping. The anatomy should be evaluated
before performing procedures. The important
anatomical structures are the sacrocutaneous lig-
ament, ischiocutaneous ligament, and superficial
fascial system. These structures (Fig.  18.2)
should be used for lifting.

18.3 General Considerations

(Fig. 18.3)

Previous literature describes ten esthetic unit

zones in consideration when performing body
contouring surgery [4]. Specific areas should be
augmented or reduced. Thus, beautiful buttock
should have a trunk and low extremities. For
example, when performing abdominoplasty in
morbidly obese patients, the resultant waist will
be wide and square looking. When performing
liposuction at the infragluteal fold, the gluteal
supporting structure may be destructed. Thus,
when performing body contouring surgeries,
the pelvis height and shape (round, A shape, V
shape) should be checked, in addition to the
gluteus maximus muscle length and thickness.
Fig. 18.3  Esthetic units/zones. 1. Sacrum V zone. 2.
Flank. 3. Upper buttock. 4. Lower back. 5. Outer leg. 6.
Gluteus. 7. Diamond zone: inner gluteal/leg injection. 8.
Mid-lateral buttock point C. 9. Inferior gluteal/posterior
leg junction. 10. Upper back
The superficial fascial system thickness and
elasticity of skin should also be assessed. All
the factors should be evaluated and then the
volume reduction and augmentation should be
decided.
18  Body Contouring Using Threads and Fat Graft
18.4 Thread Lifting Technique
The entry point for thread perforation should be
located at the sacrocutaneous ligament
(Fig. 18.2), 1 cm above the sacrocutaneous liga-
ment. A total of four to five entry points are made,
and 20–30 mL of tumescent solution is inserted
at each entry point, totaling 100–150 mL in the
ipsilateral buttock. Mild massage is recom-
mended to ensure even distribution.
The lifting vector should be superomedial to
gather gluteal soft tissue (Fig. 18.4) and three to
four threads are inserted at each entry point.
When inserting a thread, the tissue was
grasped with the left hand 1 cm below the entry
point at the ischium (already marked before sur-
gery). The thread was inserted while maintaining
tension in the left hand, such that it penetrated the
deep fat layer and superficial fascial system. The
cannula tip should not be located near the skin
area because of skin dimpling. Furthermore, the
lifting vector must be considered while gathering
the soft tissue in the superomedial direction.
Fig. 18.4  Buttock thread lifting strategy
Fig. 18.5  Dimple formation during the procedure
225
During deep insertion, the thread may involve the
gluteus maximus muscle. In such instances,
patients will experience muscle pain, and the sur-
geon may notice muscle twitching. When this
happens, the cannula should be retracted slightly
and reinserted into the deep subcutaneous plane,
parallel to the muscle. Because the buttock area
comprises large and heavy soft tissues, a single
thread may be inadequate for soft tissue gather-
ing. While maintaining the tension in the left
hand, another thread is inserted through the same
entry point in a different direction. Similarly,
three to four additional threads are inserted
through the same entry point but in different
directions. This procedure is repeated for the
remaining entry points along the sacral triangle.
To avoid pain in the sitting position, the thread
should not be inserted below the ischial line. Skin
dimpling that cannot be immediately released
may occur (Fig.  18.5). However, it will subse-
quently relax with the overall contouring of the
buttocks after all the threads have been inserted.
After surgery, immediate results can be observed.
Previously lifting was performed to lift the
gluteal soft tissue, against gravity (Fig.  18.6)
using three to four thread insertions.
More effective posterior projection is needed
to gather the upper medial area. The entry points
are made at the lateral margin of the sacral trian-
gle (Fig.  18.7). Natural lateral depression also
occurs.
The thread lifting strategy is designed such
that four divisions can be made at the buttock
Fig. 18.6  Gluteal thread lifting strategy
226 Y. C. Jung and W. Lee

18.5 Reverse Technique of Thread

Lifting

The reverse technique involves the insertion of a

Fig. 18.7  Entry point and thread lifting strategy
thread from the lower portion in an upward direc-
tion (Fig. 18.9). Eyebrow lifting can also be per-
formed using the reverse technique.
Immediate results can be seen following the
reverse technique, which can be applied to but-
tock lifts. The thread can be inserted in the
upper medial direction using the reverse tech-
nique (Fig. 18.7 blue line). When the appropri-
ate lifting is performed, buttock lifting and a
long-legged appearance can be observed
(Fig. 18.10).

Fig. 18.8  Buttock division

Fig. 18.9  Eyebrow lifting via the reverse technique

area (Fig. 18.8). Area B should be repositioned in
the upper medial direction.
Area A is the target and area B is the location
for improvement. Therefore, area A should be
augmented. Thus, thread lifting is first performed
for the posterior projection. Then fat or filler is
injected for augmentation. When medial lifting is
fully performed, the extent of augmentation can
be reduced. The first area for augmentation
should be in the upper medial side but not in the
danger zone. The lateral side can be augmented
considering the esthetic zone. Liposuction can be
performed for the frank, thigh, and infragluteal
areas concomitantly. The tumescent solution has
been reduced as compared to previous uses, Fig. 18.10  Gluteal reposition direction using the reverse
which is 60–80 mL. technique
18  Body Contouring Using Threads and Fat Graft
18.6 Thread Lifting and Fat Graft
Tumescent solution with 1% lidocaine and
1:100,000 epinephrine is injected in the prone
position. The donor site is also injected with the
tumescent solution. The entry point for fat injec-
tion is near the infragluteal fold and around the
sacral triangle, which is the same as that for
thread insertion. The fat graft is placed in the
upper medial side for projection. After the fat
graft, thread lifting is performed considering the
vector. Gluteal fat injection mortality is approxi-
mately 1/3000 patients. The causes of fat embo-
lisms are explained by two theories. First is the
direct cannulation theory wherein bolus fat is
injected into a valveless vein. Second is the lac-
eration siphon theory.
Large volumes of fat have been typically
injected into the gluteus muscle. Therefore, pre-
vious research describes local anesthesia per-
formed for fat grafts in the subcutaneous layer
and that patients feel pain when the cannula
passes the gluteus maximus fascia. Therefore, a
more superficial approach can be performed [5].
227
The patient’s pain feel is controversial, as
reported previously [6].
What are the advantages of fat graft and thread
lifting performed together (Fig.  18.11)? First,
those who want buttock lifts tend to have less fat,
so fat graft is performed, usually first, followed
by thread lifting. Threads are structural supports.
Second, relatively small quantities of fat can be
harvested to reduce donor site morbidity. Third,
the relatively small amount of fat can create an
effective posterior projection.
Since the SNS was developed, patients desire
a reduced flank and big, round buttocks
(Fig. 18.12).
Fat graft can be performed in the upper but-
tock area using threads. The esthetic aspects must
be considered in addition to the patient’s desires.
In the esthetic unit, the zone 5 outer leg and zone
9 inferior gluteal/posterior leg junction are
esthetically superior when shallow.
The posterior projections should be performed
in the upper medial direction of thread insertion
(Fig.  18.13). Fat grafts are performed for
augmentation.
228 Y. C. Jung and W. Lee

Fig. 18.11  Fat graft

and thread lifting.
Photographs taken at
pre-op and post-op
18  Body Contouring Using Threads and Fat Graft 229

Fig. 18.12  Preoperative and postoperative SNS photographs

18.7 Cases

Case 1
See Fig. 18.14
The danger zone should be considered. Fat
injections are not recommended in this area
(Fig. 18.15).

Case 2
See Fig. 18.16

Fig. 18.13  Location for thread and fat graft Case 3

See Fig. 18.17

Case 4
See Fig. 18.18

Case 5
See Fig. 18.19
230 Y. C. Jung and W. Lee

Fig. 18.14  A 46-year-old woman underwent a fat graft and thread lifting

Fig. 18.15  Danger zone

18  Body Contouring Using Threads and Fat Graft 231

Fig. 18.16  Thread lifting and fat graft, pre-op (Lt), at 2 weeks post-op (middle), at 3 months post-op (Rt)
232 Y. C. Jung and W. Lee

Fig. 18.17  A 400 mL fat graft and thread lifting. Pre-op (Lt), at 1 week post-op (middle), at 3 months post-op (Rt)
18  Body Contouring Using Threads and Fat Graft 233

Fig. 18.18  A 300 mL fat graft and thread lifting. Pre-op (Lt), at 2 weeks post-op (middle), at 3 months post-op (Rt)
234 Y. C. Jung and W. Lee

Fig. 18.19  A 300 mL fat graft and thread lifting. Pre-op (Lt), at 1 week post-op (middle), at 1 month post-op (Rt)
18  Body Contouring Using Threads and Fat Graft 235

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trends-­2015.pdf. Accessed 25 May 2019.
Vecchio D. “Brazilian Butt Lift” under local anes-
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