The Art and Science of Thread Lifting Based on Pinch Anatomy and Moving Plane

Preface
Note of Appreciation
Contents
Author’s Profile
1: History of Thread Lifting
	1.1	 Beginning and Backgrounds of Thread Lifting
	1.2	 Nonabsorbable and Absorbable Threads
	1.3	 Development History of Lifting Threads
2: Basic Considerations for Thread Lifting
	2.1	 Definition of Terms
		2.1.1	 Fixing Point
		2.1.2	 Hanging Point
		2.1.3	 Directionality
	2.2	 Importance of Fixing Points
	2.3	 Basic Method of Forming Fixing Points
	2.4	 Basic Classification According to the Purpose of Lifting Threads
	2.5	 Influencing Factors on Outcomes of Procedure
		2.5.1	 The Materials of Threads
		2.5.2	 Thickness of Thread: Tensile Strength
		2.5.3	 Shape, Location, and Number of Cogs: Anchoring and Holding Strength
		2.5.4	 Direction of Cogs
		2.5.5	 Insertion Depth of Threads According to the Toughness of Tissues
		2.5.6	 Selection of Appropriate Lifting Vectors and Fixing Points According to Facial
			2.5.6.1	 Areas
		2.5.7	 Difference Between Flap and String Methods
		2.5.8	 The Expiration Date of Absorbable Threads
3: Facial Anatomy for Thread Lifting
	3.1	 Layers of the Face
		3.1.1	 Skin
		3.1.2	 Subcutaneous Tissue (Fat)
		3.1.3	 Facial Expression Muscle/ SMAS
		3.1.4	 Deep Fat or Spaces
		3.1.5	 Periosteum or Deep Fascia
		3.1.6	 Moving Plane
	3.2	 Anatomic Finding of Layers of the Face
	3.3	 Vessels of the Face
		3.3.1	 Superficial Temporal Artery
		3.3.2	 Zygomatico-Orbital Artery
		3.3.3	 Transverse Facial Artery
		3.3.4	 Middle Temporal Vein
	3.4	 Nerves of the Face
		3.4.1	 Facial Nerve
		3.4.2	 Great Auricular Nerve
	3.5	 Retaining Ligaments of the Face
	3.6	 Fat Compartments of the Face
	3.7	 Space of the Face
	3.8	 Parotid and Submandibular Glands
	3.9	 Fibrous Connective Tissue of the Face
4: Pinch Anatomy for Thread Lifting
	4.1	 Definition of Pinch Anatomy
	4.2	 Importance of Pinch Anatomy
	4.3	 Method of Studying Pinch Anatomy
		4.3.1	 Methods
		4.3.2	 Overall Results
	4.4	 Pinch Anatomy for Each Part of the Face
		4.4.1	 Posterior Temple
			4.4.1.1	 Gross Anatomic Finding: Posterior Temple (Fig. 4.6)
			4.4.1.2	 Histologic Finding: General Pinching in Posterior Temple (Fig. 4.7)
			4.4.1.3	 Gross Anatomic Finding: Comparison of General Pinching and Thick Pinching in Posterior Temple (Fig. 4.8)
			4.4.1.4	 Histologic Finding: Thick Pinching in the Posterior Temple (Fig. 4.9)
		4.4.2	 Anterior Temple
			4.4.2.1	 Gross Anatomic Finding: Anterior Temple (Fig. 4.11)
			4.4.2.2	 Histologic Finding: Anterior Temple (Fig. 4.12)
		4.4.3	 Zygomatic Arch
			4.4.3.1	 Gross Anatomic Finding: Zygomatic Arch (Fig. 4.15)
			4.4.3.2	 Histologic Finding: Zygomatic Arch (Fig. 4.16)
		4.4.4	 Subzygomatic Area
			4.4.4.1	 Gross Anatomic Finding: Subzygomatic Area (Fig. 4.18)
			4.4.4.2	 Histologic Finding: Subzygomatic Area (Fig. 4.19)
		4.4.5	 Lateral Cheek
			4.4.5.1	 Gross Anatomic Finding: Lateral Cheek (Fig. 4.21)
			4.4.5.2	 Histologic Finding: Lateral Cheek (Fig. 4.22)
	4.5	 Summary of Pinch Anatomy
		4.5.1	 Important Area for Pinch Anatomy
			4.5.1.1	 Posterior Temple
			4.5.1.2	 Zygomatic Arch
5: PDO Thread Lifting
	5.1	 Beginning of PDO Monofilament Thread Lifting
	5.2	 Beginning of PDO Cogged Threads for Lifting
	5.3	 Action Mechanism of PDO Thread Lifting
		5.3.1	 Reinforcement Effect
		5.3.2	 Scaffold Effect
		5.3.3	 Indirect Block Effect of Cutaneous Insertion Sites of Facial Muscles
		5.3.4	 Lifting Effect
		5.3.5	 Histological Effect
6: Recent Advances in Thread Lifting
	6.1	 Definition of Moving Plane
		6.1.1	 Understanding Facial Layer and Moving Plane
		6.1.2	 Main Moving Planes for each Facial Area
		6.1.3	 Pinch Maneuver and Moving Plane
	6.2	 SMAS Repositioning Technique for Cogged Thread Lifting Based on the Moving Plane Concept
	6.3	 Improvement of Sagging and Wrinkles around Nose and Mouth—Reverse Technique Using Cogged Threads and Cross Technique Using Volumizing Non-Cogged Threads
		6.3.1	 Mechanisms of Nasolabial Folds and Marionette Lines
		6.3.2	 Reasons for the Reverse Technique Using Cogged Threads and the Cross Technique Using Volumizing Non-Cogged Threads
		6.3.3	 The Reverse Technique with Cogged Threads and the Cross Technique with Volumizing Non-Cogged Threads for Nasolabial Folds
			6.3.3.1	 Anatomical Considerations
			6.3.3.2	 Procedure Designs and Techniques
		6.3.4	 The Reverse Technique with Cogged Threads and the Cross Technique with Volumizing Non-Cogged Threads for Marionette Lines
			6.3.4.1	 Anatomical Considerations
			6.3.4.2	 Procedure Designs and Techniques
	6.4	 Procedures Possible to Be Used in Combination
	6.5	 Evolution of Absorbable Thread Type
		6.5.1	 Generational Differences in Absorbable Thread Lifting
		6.5.2	 Various Types of Absorbable Threads
	6.6	 Introducing the Structure of the Latest Absorbable Thread Products
		6.6.1	 I-THREAD
		6.6.2	 Reversed Trapezoidal PDO Cogged Thread
		6.6.3	 Cone Mixed-Type PLLA Thread
7: Basic Treatment Process for Thread Lifting
	7.1	 Patient Selection and Design
		7.1.1	 Finding Vector
		7.1.2	 Making Reference Points (Fig. 7.2)
		7.1.3	 Marking Hazardous Areas
			7.1.3.1	 The Importance of Thread and Patient Selection
			7.1.3.2	 The Importance of Design and Vectors
	7.2	 Anesthesia
		7.2.1	 Anesthesia with Dental Lidocaine
		7.2.2	 Anesthesia with Cannula
	7.3	 Entry Points
		7.3.1	 The Position of Entry Point
		7.3.2	 The Number of Entry Point
		7.3.3	 Selection of Entry Point Making Tools
		7.3.4	 Precautions During Entry Point Puncture—Bleeding (Superficial Temporal Artery and Vein) (Figs. 7.10, 7.11 and 7.12)
	7.4	 Insertion of Threads
		7.4.1	 Various Techniques and Insertion Tools
			7.4.1.1	 Disposable Cannula (Blunt/Sharp Cannula)
		7.4.2	 Insertion of the Thread After Cannula Insertion
		7.4.3	 Temporal Fixation (Long Thread—41 Cm)—U Pattern (Fig. 7.16)
		7.4.4	 Insertion Using a Thread with Needles Attached at both Ends
	7.5	 Cutting and Finishing
		7.5.1	 Removal of Cannula
		7.5.2	 Cutting
			7.5.2.1	 Cutting while Pulling
				Points to Watch
				Prevention of Complication
			7.5.2.2	 Cutting with Sterilizing Scissors while Slightly Pushing the Skin
8: Various Techniques for Thread Lifting
	8.1	 Basic Techniques Using the Mono-Thread
		8.1.1	 Mono-Thread Insertion
		8.1.2	 Expected Outcomes Based on the Mono-Thread Procedure
		8.1.3	 Procedure Method
			8.1.3.1	 Treatment of Neck Line
			8.1.3.2	 Mono-Thread Technique for Inner Cheek
			8.1.3.3	 Mono-Thread Technique—Frontal Cheek and Nasolabial Area
	8.2	 Basic Techniques Using the Cogged Threads
		8.2.1	 Unidirectional Cog Thread
		8.2.2	 Spike-Type Cog Thread
		8.2.3	 Zigzag Method
		8.2.4	 Engraved Thread
		8.2.5	 Bidirectional Cog
			8.2.5.1	 Understanding Bidirectional Cog
			8.2.5.2	 Angle Technique Using Bidirectional Cogs
			8.2.5.3	 V Technique (Bending and Fixing) (Fig. 8.21)
			8.2.5.4	 Tying Method
			8.2.5.5	 X-Cross Technique
	8.3	 Techniques of Tagging the Long Cogged Threads to the Temples
		8.3.1	 Mechanism
		8.3.2	 Insertion Method
			8.3.2.1	 Design
			8.3.2.2	 Anesthesia
				Anesthesia of Entry and Exit Point—Needle
				Anesthesia of Thread Progression Route
		8.3.3	 Entry Point and Anchoring
			8.3.3.1	 Tools for Entry Points
			8.3.3.2	 Anchoring Tools
				Needle
					Temporal Ring
				Depth and Direction of Anchoring Point
				Complication—Prevention and Treatment of Headache
		8.3.4	 Adequate Cannula for Long Thread Insertion (17G)
		8.3.5	 Cutting and Finishing
			8.3.5.1	 Finishing (Tightening)
			8.3.5.2	 Cutting
			8.3.5.3	 Changes in the Skin around the Entry Point (Dimple)
			8.3.5.4	 Fine Wrinkles around the Eyes and Zygomatic Area (Skin Distortion)
		8.3.6	 Differences in the Procedure According to the Number of Threads
			8.3.6.1	 One Thread per One Side of the Face (Figs. 8.36, 8.37 and 8.38)
			8.3.6.2	 Two Threads per One Side of the Face (Figs. 8.39, 8.40 and 8.41)
	8.4	 Techniques Using the Bidirectional Needle Cogged Thread (I-THREAD Magic Plus)
		8.4.1	 Principle
		8.4.2	 Bidirectional Needle Cogged Thread Introduction
		8.4.3	 Procedure Method
			8.4.3.1	 Design
				Straight Pattern
				U-Pattern
			8.4.3.2	 Anesthesia
			8.4.3.3	 Entry Point
			8.4.3.4	 Needle Insertion
			8.4.3.5	 Cutting and Finishing (Traction: Pulling Threads)
	8.5	 Considerations for Skilled Thread Lifting Procedures
		8.5.1	 Temporal Muscle Hypertrophy (or Trigonocephaly)
		8.5.2	 Temporal Hollowness
		8.5.3	 Zygomatic Prominence
		8.5.4	 Sunken Cheek
		8.5.5	 OP Scar (Bone Surgery, Face Lifting Surgery, Etc.)
		8.5.6	 Liposuction/Accusculpt
		8.5.7	 Acne Scar
		8.5.8	 Previous Lifting Procedure History
		8.5.9	 Points to Check with the Patient Before the Procedure
			8.5.9.1	 Lateral Canthus Lifting
			8.5.9.2	 Show Simulation of Treatment Results
			8.5.9.3	 Entry Point Downtime/Hairline Shaving
			8.5.9.4	 Asymmetry Check
		8.5.10	 Prognostic Factor
			8.5.10.1	 Masseter Muscle Hypertrophy
			8.5.10.2	 Thickness of Facial Fat Tissue
			8.5.10.3	Degree of Sagging in the Marionette Line or Jowl
			8.5.10.4	 Degree of Submandibular Fat Sagging
			8.5.10.5	 Elasticity of Tissues in the Front of the Face
9: Procedural Methods of Cogged Thread Lifting by Target Site
	9.1	 Eyebrow Lifting
		9.1.1	 Considerations for Forehead-Eyebrow Lifting
		9.1.2	 Simulation of Eyebrow Lifting (Frontalis Pulling/Traction Test)
		9.1.3	 Simple Fixing Method
			9.1.3.1	 Cog Thread Tie or X-Cross Technique
			9.1.3.2	 Anchoring Method
		9.1.4	 Anatomical Considerations
		9.1.5	 Design
	9.2	 Lateral Canthus and Temporal Hairline Lifting
		9.2.1	 Anatomy of Eye Area
			9.2.1.1	 Techniques That Can Be Used Around the Eyes
			9.2.1.2	 Creating Fixing Points Around the Eyes
		9.2.2	 Precautions
	9.3	 Anterior Malar Lifting for Ogee Curve
		9.3.1	 Anatomical Considerations
		9.3.2	 Procedural Design and Techniques
	9.4	 Lateral and Buccal Cheek Lifting for Oval Shape
		9.4.1	 The Method of Inducing Movement in the Zygomatico-Cutaneous Ligament
		9.4.2	 The Method of Pulling the Sagging Tissues of the Lower Face Toward the Zygomatico-Cutaneous Ligament
			9.4.2.1	 Tie Method
			9.4.2.2	 X-Cross Method
			9.4.2.3	 Reverse Technique
	9.5	 Nasolabial Fold Lifting
	9.6	 Marionette Line and Jowl Lifting
		9.6.1	 Considerations for Marionette Line Lifting
			9.6.1.1	 Angle Technique
			9.6.1.2	 L-Technique
			9.6.1.3	 Tagging Method: Technique for Pulling Behind the Jaw Line
	9.7	 Mandible Borderline Lifting
		9.7.1	 Anatomical Considerations
		9.7.2	 Procedural Design and Techniques
	9.8	 Double Chin Lifting
		9.8.1	 Considerations for Double Chin Lifting
		9.8.2	 Necklace Technique
			9.8.2.1	 Principle
			9.8.2.2	 Design
			9.8.2.3	 Schematic Diagram
			9.8.2.4	 Making an Entry Point
			9.8.2.5	 Insertion of Needle
			9.8.2.6	 Traction and Cutting
			9.8.2.7	 Complications: Pain, Dimpling, and Skin Fold
			9.8.2.8	 Considerations When Choosing a Patient
				Indications (Favorable Outcomes Are Expected)
				Contraindications (Unfavorable Outcomes Are Expected)
			9.8.2.9	 Factors Affecting the Results of the Procedure
		9.8.3	 Under-Ear Tagging Method
		9.8.4	 Neck-Marionette Mixed Method
		9.8.5	 Tie or Simple Burying Method
10: Procedural Methods of Mono-Thread Lifting by Target Site for Wrinkle Improvement
	10.1	 Forehead and Glabellar Wrinkles
	10.2	 Periorbital Lines (Crow’s Feet)
	10.3	 Perioral Lines (Smoker’s Lines)
	10.4	 Neck Lines
		10.4.1	 Wrinkle Filling Method: Mesh-Type Thread
		10.4.2	 Multi-filament-Type Thread Insertion
11: PDO Volumizing Multithread Lifting
	11.1	 Theoretical Backgrounds
	11.2	 The Mechanism and Effect of PDO Volumizing Multithread Lifting
	11.3	 Classification of PDO Volumizing Multithreads
	11.4	 Facial Contouring with PDO Volumizing Multithreads
	11.5	 Possible Target Areas and Applicable Methods for Each Area
		11.5.1	 Forehead and Glabella
		11.5.2	 Temples
		11.5.3	 Nose
		11.5.4	 Infraorbital Hollowness and Midcheek Groove
		11.5.5	 Nasolabial Folds
		11.5.6	 Lateral Cheek Hollow
		11.5.7	 Lips
		11.5.8	 Marionette Lines and Prejowl Sulcus
		11.5.9	 Chin and Jawline
12: Evaluation of Procedural Outcome
	12.1	 Typical Method of Evaluating the Results of Thread Lifting
	12.2	 Evaluation of the Outcomes Using the Morpheus
		12.2.1	 Simulation Using the Morpheus
			12.2.1.1	 Treatment Result Simulation
			12.2.1.2	 Effectiveness Evaluation
			12.2.1.3	 Interpretation of Results
		12.2.2	 Evaluation of Actual Pre- and Post-treatment Photos Using the Morpheus
	12.3	 The Potential and Future of Pre-treatment Prediction or Post-treatment Result Evaluation System
13: Overall Adverse Events of Thread Lifting and Its Management
	13.1	 Common Complications
		13.1.1	 Dissatisfaction
			13.1.1.1	 Excessively High Expectations of the Patient
			13.1.1.2	 Patients Who Are Difficult to Treat
			13.1.1.3	 Structural Limitations of Thread Lifting Products
			13.1.1.4	 Issues with the Practitioner’s Technique
		13.1.2	 Stiffness and Pain
			13.1.2.1	 Pain Due to Infection
			13.1.2.2	 Pain Caused by Hematoma
			13.1.2.3	 Pain Caused by a Cog Catching on Skin Tissue
			13.1.2.4	 When the End of the Thread Irritates the Skin
		13.1.3	 Swelling
		13.1.4	 Bruising and Hematoma
			13.1.4.1	 Damage to the Dermal Plexus Caused by Needle-Based Threads
			13.1.4.2	 Entry Point Bleeding
			13.1.4.3	 Bleeding Along the Path of the Cannula
		13.1.5	 Dimpling
			13.1.5.1	 The Principle Behind the Formation of Dimples
				When the Insertion Depth of the Cog Is Not Uniform
				Indentation at the Cutting Site
				When Some Cogs Catch Unevenly in the Dermal Layer
			13.1.5.2	 Types of Dimples by Facial Area
				Dimples Along the Thread Path
				Exit Point Dimple: Temporal Tagging Method
			13.1.5.3	 Entry Point Dimple: Temporal Tagging Method
				Principle of Entry Point Dimple
				Prevention of Entry Point Dimple
				Solutions
		13.1.6	 Skin Fold
			13.1.6.1	 Check Point
			13.1.6.2	 Causes and Solutions
		13.1.7	 Bulging of Entry Points
			13.1.7.1	 Frequent Area
			13.1.7.2	 Solutions
			13.1.7.3	 Preventions
		13.1.8	 Protrusion of Threads
			13.1.8.1	 Protrusion Outside the Skin
			13.1.8.2	 Protrusion in the Oral Cavity
			13.1.8.3	 Thread Near Protrusion (Fig. 13.19)
		13.1.9	 Migration of Threads
			13.1.9.1	 Thread Without Cogs
			13.1.9.2	 Incorrect Cutting of Bidirectional Cogged Threads
			13.1.9.3	 Damage to the Thread Due to Prolonged Storage
		13.1.10	 Relapse
	13.2	 Unusual Complications
		13.2.1	 Temporary Paralysis of Facial Nerve
			13.2.1.1	 Etiology
			13.2.1.2	 Clinical Presentation
			13.2.1.3	 Solution
		13.2.2	 Permanent Facial Nerve Injury
		13.2.3	 Sensory Nerve Injury: Greater Auricular Nerve Injury
		13.2.4	 Elevation of Lateral Canthus
			13.2.4.1	 Etiology
			13.2.4.2	 Solutions
			13.2.4.3	 Prevention
		13.2.5	 Sunken Cheek
			13.2.5.1	 Anatomical Structure
			13.2.5.2	 Clinical Significance
			13.2.5.3	 Precautions
		13.2.6	 Penetrating Salivary Gland
		13.2.7	 Infection
			13.2.7.1	 Thread Lifting and Infection
			13.2.7.2	 Prevention of Infection
			13.2.7.3	 Treatment at Infection Case
Further Reading