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15 Soft Tissue Surgery Combined withtheMandible Contouring Surgery
15.7 Case Study
Case 1
A 34-year-old woman visited the clinic for the V-line surgery to achieve a more slender face.
But she had risk factors of soft tissue sagging after mandible reduction surgery, such as abundant soft tissue on the cheek and loose skin tension. Therefore, laser-assisted liposuction and
barbed thread lifting were done simultaneously with the V-line surgery. The amount of aspirate
was 12cc on each cheek and 10cc on submental area, so a total of 34cc. Then, barbed thread
lifting was performed, four threads on each side. After 2months, the patient was satised with
the V-line face (Fig.15.4).
Fig. 15.4 A 34-year-old
patient with history of
mandible reduction
operation 18months
ago. (a) Before the V3
lift procedure, (b)
1month after the V3 lift
procedure
151
b
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152
a
Case 2
S. Park and J. Y. Kwon
A 38-year-old woman with a surgical history of a conventional mandible angle reduction complained of the jowl and deep nasolabial folds. Elastic lifting was performed for the improvement
of jowl and nasolabial folds. After 2months, the patient was satised with the youthful appearance (Fig.15.5).
Fig. 15.5 A 38-year-old
patient who underwent
mandible reduction
operation complains of
jowl and deep nasolabial
fold. (a) Before the
elastic lift, (b) 1month
after the elastic lift
b
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15 Soft Tissue Surgery Combined withtheMandible Contouring Surgery
153
15.8 Complications
andManagement
15.8.1 Skin Depression
andPalpability
Both barbed and elastic thread lifts, while effective in facial rejuvenation, can potentially cause
complications such as dimpling or depression if
not executed with precision. Dimpling can occur
with barbed thread lifts, particularly if the thread
is placed too supercially or if the remaining end
of the barbed thread near the exit site is too long.
To prevent this, surgeons should ensure the thread
is inserted at the appropriate depth and trim the
end of the barbed thread sufciently after exiting
the skin. If dimpling does occur, gentle massage
or spreading the overlyin skin can often resolve
the issue. However, in more severe cases where
massage is ineffective, the removal of the barbed
thread might be necessary. If passed too supercially, multiple barb may be palpable, necessitating their removal.
While elastic threads, which lack barbs, generally have a lower risk of causing dimpling, they
can still lead to depression or dimpling at the target lifting site if excessive traction force is
applied. To avoid this, surgeons should carefully
control the traction force and evaluate the lifting
results with the patient in a sitting position, as
this provides a more accurate assessment than
when the patient is lying down. If complications
such as dimpling or depression occur after an
elastic lift, massage is typically not effective. In
such scenarios, removing the elastic thread is
often the only viable solution.
Both types of lifts require a delicate balance
between achieving the desired lifting effect and
avoiding undue pressure on the skin and underlying tissues.
15.8.2 Neurapraxia
In the realm of facial rejuvenation procedures
like laser-assisted liposuction, barbed thread
lifting, and elastic lifting, nerve-related complications, though rare, can have signicant impacts.
With laser-assisted liposuction, there’s a risk of
damaging the marginal mandibular branch of the
facial nerve due to the thermal energy used. This
can lead to symptoms such as lip twisting or pulling of the mouth corner toward the unaffected
side. Similarly, during barbed thread lifting and
elastic lifting, the frontal nerve may be at risk,
especially when maneuvers are performed near
the area between the ear and eyebrows. The use
of tools like the Owl, particularly around Lore’s
fascia, can accidentally encircle branches of the
facial nerve, causing transient muscle expression
weakness. If symptoms of nerve found, immediate release of thread should be considered. Most
cases of transient neurapraxia can be effectively
managed with conservative treatments, such as
administering intravenous or oral steroids. In
cases of severe asymmetry, strategic use of botulinum toxin injections on the unaffected side can
help balance the facial appearance until it recovers. Thankfully, there have been no reports of
permanent paralysis in patients monitored over a
6-month follow-up period. Patient education
about the potential risks and postoperative management strategies is also an essential aspect of
preoperative consultation.
15.8.3 Infection
In cases where facial bone contouring surgery is
performed simultaneously with rejuvenation procedures such as laser-assisted liposuction, barbed
thread lifting, or elastic lifting, there is an elevated risk of infection. This risk primarily arises
from the potential connection between the intraoral space and the subcutaneous plane during
these procedures. To minimize this risk, surgeons
must meticulously adhere to the appropriate subcutaneous layer, avoiding any breach of the elevated supraperiosteal plane.
Infection signs in patients, such as pain, a sensation of heat, redness, excessive swelling, and
uctuation due to uid collection, necessitate
prompt attention. Managing these infections can
be challenging due to their extensive nature.
Prompt removal of thread should be considered if
symptom shows spreading signs along the course
t.me/Dr_Mouayyad_AlbtousH
154
S. Park and J. Y. Kwon
of thread. While mild infections may respond
well to conservative treatment with intravenous
antibiotics, severe cases often require surgical
intervention, including debridement and irrigation, to effectively manage the infection and prevent further complications.
15.9 Discussion
Laser-assisted liposuction has emerged as a more
effective alternative to conventional liposuction
for facial applications, due to its ability to efciently target and remove even small amounts of
fat. This technique, rst introduced by Apfelberg
in the 1990s, is particularly suited for the facial
area where fat layers are thinner and denser compared to body areas like the abdomen or thigh.
The laser’s ability to melt fat reduces the risk of
contour irregularities that are typically associated
with the uneven suctioning and repetitive cannula
movements of traditional liposuction [15]. A signicant benet of laser-assisted lipolysis is its
skin-tightening effect. By heating the dermal and
subdermal tissues while removing fat, it triggers
an inammatory reaction that leads to the formation of new collagen and elastin bers, resulting
in skin tightening [16, 17].
Initially, the 1064-nm Nd:YAG laser was the
primary choice for lipolytic procedures, proven
effective in numerous studies [18–20]. However,
the 1444nm Nd:YAG laser has shown to have a
fat absorption rate more than ten times higher
than the 1064 nm wavelength, offering greater
thermal connement and less damage to surrounding tissues [22, 23]. This makes the
1444nm laser a more effective and safer option
for laser lipolysis [24, 25]. Its application in
laser-assisted facial contouring, either as a standalone procedure or in combination with facial
contouring surgeries, has demonstrated signicant improvements in facial contours [26, 27].
In our practice, we have integrated the use of
barbed suture lifts alongside laser-assisted liposuction to enhance facial rejuvenation. This
approach effectively addresses the limitations of
each procedure when used independently. The
barbed suture lift, initially introduced globally as
Aptos threads in 1999, was designed to elevate
the soft tissues of an aging face through 2-0 polypropylene sutures with bidirectional barbs,
anchored in the dermis [5, 6]. The technique
evolved with modications by Lee and Isse in
2005, resulting in the Isse Endo Progressive Face
Lift suture, anchored in the temporalis fascia for
greater load-bearing capacity [7]. Gaining FDA
approval in 2005, barbed sutures were introduced
to the market as contour threads, specically for
lifting ptotic skin of the face and neck [8, 9].
Subsequently, Angiotech Pharmaceuticals
released the Quill Suture Retained Suspension
(SRS) in 2007, offering both nonabsorbable
polypropylene and absorbable monoderm and
polydioxanone variants [28, 29].
Our preference leans toward the “xation
type” barbed suture, which anchors superiorly, as
opposed to the “non-xing oating type,” due to
its enhanced capacity to counteract gravitational
forces. We typically utilize the 0-0 bidirectional
barbed absorbable PDO suture (Quill SRS
suture), anchoring the suture material to the temporal fascia and tympanoparotid fascia (Lore’s
fascia). This anchoring technique, involving a
hooking maneuver on the fascia, provides a more
robust lift of the soft tissue. The temporal and
Lore’s fascia have proven to be the most effective
sites for anchoring and sustaining the thread lift’s
effectiveness.
While the barbed suture lift has faced criticism for providing only short-term improvement,
we nd it particularly benecial for younger
patients experiencing soft tissue ptosis, such as
cheek drooping and jowls, following facial bone
contouring surgery. This method is especially
appealing to those who wish to avoid more extensive surgical procedures.
The elastic lift technique presents several
advantages compared to the barbed thread lift,
primarily due to its unique properties and
application methods. Firstly, elastic lifting
offers a more durable elevation effect compared to absorbable barbed threads. The nonabsorbable elastic thread, unlike barbed
threads, features a braided polyester surface.
According to Huggins etal., the connective tissue integration within the braided suture’s
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15 Soft Tissue Surgery Combined withtheMandible Contouring Surgery
155
interstices resembles ligament characteristics,
contributing to its long-term stability [30].
Secondly, the inherent elasticity of the thread
ensures a more natural lifting effect, both in
resting and dynamic facial expressions. It’s
crucial to avoid overtightening the thread during knotting, as this allows for a more natural
immediate postoperative appearance, unlike
the rigidity often observed with barbed suture
lifting. Thirdly, the elastic thread is designed to
be impalpable. Its consistency closely matches
that of the surrounding soft tissues, and its
smooth, non-barbed surface further minimizes
palpability, enhancing patient comfort.
Fourthly, the ease of removal is a notable
advantage. The core of the nonabsorbable
thread, made of silicone, does not adhere
strongly to surrounding tissues, facilitating its
removal if necessary.
However, there are limitations to consider
with elastic lifting. Some patients express apprehension about having nonabsorbable materials
placed in their faces. Additionally, mastering the
technique requires time and experience, particularly in aspects like insertion layers and traction
force control. Lastly, compared to the barbed
thread lift, there is comparatively less long-term
data available regarding the efcacy and potential
complications of the elastic lift. Despite these
limitations, the elastic lift remains a valuable and
effective option in facial rejuvenation, particularly for patients seeking a more natural and
long-lasting result.
References
1. Jin H.Reduction malarplasty. J Korean Soc Aesthetic
Plast Surg. 2010;16:1–8.
2. Baek RM, Kim J, Kim BK. Three-dimensional
assessment of zygomatic malunion using computed
tomography in patients with cheek ptosis caused by
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2012;65(4):448–55.
3. Jin H. Reduction malarplasty using an L-shaped
osteotomy through intraoral and sideburns incisions.
Aesth Plast Surg. 2011;35(2):242–4.
4. Villa MT, White LE, Alam M, Yoo SS, Walton
RL.Barbed sutures: a review of the literature. Plast
Reconstr Surg. 2008;121(3):102e–8e.
5. Sulamanidze MA, Fournier PF, Paikidze TG,
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6. Sulamanidze MA, Paikidze TG, Sulamanidze GM,
Neigel JM.Facial lifting with “APTOS” threads: featherlift. Otolaryngol Clin N Am. 2005;38(5):1109–17.
7. Lee S, Isse N.Barbed polypropylene sutures for midface elevation: early results. Arch Facial Plast Surg.
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8. Horne DF, Kaminer MS.Reduction of face and neck
laxity with anchored, barbed polypropylene sutures
(contour threads). Skin Ther Lett. 2006;11(1):5–7.
9. Kaminer MS, Bogart M, Choi C, Wee SA.Long-term
efcacy of anchored barbed sutures in the face and
neck. Dermatologic Surg. 2008;34(8):1041–7.
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2009;36(2):281–306.
11. Bisaccia E, Kadry R, Rogachefsky A, Saap L,
Scarborough DA. Midface lift using a minimally
invasive technique and a novel absorbable suture.
Dermatologic Surg. 2009;35(7):1073–8.
12. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes
in thread lift for facial rejuvenation. Ann Plast Surg.
2009;62(5):482–5.
13. Abraham RF, DeFatta RJ, Williams EF III.Threadlift for facial rejuvenation: assessment of long-term
results. Arch Facial Plast Surg. 2009;11(3):178–83.
14. Rachel JD, Lack EB, Larson B.Incidence of complications and early recurrence in 29 patients after facial
rejuvenation with barbed suture lifting. Dermatologic
Surg. 2010;36(3):348–54.
15. Apfelberg DB, Rosenthal S, Hunstad JP, Achauer
B, Fodor PB. Progress report on multicenter study
of laser-assisted liposuction. Aesth Plast Surg.
1994;18(3):259–64.
16. Goldman A, Wollina U, de Mundstock EC.Evaluation
of tissue tightening by the subdermal Nd: YAG laserassisted liposuction versus liposuction alone. J Cutan
Aesthet Surg. 2011;4(2):122–8.
17. Kim JH, Min KH, Heo CY, Baek RM, Park HJ, Youn
SW, Kim EH.Histological evaluation of dermal tissue
remodeling with the 1444-nm neodymium:yttriumaluminum- garnet laser in invivo model. J Dermatol.
2013;40(9):706–10.
18. Woodhall KE, Saluja R, Khoury J, Goldman MP. A
comparison of three separate clinical studies evaluating the safety and efcacy of laser-assisted
lipolysis using 1,064, 1,320 nm, and a combined
1,064/1,320nm multiplex device. Lasers Surg Med.
2009;41(10):774–8.
19. Badin AZ, Moraes LM, Gondek L, Chiaratti MG,
Canta L. Laser lipolysis: accidity under control.
Aesth Plast Surg. 2002;26(5):335–9.
20. Fakhouri TM, El Tal AK, Abrou AE, Mehregan
DA, Barone F. Laser-assisted lipolysis: a review.
Dermatologic Surg. 2012;38(2):155–69.
21. Jacono AA, Bryant LM.Extended deep plane facelift incorporating facial retaining ligament release
and composite ap shifts to maximize midface,
jawline and neck rejuvenation. Clin Plast Surg.
2018;45:527–54.
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22. Tark KC, Jung JE, Song SY. Superior lipolytic
effect of the 1,444 nm Nd:YAG laser: comparison
with the 1,064nm Nd:YAG laser. Lasers Surg Med.
2009;41(10):721–7.
23. Youn JI, Holcomb JD.Ablation efciency and relative thermal connement measurements using wavelengths 1,064, 1,320, and 1,444nm for laser-assisted
lipolysis. Lasers Med Sci. 2013;28(2):519–27.
24. Sasaki GH. Early clinical experience with the
1440-nm wavelength internal pulsed laser in facial
rejuvenation: two-year follow-up. Clin Plast Surg.
2012;39(4):409–17.
25. Jung YC.Preliminary experience in facial and body
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2011;20(1):39–46.
26. Holcomb JD, Turk J, Baek SJ, Rousso DE. Laserassisted facial contouring using a thermally con-
ned 1444-nm Nd-YAG laser: a new paradigm for
facial sculpting and rejuvenation. Facial Plast Surg.
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27. Sasaki GH, Tevez A.Laser-assisted liposuction for
facial and body contouring and tissue tightening:
a 2-year experience with 75 consecutive patients.
Semin Cutan Med Surg. 2009;28(4):226–35.
28. Paul MD.Barbed sutures for aesthetic facial plastic
surgery: indications and techniques. Clin Plast Surg.
2008;35(3):451–61.
29. Mulholland RS, Paul MD. Lifting and wound
closure with barbed sutures. Clin Plast Surg.
2011;38(3):521–35.
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t.me/Dr_Mouayyad_AlbtousH
Part III
Midface
t.me/Dr_Mouayyad_AlbtousH
The Comprehensive Aesthetic
Analysis forMidface
SanghoonPark
16
16.1 Pearls
1. The assessment of zygomatic prominence
involves objectively examining key elements
such as the position and volume of the zygomatic body, arch width, and its balance with
other facial structures.
2. A comprehensive evaluation includes clinical
consultation, photographic documentation,
and both radiologic and 3D imaging
analyses.
3. Our classication system categorizes prominent zygoma into four distinct types, each
dened by unique morphological characteristics of various subcomponents.
4. Corresponding to these classications, four
different surgical principles are applied.
Surgical techniques employed I-, L-, and high
L-osteotomies, orbital rim shaving, and tripod
osteotomy.
5. This classication system’s efcacy is validated by improved results, emphasizing the
importance of recognizing individual differences and avoiding common surgical pitfalls.
6. The thickness of the overlying soft tissues,
including skin, subcutaneous fat, muscles,
and buccal fat, is a critical consideration.
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
Patients with thin skin and minimal cheek fat
tend to exhibit more pronounced operative
results and a lower risk of postoperative soft
tissue drooping. Conversely, those with
thicker skin and abundant fat may experience
less noticeable effects and a higher likelihood
of cheek drooping. It’s essential to inform
such patients about the potential for cheek
drooping and to discuss possible adjunctive
measures.
7. Factors identied as high risks for skin and
soft tissue sagging after zygomatic reduction
include being over 40 years of age, having
abundant cheek fat, possessing thin skin with
laxity, presenting with a class II mandible or
ill-dened mandible-neck line, and exhibiting
a deep nasolabial fold or jowls. These considerations are crucial in surgical planning and
patient counseling to ensure optimal outcomes and patient satisfaction.
16.2 Introduction
The zygoma, a pivotal structure in the midface,
possesses a complex three-dimensional character
that poses challenges for quantitative description
and analysis. While Hinderer made signicant
strides in effectively describing the zygoma, the
objectivity and practical applicability of these
descriptions are still not fully assured. Our team
has pioneered in developing an objective classication of the zygoma and the subdivision of the
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. Park (ed.), Facial Bone Contouring Surgery, https://doi.org/10.1007/978-981-97-4992-8_16
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159
160
S. Park
Fig. 16.1 An example of unfavorable results after standard reduction malarplasty. A 27-year-old male showing
under-corrected prominent cheekbone, which was treated
zygomatic body, a crucial advancement given the
historical lack of detailed description of the
zygoma’s subcomponents and their aesthetic
implications. Until recently, these subcomponents were not distinctly identied, and their
roles in achieving aesthetic results were not
clearly understood. Consequently, the recent
surge in the popularity of zygomatic surgeries
has led to a number of suboptimal outcomes
(Fig.16.1). An objective diagnosis of zygomatic
prominence, grounded in a thorough anatomical
understanding, is key to achieving superior
results.
With the evolution of craniofacial surgery, surgeons now have a more extensive array of techniques for zygoma reduction. These techniques
vary in invasiveness and include the less invasive
mini-zygoma reduction (performed via intraoral or
Gillies’ approaches, with or without a preauricular
approach), standard zygoma reduction (employing
both intraoral and preauricular approaches), and
the more aggressive coronal approach [1–5]. The
careful selection and application of these options,
tailored to the specic classication of zygomatic
prominence and the patient’s individual needs, are
crucial for optimal results.
In this article, we provide a detailed description of the subtypes of zygomatic prominence
by conventional L-shaped osteotomy technique. (Left)
Preoperative view, (Right) 3months after reoperation
and the corresponding surgical techniques, offering insights into the nuanced approaches required
for effective aesthetic enhancement of the zygomatic area.
16.3 Patient Consultation
andAssessment
Preoperative assessment should include a history
of previous malar contouring procedures, including autologous fat injection, ller injection, or
alloplastic implant placement such as silicone or
Medpor®. Especially, patients with prior history
of fat or ller injection are more likely to have
greater chance of cheek drooping. In addition,
special care should be taken not to neglect the
inammatory conditions such as sinusitis or
periodontal disease. This is because such conditions can be exacerbated by surgery and are
therefore best treated prior to surgery. The degree
of eye prominence should also be examined
prior to surgery, as this can inuence the optimal
reduction of protruding inferolateral orbital rim.
In particular, patients with enopthalmic eyeballs
are at risk for undercorrection and should be
considered for sufcient reduction of external
orbital rim.
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16 The Comprehensive Aesthetic Analysis forMidface
16.3.1 Preoperative Analysis
The evaluation of the malar area is somewhat
hindered by a lack of anthropometric or
cephalometric landmarks along its complex
three- dimensional curvature [6]. The point zygion (Fig.16.4, point Zy), which denes the maximum interzygomatic distance (zygion-zygion),
does not correspond to the area of maximum
malar prominence (MMP). Malar contouring
involves not only the zygomatic region but also
the periorbital region. Pitfalls can be avoided if
one is conscious about these relationships.
Evaluation should include the three basic views:
frontal, three-quarter oblique, and basal. Direct
physical examination is the key process to evaluate the patient’s problems and establish a surgical
plan. Clinical photos are necessary as is radiologic examination including frontal view, lateral
view, submentovertex view, and Waters’ view.
CT scan with 3D view is also essential to evaluate
the shape of the zygomatic complex.
161
16.3.1.1 Frontal Evaluation
The frontal evaluation can be simplied by visualizing an anterior and posterior facial plane
(Fig.16.2). The anterior facial plane is dened by
the superior temporal line, lateral border of the lateral orbital rim, malar prominence, midface, and
mentum (Fig.16.2, blue line). The posterior facial
plane is circumscribed by the contour line of the
head (Fig.16.2, red line). A combination of variable forms of these two planes denes a variety of
facial shapes. In the case where the cheekbones
protrude outwardly, the facial line connecting the
temple-zygoma-cheek-mandible angle constitutes
a very convoluted line (Fig. 16.2). Volume and
position of zygomatic body and bizygomatic
width are key variables to be considered. The volume of zygomatic body determines the amount of
ostectomy during the surgery. If the volume of
zygomatic body is large, wider resection of zygomatic body is planned. However, overzealous
reduction results in at or decient look. Therefore,
keeping the adequate volume of zygomatic body
in anteroposterior dimension and transverse plane
Fig. 16.2 Anterior and posterior facial contour lines. The
anterior facial contour line connects the temple, zygomatic body, cheek, and mandible body (blue line), while
the posterior facial contour line connects the temple,
zygomatic arch, mandible angle, and chin (red line). If the
anterior contour line is too convoluted, the patient gives a
“strong,” “offensive,” “old,” “tired,” “masculine” impression. The posterior contour line reects the facial width
and facial size
is essential. The position of zygomatic body is
measured in both, its most lateral margin and in its
maximal projection. Outer margin of zygomatic
body is observed in conjunction with temple and
cheek. To narrow the anterior midfacial width, lateral margin of cheekbone should be trimmed or
moved inward. If the outer margin of cheekbone is
placed wide, the amount of narrowing and medialization should be maximized, and ostectomy
should be combined.
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