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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
xii
About the Authors
Published Books
• The Art and Science of Thread Lifting Based
on Pinch Anatomy and Moving Plane (2024)
Springer Nature Singapore Pte Ltd.
• Arteries & Veins of the Face (2024)
MDWORLD Medical Publishing Co.
• The Art and Science of Thread Lifting (Korean
Version) (2024) KOONJA Publishing Inc.
• The Art & Science of Filler Procedure (Korean
Version) (2024) KOONJA Publishing Inc.
• All About Fillers (2023) MDWORLD Medical
Publishing Co.
• HA Filler Guide Book for Restylane (2023)
MDWORLD Medical Publishing Co.
• Minimally Invasive Aesthetic Surgery
Techniques (2022) Springer Nature Singapore
Pte Ltd.
• Nerves of the Face (2021) MDWORLD
Medical Publishing Co.
• The Art and Science of Filler Injection (2021)
Springer Nature Singapore Pte Ltd.
• Botulinum Toxin Clinical Usage (2020)
MDWORLD Medical Publishing Co.
• Thread Lifting Clinical Usage (2020)
MDWORLD Medical Publishing Co.
• Practical Guidelines for Effective and Safe Filler
Procedures (2019) KOONJA Publishing Inc.
• Clinical Application of Thread Lifting (2019)
MDWORLD Medical Publishing Co.
• Clinical Application of Botulinum Toxin
(2019) MDWORLD Medical Publishing Co.
• Clinical Anatomy for Filler & Toxin (2018)
MEDICAL Observer
• Practical Guideline for Effective and Safe
Filler Procedure (2018) KOONJA Publishing
Inc.
• Filler.Toxin Practical Knowhow (2017)
MDWORLD Medical Publishing Co.
• Practical Knowhow of Minimally Invasive
Aesthetic Surgery (2016) Most M.D&PS
Publishing Inc.
• Minimally Invasive Plastic Surgery (MIPS)
Hand Book (2015) Medimembers
About the Authors
xiii
SeungminOh, MD, MMBA
Specialty
Aesthetic Physician
Director of ON Clinic Dermatology & Plastic
Surgery
Education & Professional Background
• Graduated from Seoul National University
College of Medicine
• Trained at Seoul National University Hospital
• Clinical Lecturer at Seoul National University
Hospital
• Chair of Academic Committee, Korean
Association for Laser, Dermatology and
Trichology (KALDAT)
• Board Member, ICLAS
• CEO, OK Medi Co. Ltd.
• Advisory Board Member, Galderma—
Restylane
• Advisory Board Member, S.Thepharm—QT ll
Books
• The Art and Science of Thread Lifting based on
Pinch Anatomy and Moving Plane. Springer
Nature, 2024
• The Art and Science of Thread Lifting. Springer
Nature, 2019
• The Art and Science of Filler Injection.
Springer Nature, 2020
Awards
• Best Experimental Paper Award 2021. Plastic
and Reconstructive Surgery (PRS)
Scientic Articles (SCI & SCIE)
• Changes in the neck tissue layers during pinch
manipulation: implications for lipolytic deoxycholate injections for double chin. Journal of
Cosmetic Dermatology. https://doi.
org/10.1111/jocd.14696
• Tissue changes over time after polydioxanone
thread insertion: an animal study with pigs.
Journal of Cosmetic Dermatology. 2018:1–7
xiv
About the Authors
• Changes in the layers of the temple during
pinch manipulation: implications for thread
lifting. Dermatologic Surgery. 2019;00:1–6
• Development and usability of a virtual realitybased ller injection training system. Aesthetic
Plastic Surgery. 2020. https://doi.org/10.1007/
s00266- 020- 01872- 2
• Comparative effectiveness of different interventions of perivascular hyaluronidase. Plastic
and Reconstructive Surgery. 145:957, 2020
• Comparison of hyaluronic acid ller ejection
pressure with injection force for safe ller
injection. Journal of Cosmetic Dermatology.
2021;00:1–6
• Current practices and perceived effectiveness
of polynucleotides for treatment of facial erythema by cosmetic physicians. Skin Research
and Technology. 2023:29:e13466
• Lateral facial thread lifting procedure with
temporal anchoring in deep temporal fascia:
Anatomical perspectives of supercial temporal artery. Skin Research and Technology.
2024:30:e13587
• Aesthetic doctors’ perception and attitudes
toward tolerance in botulinum toxin. Skin
Research and Technology. 2024:30:e13691
• Investigating the mechanisms of intradermal
injection for easier “skin booster” treatment: a
uid mechanics approach to determine optimal
delivery method. Plastic and Reconstructive
Surgery– Global Open. 2024;12:e5723. https://
doi.org/10.1097/GOX.0000000000005723
• Polynucleotide injection treatment for iatrogenic fat atrophy in two patients: Potential for
safe volumization in aesthetic medicine. Skin
Research and Technology. 2023;29:e13439
• Assessment of current practices and perceived
effectiveness of injectable polynucleotide for
enlarged facial pores among cosmetic physicians: A survey-based evaluation. Skin
Research and Technology. 2024;30:e13738
• High-Intensity Focused Ultrasound Increases
Facial Adipogenesis in a Swine Model via
Modulation of Adipose-Derived Stem Cell
Cilia. International Journal of Molecular
Sciences. 2024;25:7648. https://doi.
org/10.3390/ijms25147648
About the Authors
xv
YongwooLee
• Board-certied Plastic Surgeon
• President of LIKE Plastic Surgery Clinic
• Director of External Relations, Committee of
Korean Association of MIPS (Minimally
Invasive Plastic Surgery)
• Member of The Korean Society of Plastic and
Reconstructive Surgery
• Member of The Korean Society of Aesthetic
Plastic Surgery
• Clinical Professor, Department of Plastic
Surgery, Han-Yang University Medical Center
• Editorial Board Member of AA (Atlas
Aesthetics) Journal
• Advisory Board Member of Samyang
holdings
• Advisory Board Member of Galderma Korea
• Advisory Board Member of Medytox
• Advisory Board Member of Hugel
• Advisory Board Member of Dongbang
medical
• Advisory Board Member of N-nders
Published Books
• Minimally Invasive Aesthetic Surgery
Techniques (2022) Springer Nature Singapore
Pte Ltd.
• The Art and Science of Filler Injection (2021)
Springer Nature Singapore Pte Ltd.
• Botulinum Toxin Clinical Usage (2020)
MDWORLD Medical Publishing Co.
• Thread Lifting Clinical Usage (2020)
MDWORLD Medical Publishing Co.
• Practical Guidelines for Effective and Safe
Filler Procedures (2019) KOONJA Publishing
Inc.
• Clinical Anatomy for Filler & Toxin (2018)
MEDICAL Observer
• Filler techniques based on in-depth anatomical
deliberation (2018) KOONJA Publishing Inc.
xvi
About the Authors
JeongmokCho
• Board Certied Plastic Surgeon
• President of Etonne Plastic Surgery Clinic
• Seoul National University College of Medicine
• Residency, Dept of Plastic and Reconstructive
Surgery, Seoul National University Hospital
• Master’s degree, Dept of Plastic and
Reconstructive Surgery, Seoul National
University College of Medicine
• Ph. D candidate, Dept of Plastic and
Reconstructive Surgery, Seoul National
University College of Medicine
• Active member, Korean Society of Plastic and
Reconstructive Surgeons
• Active member, Korean Society of Aesthetic
Plastic Surgery
• Active member, Korean Cleft PalateCraniofacial Association
• Director of General Affairs, Breast Plastic
Surgery Research Society of the Korean
Society of Plastic and Reconstructive Surgeons
• Director of General Affairs, The Association of
Minimal Invasive Plastic Surgery of the Korean
Society of Plastic and Reconstructive Surgeons
(MIPS)
• Executive Director, Korean Association of
Plastic Surgeons
• Medical Advisor for Jungheon Pharmaceutical
• Medical Advisor for MERZ Korea
• Medical Advisor for Galderma Korea
• Editorial Board Member for Restylene AA
• Editorial Board Member for Filler & Toxin
Textbook Publications
• Minimally Invasive Aesthetic Surgery
Techniques (2022) Springer Nature Singapore
Pte Ltd.
• Minimal Invasive Plastic Surgery (2022)
MDWORLD Medical Publishing Co.
Journal Publications
• Etiology of Delayed Inammatory Reaction
Induced by Hyaluronic Acid Filler. Arch. Plast.
Surg. 51, 020–026 (2023).
• Effect of platelet-rich plasma on ultraviolet
b-induced skin wrinkles in nude mice. Journal
of Plastic, Reconstructive & Aesthetic Surgery:
JPRAS. 2011;64(2):e31–9.
The Art andScience ofFiller
Procedures foraMore Attractive
Face
1
1.1 History ofFiller Procedures
The current trend and prevailing issue in aesthetic
medicine are creating natural beauty. In addition
to enhancing natural beauty with cosmetics, hair
products, and fashion items, more and more people are fervently striving for healthier lifestyles
and well-being. Such social and cultural changes
have not only impacted the eld of aesthetic
medicine but have also changed how people react
to facial changes related to aging. People seek to
age beautifully but focus has shifted. From deliberately reverting and masking the signs of aging
and inadvertently looking awkward, more and
more people are pursuing beauty that is natural,
graceful, and effortless.
Minimally invasive cosmetic procedures,
including ller procedures, do not require the
patient to go under the knife. There is less swelling, and there are barely any signs of having
undergone a medical aesthetic procedure. Patients
can be discreet and are able to return to their daily
lives with more convenience. Moreover, because
minimally invasive procedures do not cause signicant changes to the facial skin and tissue, they
are highly unlikely to cause any permanent side
effects. Moreover, additional procedures may be
performed at any time.
Facial llers are in widespread use today and
have rmly established their place in the aesthetic armamentarium among the minimally
invasive cosmetic procedures. Unlike in the ear-
lier years, the materials and manufacturing methods used to produce llers have become much
more sophisticated. The indications for ller procedure have broadened, and the efcacy of ller
procedures has also advanced extensively. Fillers
account for a signicant portion of the medical
aesthetics market, and ller procedures performed indiscriminately by professionals who
lack adequate medical knowledge regarding clinical anatomy, accurate injection techniques, and
the potential complications have led to reports of
many adverse events. To ensure optimal outcomes without complications, in-depth studies
and discussions regarding the most appropriate
procedural methods is paramount. In addition,
the physician must assess the patient’s psychosocial, philosophical, and cultural perspectives on
beauty during the initial consultation and take
these factors into consideration when coming up
with a treatment plan.
Filler administration, a minimally invasive
procedure, offers the advantages of immediate
results, short recovery time, high satisfaction relative to the convenience of the procedure, average results relative to ease of procedure, and ease
of repeat treatments. Disadvantages include low
protability due to price competition, limitations
in procedural outcomes when compared to surgery, short duration of effect, sensation of a foreign body, post-procedure swelling, intra- and
post-procedure pain, and concerns about procedure process including anesthesia.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
G. Hong et al., The Art and Science of Filler Injection,
https://doi.org/10.1007/978-981-96-9215-6_1
1
2
1 The Art andScience ofFiller Procedures foraMore Attractive Face
However, ller types and quality have
improved markedly, and volumizing ller procedures are supplanting fat graft procedures. Fillers
are used beyond the scope of merely lling out
supercial wrinkles and depressions. Fillers can
create facial shape harmonization and even
improve skin quality.
Although ller injections have become prevalent recently, the actual practice of using substances such as Vaseline to ll depressed areas
was practiced as early as the 1900s. Subsequently,
parafn wax with a low-melting point was used
and became very popular as a ller material for
nearly 20years. However, these substances have
disappeared from the market as they caused
adverse events with serious sequelae. Then during the 1940s, liquid silicone injections into the
breast, hip, and face became very popular in the
United States. However, this too was plagued by
reports of foreign body reactions, and the practice of using chemical substances as llers was
discontinued. Even in Korea, there have been
reports of removing foreign substances from
patients who experienced adverse events. These
patients had illegally received ller injections
from unlicensed practitioners, and the substances
removed were identied as parafn wax and
industrial silicone.
In 1976 collagen llers were introduced but
failed to gain much popularity for various reasons. In 1996, rst-generation HA ller Hylans
was introduced for the rst time. That same year,
second-generation HA ller Restylane entered
the market. Widespread use of llers was
observed in the 2000s. Introduction of Restylane
in Europe was followed by the introduction of
Juvéderm in 2000. The company that manufactured Juvéderm was acquired by an American
company in 2006 and is still being produced
today. Subsequently, many new products have
been introduced, including Teosyal (2003),
Esthelis (2005), Stylage (2007), Glytone (2008),
and Hylaform (2008). European countries are
still producing various types of HA-based llers.
Currently, these countries have established their
positions as industry leaders and produce approximately 300 different ller products (Table1.1).
Table 1.1 History of injectables
Vaseline: 1900~1910
Parafn: 1900~1920
Liquid injectable silicone: Early 1940~1965
Collagen: 1976~2003
PMMA (Polymethyl
methacrylate):
PAAG (Polyacrylamide gel): 1984, 1996~2001
HA (Hyaluronic acid): 1996~2003
PTFE (Polytetrauoroethylene): Late 1990s
PLA (Polylactic acid): 1999~2009
Polyalkylimide: Early 2000s
Ca-HA (Hydroxyapatite): 2001~2006
PCL (Polycaprolactone): 2010s
1992~2006
1.2 The Meaning
ofanAttractiveFace
The sociologist Beverley McNamara stated that
people all have inner desires to look good for
their age, albeit to a different degree. In addition,
there are scholars who state that human health
today does not simply signify physical health, but
also comprises mental, sexual, and aesthetic
health.
An anecdote about Dr. Ivo Pitanguy, a
famous Brazilian plastic surgeon, illustrates
this point. In 1961, a re broke out during a circus performance in Rio de Janeiro, Brazil,
causing burns and other injuries to many children. Dr. Pitanguy treated children whose faces
had been disgured by the re and became a
national hero. After this event, he became a philanthropist who offered free cosmetic surgeries
to the rich and poor and gained international
acclamation. He played a pivotal role in creating a favorable public opinion toward cosmetic
surgery in Brazil. Subsequently, Brazil became
one of the world leaders in cosmetic surgery.
Dr. Pitanguy stated that “even poor people have
the right to beautiful,” suggesting that pursuit
of beauty is a universally fundamental human
desire and may be one of the driving factors in
people’s lives.
Historically, some Western philosophers
emphasized “inner beauty” or the person’s char-
1.2 The Meaning ofanAttractiveFace
3
acter as opposed to his or her external appearance
when discussing beauty. Likewise, up until the
mid-twentieth century, Koreans, strongly inuenced by Confucian philosophy, believed that
they should not be reckless with the faces and
bodies they had inherited from their parents. Even
just few decades ago, satirical cartoons and editorials appeared in newspapers, lamenting the fact
that women had received cosmetic surgery from
doctors who had been trained in Japan. In this
context, it is astonishing that Korea has become a
leader in cosmetic surgery, surpassing even Japan.
The initial surge in popularity of cosmetic surgery and introduction of Western culture coincided with patients undergoing extreme cosmetic
surgeries to attain Caucasian facial characteristics. This led to numerous complications and in
the disappearance of traditional Korean beauty.
In the early 2000s, there was a shift from the
materialistic “fast food” culture to the “slow
food” movement that encompassed a return to
nature. With the “slow food” movement gaining
momentum, there was also a shift from drastic,
articial altering of the face to minimally invasive cosmetic procedures that produced subtle
and natural results. In addition, with increase in
life expectancy, people are socially active until a
later stage and more people seek to recover
younger versions of themselves and do not wish
to alter their faces. The shift allowed minimally
invasive cosmetic procedures to meet the patients’
desires and thus underwent tremendous advancement since 2005.
According to statistics from the United States
on data from 1997 to 2013, the number of people
who received surgical cosmetic procedures
increased by 73%, whereas the number of people
who received minimally invasive cosmetic procedures increased by 356%.
Patients today seek three-dimensional contouring and rejuvenation of the entire face over
adding volume to a specic part of the face,
removing wrinkles, or making the face look slimmer. Standards of beauty are ever changing and
relative. They are inuenced by many factors
including historical period, culture, and geographical location. Accordingly, there is a need
for objective standards or references to dene the
attractive face archetype that people desire.
Undertakings of this mission have persisted
since ancient times. Artists and scholars historically used the concept of the “golden ratio” to
dene the ideal form and stated that when the
face is divided into numerous compartments in
relation to the eyes, nose, and mouth, the ratio of
shortest and longest sides that make up each
compartment should have a ratio of 1:1.618 to be
considered beautiful. As an example, Dr. Stephen
Marquardt, an American oral and maxillofacial
surgeon, created the Marquardt mask so that individuals can measure how close his/her face was
to the ideal ratio. In the Marquardt mask, ratios
such as lower lip-nasal tip distance/nasal tipsellion distance and width of the eye/sellionlateral canthus distance are measured. Marquardt
claimed that the facial ratios of people recognized around the world as being beautiful have
ratios that are closer to the golden ratio masks
that he created for each ethnicity.
However, many questions have been raised as
to whether Marquardt’s claim is valid. Indeed,
there are counterclaims stating that when the
Marquardt mask was used to create the ideal beautiful female face using 3D graphics, the resulting
face had masculine characteristics. Moreover,
although the golden ratio can be used as a means to
assess beauty from an artistic or academic perspective, there are limitations to using this tool in
clinical practice on the faces of actual patients.
In addition, according to a study conducted
by David Perrett, a professor of psychology at
the University of St. Andrews in Scotland, there
are both absolute and relative standards of beauty
when determining facial attractiveness.
According to his theory, absolute standards of
beauty are standards that apply universally.
“Left- right symmetry,” “proximity to average
ratios,” “emotions and facial expressions,” “skin
condition,” and “severity of wrinkles” are examples of absolute standards. Relative standards
may include “similarity in appearance,” “difference,” and “differences in values,” and what is
perceived as beautiful varies from individual to
individual.
4
1 The Art andScience ofFiller Procedures foraMore Attractive Face
The author agrees with this latter theory more
than the golden ratio. Specically, having a
higher degree of “left-right symmetry,” which is
one of the absolute standards of beauty, is an
indication of health and normal genes, and the
provision of visual harmonization enhances
attractiveness. Biologically, the “average ratio”
refers to the proportions of the average human
face. Proportions of facial structures relative to
the eyes, nose, and mouth and features such as
hair, eyebrows, and mustache are considered.
Faces closer to the “average ratio” are perceived
to be more beautiful and associated with good
health. Indeed, people perceive faces with proportions closest to the average facial ratios over
faces that are unique or different to be more
attractive. Proportions close to the average ratio
signies the optimum for that given physical
trait.
Skin color varies by race but regardless of skin
color, skin quality, facial wrinkles, and degree of
sagging are all absolute standards of beauty. In
addition, positive emotions and bright and cheerful facial expressions are important factors in creating a favorable impression. People have a
tendency to place importance only on the physical appearance of the face. The fact that emotions
and facial expressions also play a signicant role
in how attractive a person is perceived to be is
often overlooked. In fact, study results have
shown that patients with Moebius syndrome,
who are not capable of forming facial expressions, do not give a psychologically favorable
impression to others due their expressionless
faces. Guillaume Duchenne, a French neurologist, stated that only a genuine true smile that
involves both the contraction of the orbicularis
oculi and zygomaticus major muscles is considered to be emotionally pleasing. Moreover, the
Pan Am smile, which refers to a smile involving
just the mouth, is perceived as a false smile and is
associated with disingenuity.
In his book titled “The Expression of the
Emotions of Man and Animals,” Charles Darwin
claimed the universal nature of expression.
According to his theory, humans universally feel
six emotional states, happiness, sadness, anger,
fear, disgust, and surprise. Each emotional state
is conveyed by the same facial expression.
However, Paul Ekman, an American psychologist, made the argument that throughout the
world a specic emotion is not communicated
with the same facial expression and in fact varies
depending on culture. To support this claim, he
investigated the indigenous people of Papua New
Guinea. As these people had lived in isolation,
the way they expressed and reacted to the six
major human emotions would not have been
inuenced by Western culture. The results
showed that the indigenous people responded
similarly to people from the West. Contrary to
Ekman’s initial theory, the study results demonstrated that human response to the six universal
emotional states does not vary by race or culture.
The portrayal of and response to emotions was
not relative but universally shared, absolute, and
innate. These ndings show that plastic surgeons
must take natural facial expressions into consideration when performing procedures on patients.
There are instances when patient express dissatisfaction despite successful aesthetic outcomes
with effective correction of wrinkles and sagging.
When procedure results are too drastic or cause
discomfort in forming facial expressions, patients
feel that their face has become abnormal.
Naturally, the eld has also seen an emergence of
a new trend called “dynamic cosmetic surgery,”
and practitioners consider aesthetic outcomes of
the face in the dynamic state as well.
The relative standards of beauty which are
“similarity in appearance,” “difference,” and
“differences in values” will be discussed. First
“similarity in appearance” denotes that people
will generally perceive family and friends or people with whom they have a relationship to be
more attractive. The opposite, people being
attracted to others who possess traits that they do
not have, may be true. However, people are predominantly attracted to familiarity.
“Difference” is based on the concept that
women are attracted to men who are masculine
and men are attracted to women who are feminine. Men also show preferences for women with
child-like appearances. In particular, women who
are considered beautiful today have facial ratios
similar to that of a 6–7years old child.
1.2 The Meaning ofanAttractiveFace
5
Lastly, beauty standards may vary by “difference in values.” Standards vary from one generation to another and are inuenced by societal and
cultural factors. In particular, humans have a tendency to emulate the appearance of the ruling
class due to inner desires to obtain higher societal
status. This is exemplied in Asia where there are
both people who aspire to Asian beauty ideals but
also people who, under the notion that Western
culture is superior, seek Caucasian features.
The four common factors identied in both
the absolute and relative standards of beauty are
“factors that contribute to a youthful appearance,” “left-right symmetry,” “facial harmonization close to average ratio,” and “gender and age
appropriate characteristics.” In particular, skin
quality and wrinkles affect all four factors. Skin
brightness, evenness of skin tone, size of moles,
and blemishes, all have a major impact on a person’s perceived age.
According to a study, when one facial feature
looks older than another, people tend to judge
that person by the oldest looking feature. For
example, no matter how young the person may
be, if that person is bald, people would perceive
that person as being old. In addition, there are
studies showing that an individual with severe
wrinkles imparts a negative impression as the
wrinkles serve as a distraction to the individual’s
positive facial traits. As negative traits obscure
positive traits, it is necessary to correct the negative trait(s). For optimal results, a comprehensive
approach should be taken over partial correction.
In 2011, Dr. Seung-Chul Rhee, a plastic surgeon, presented composite photographs of the
archetypal attractive face by race. The aforementioned factors contributing to facial attractiveness
were evident in all the faces regardless of race. As
racial groups have their own distinct characteristics, cosmetic procedures appropriate for that
race should be performed rather than attempting
to “Westernize” the appearance of Asian people
(Fig.1.1).
According to Yong-Jin Cho, a face scientist,
the perception of beauty has changed in Korea as
a result of cultural adaptation by cultural learning. These shifts in beauty standards occur over
time with changes in culture and values.
Fig. 1.1 Differences in standards of beauty according to race and culture