Non-Surgical Thread Lifting: Understanding Facial Anatomy, How to Avoid Vessel Damages and Prevent Nerve Injuries

August 28, 2019

Non-surgical thread lifting has steadily gained significant popularity around the world in the recent years, and the numbers continue to grow as patients actively seeking non-surgical procedures for the face, eyes, nose, lips and neck using threads.

 

Today, thread lift is no-longer considered to be a “new” procedure and precisely because so, it is all the more important for a practitioner to be equipped with the latest and most advanced techniques to keep ahead of trends and demand.

 

To deliver best results for a successful and effective thread lifting procedure, a practitioner must not only have a thorough understanding of facial anatomy, but also knowledge in the different ageing patterns, available tools as well as the various techniques. 

 

Facial Anatomy for Thread Lifting: 5 Different Layers of the Skin

 

Comprehension of anatomy is an important basis for a practitioner to be successful in any procedure, and just as equally, is the acknowledgement and understanding that the skin can vary very differently based on factors such as gender, age and ethnicity. Like the scalp, facial tissue can be divided into 5 different layers, namely - skin, superficial fat, facial expression muscle/SMAS (musculo-aponeurotic layer), deep fat and deep fascia.

 

Image credit: Kwan-Hyun Youn, 2018 via The Art and Science of Thread Lifting, Springer (2019)

 

Skin: In general, men have slightly thicker skin than women, and in a recent study, it was observed that the thickness of the dermis in Koreans do not differ too much from that of Caucasians, but in the epidermis, Koreans tend to have it thicker than that of Caucasians. Furthermore, other skin conditions can also play part in affecting the kind of treatment required for each and every individual patient. Factors such as, but not limited to, photo-damage, lifestyle, acne, and ageing can affect the skin conditions of patients so does the methodology used to determine the type of procedure to be implemented.

 

Superficial Fat: This layer corresponds to the hypodermis, and is located superficial to the facial expression muscles, consisting of several compartments. Because superficial fat tends to sag downwards due to gravity and ageing, it can have an effect on the overall ageing pattern of a patient as well as results of the procedure. 

 

Additionally, the hypodermis layer contains larger blood vessels and nerves than that of the dermis, therefore, extreme care should be taken when working on this layer, especially if using smaller cannulas or needles. Therefore, the type of threads used and the techniques applied to this layer may differ to that of the other layers, if a practitioner choose to lift sagging in this area.

 

Facial Expression Muscle/SMAS: Made up of facial expression muscles and aponeurosis, this layer is connected to the galea aponeurotic of scalp. Interconnecting the platysma muscle and frontal muscle, the aponeurosis is named differently by its relative location of the zygomatic arch with the upper being the temporoparietal fascia (aka superficial temporal fascia), while the lower part to the zygomatic arch known as the Superficial Musculo-Aponeurotic System (SMAS). 

 

It is important that a physician understands that the branches of the facial nerve innervating the facial expression muscles travel deeper than this layer, and some blood vessels; for example, the superficial temporal artery, travel within the temporoparietal fascia - as failing to understand this may result in dire consequences due to vessel damage during the procedure.

 

Deep Fat: In the fourth layer of the face, there are several spaces; and the retaining ligaments traverse between them, connecting the periosteum/deep fascia to the skin. Deep fat is located deeper to the facial expression muscles and divided into several compartments. In the temporal area, the connective tissue beneath the temporopariteal fascia is the innominate fascia. Care should be taken during procedure so as to not damage any ligament between this layer and the connecting deep fascia of the skin.

 

Deep fascia: Deep fascia over the temporalis m. attaches to the zygomatic arch after being split into a superficial and deep layer; with a superficial temporal fat pad in between the two layers. In the mandible, the deep fascia surrounds both the masseter m. as well as the parotid gland, attaching to the zygomatic arch.

 

Here, the temporal branch of the facial nerve can be found in the parotid gland where it penetrates the parotidemasseteric fascia, crossing the zygomatic arch and traversing the innominate fascia to innervate the orbiculares oculus muscle and frontal muscle. Therefore, caution should be exercised during the procedure so as to avoid damaging the temporal branch of the facial nerves that can be found in/near this area.

 

Avoiding Vessel Damages

 

By understanding the different anatomical layers of the face, a physician can then be able to better understand sites where the vessels and arteries run, thereby determine safe-zones and areas to avoid.

 

 

Blood vessels: While it is not as easy to cause injury to blood vessels during thread lifting as with filler injection, vascular complications relating to thread lift do occur - although often limited to bruising, pain and in more serious cases, hematoma and edema; these complications usually can be very easily managed.

 

Considering the general anatomy of the face and the course of the superficial temporary artery, it is inevitable that threads should cross the superficial temporary artery in mid-face thread lifting procedures, and one recommended way to prevent and avoid severe damages, is the use of the right-sized cannula, and as much as possible, avoid the use of needles.

 

Superficial Temporal Artery: Due to the relationship between blood vessels, the fascia and the subcutaneous fat layer, a physician should action caution when progressing through this area and by using a blunt cannula of the correct size with the right technique, a physician can reduce the risks of vessel injury during penetration as the superficial temporal artery is relatively thick and elastic.

 

Transverse Facial Artery: The transverse facial artery branches from the superficial temporal artery within the parotid gland, running embedded in it and emerging from the parotid gland, extending beneath the SMAS and facial expression muscles. Therefore, extreme care should be taken during the thread lifting procedure so that the artery branches are not accidentally damaged during the process.

 

Preventing Nerve Injuries

 

The importance of understanding facial anatomy is crucial not only to avoid vessel damages, but also prevent adverse complications resulting from possible nerve injuries. By understanding the anatomy of the face, a practitioner can determine, plan and design safe-zone sites to ensure that nerve injuries are avoided. In addition, the performing physician has to ensure that the threads are inserted through the safe facial plane into the correct layer of the face. 

 

 

 

Generally, thread lifting is a minimally-invasive procedure and facial nerves ramify into numerous branches and anastomosis exists between them; therefore, the incidence rate of nerve injuries and side effects are low, but not non-existent. Due to the thickness of soft tissues, the zygomatic arches are the most likely places for nerve damage during a thread lift procedure, as the facial nerve passes the zygomatic arch, running below the SMAS, traveling very closely to the bone. As with the probability of damaging vessels, the use of blunt cannula and right tehcnique can prevent accidental damage to the nerves, especially when passing through/over the zygomatic arch area.

 

Thread Lifting: A Growing Trend in Demand

 

As we move forward and advance in the fields of medical sciences, the demand for non-surgical procedures grows in linear, and so does the need for a practitioner to be equipped with the latest and most advanced set of skills and techniques. More than just having good knowledge in anatomy as the basis and foundation to a successful thread lifting procedure, a physician must be equipped with the right skill-set as well as techniques to not only help patients achieve best results but also to minimise risks and leverage patient comfort to improve overall patient satisfaction.

 

Hope you have enjoyed the article & video! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses! 

 

 

 

 

Reference:

The Art and Science of Thread Lifting (2019)

 

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