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The Vertical Lifting Technique for Creation of Apple Cheeks: Tailored Solutions for Asians


The growing desire to reverse the signs of aging on the face has sparked the development of different rejuvenation methods. As the preference for less invasive procedures has gained traction, thread lifting has emerged as a highly sought-after technique.


While the global popularity of thread lifting for facial rejuvenation has risen, there is a lack of differentiation in most consensus statements regarding its application across different ethnic groups. Nonetheless, it is crucial to recognize that there are notable variations in the preferred facial aesthetics between white and Asian populations. These differences arise from not only cultural disparities but also distinct treatment objectives.


In contrast to Western beauty standards, high cheekbones, which create a prominent malar eminence, are not considered attractive or desirable in Asia. Instead, a rounder and fuller cheek, often referred to as an "apple" cheek without emphasis on the zygomatic area, is generally preferred. Currently, during midface and mandibular jowl lift procedures, threads are commonly inserted in an oblique manner with the aim of rejuvenating the face towards the temple. However, this technique inevitably crosses the malar eminence, leading to an accentuation of the cheekbones. While this unintended consequence may be appealing to individuals of Caucasian descent, it has caused significant dissatisfaction among Asians.


To address this issue, doctors in South Korea have devised a vertical lifting technique specifically designed to mitigate the sagging and looseness of the Asian face. This technique involves the insertion of short (6 cm in length) wedge-shaped PDO sutures in a vertical downward direction within the anterior malar and submalar regions. The primary objective of these authors was to assess the efficacy and safety of this innovative technique in combating the descent and laxity commonly observed in Asian individuals.


Treatment efficacy was assessed by comparing photographs at the 6-month follow-up with those taken at baseline using a 5-point Global Aesthetic Improvement Scale (GAIS) (5- “very much improved,” 4- “much improved,” 3- “improved,” 2- “no change,” and 1- “worse”). The grading was performed by 2 independent, blinded physicians. Side effects were recorded. Patients were followed up after surgery, and their outcomes were evaluated by asking them to rate their overall satisfaction using the following scale: “excellent,” “very good,” “good,” “fair,” or “poor.” All statistical analyses were conducted using PASW version 18.0 (IBM, Armonk, NY). Descriptive statistics are presented as both numbers and percentages of the patients or as means and SDs.


Vertical Lifting Technique for Apple Cheeks

Bidirectional wedge-shape PDO threads with the following specifications were used: 19 G 6 cm/2 to 0. The product contains a 45 blunt needle.


See below the short (6 cm), bidirectional, wedge-shaped polydioxanone thread.


During the preoperative phase, the authors marked the skin by drawing vertical lines on the anterior malar and submalar areas, being cautious not to involve the malar eminence. Following this, they inserted bidirectional wedge-shaped PDO sutures, measuring 6 cm in length and ranging from size 2 to 0, based on the marked guidelines. The procedure was performed with the patient positioned in a 45° head-down tilt position. For the anterior malar area, the needle was inserted 1 cm below the lower eyelid margin and between the inner and lateral canthus. The desired depth of insertion was the layer directly beneath the superficial muscular aponeurotic system. The needle was inserted vertically downward until reaching the level of the marionette lines. Approximately six to eight threads were subcutaneously inserted into each cheek, with the vector of insertion directed against gravity. In cases where prominent marionette lines or jowls were present, additional threads (4-5 short wedge-shaped PDO sutures) were inserted in a fan-like pattern, with vectors directed against the sagging folds and positioned below the level of the malar eminence.

To reduce swelling and bruising, the patients were instructed to apply ice packs. They were also prescribed oral cephalosporin, which was taken for a duration of up to 5 days following the procedure. Additionally, patients were advised to sleep in a supine position during the initial 2 to 3 weeks after surgery. These measures were implemented to minimize postoperative edema and optimize the healing process.


See below the figure where the vertical thread lift procedure involves the insertion of short wedge-shaped polydioxanone threads in a vertical manner within the anterior malar and submalar regions. Special attention is given to avoid engaging or affecting the malar eminence during the insertion process. This technique is designed to address specific areas of the face and achieve desired lifting and rejuvenation effects.


See below in the variant form of the vertical thread lift, when patients have pronounced marionette lines or jowls, an additional technique is employed. In such cases, extra threads are inserted in a fanning pattern, with the vectors of insertion directed against the sagging folds. These additional threads are positioned below the level of the malar eminence. This modified approach is intended to address the specific concerns associated with significant marionette lines or jowls and further enhance the rejuvenation effects of the vertical thread lift procedure.



Procedure Outcome

The study included a total of 39 patients who underwent vertical thread lifting using short, wedge-shaped polydioxanone (PDO) sutures. These patients regularly attended follow-up visits and were included in the analysis. With the exception of one male patient, all participants were female. The average age of the study population was 45 years, ranging from 31 to 70 years.


During the 6-month follow-up, a majority of the patients, specifically 35 out of 39 (89.7%), expressed satisfaction with the results of the vertical thread lifting procedure. Among these satisfied patients, 10 individuals (25.6%) rated the outcomes as excellent, 20 patients (51.3%) rated them as very good, and 5 patients (12.8%) rated them as good. These findings indicate a high level of patient satisfaction with the procedure's effectiveness in achieving their desired outcomes. The objective outcomes of the vertical thread lifting procedure were assessed by comparing preoperative and 6-month follow-up photographs. The results were categorized into four groups: "very much improved" (10.3%), "much improved" (43.6%), "improved" (33.3%), and "no change" (12.8%). This categorization provides a quantitative measure of the degree of improvement observed in the treated areas.


See below the table for Patients’ Characteristics and Postoperative Outcomes and Complications


The vertical thread lifting treatment was generally well tolerated by the patients, causing minimal discomfort. Out of the 39 patients, six individuals (15.4%) experienced procedure-related complications. The most common side effect was dimpling, observed in two patients (5.1%). Other complications included bruising in one patient (2.6%), facial asymmetry in one patient (2.6%), thread extrusion in one patient (2.6%), and malar eminence accentuation in one patient (2.6%). However, significant adverse events such as nerve damage or foreign body granuloma were not observed in this study. While complications occurred in a small percentage of patients, it is important to note that the overall occurrence of adverse events was relatively low.


Barbed Sutures in Vertical Thread Lifting

Barbed sutures serve a dual purpose in facial rejuvenation procedures. They are not only used to initially apply tension but also to maintain that tension over time without sagging or slipping. Research on barbed threads has shown that the cogs or barbs on the sutures induce a fibrotic reaction through the activation of myofibroblasts, resulting in the lifting of the aging face. However, it's important to note that until the suture becomes enveloped by a supportive sheath of fibrotic tissue, the suture itself bears the load of the lifted skin.


The holding strength of barbed sutures can be enhanced by using less traumatic needles, such as blunt needles with narrow diameters. Additionally, the technique or vector of thread insertion is believed to have a significant impact on the overall results of the procedure. The precise direction and placement of the barbed sutures play a crucial role in achieving the desired lifting and rejuvenation effects.


In conventional practice, when performing midface and mandibular jowl lift procedures, threads are typically inserted in an oblique manner with vectors directed towards the temple. However, the authors have questioned why vectors that directly counteract the effects of gravity are not utilized. As a result, they have developed a vertical lifting technique where threads are inserted in a downward direction.


The authors hypothesized that this vertical lifting technique would effectively lift the cheek and jowl by opposing the natural sagging of the malar skin. For patients with pronounced marionette lines or jowls, a variant form of the technique is available and can be incorporated to further enhance the lifting effects. By utilizing this approach, the authors aim to achieve more significant and targeted improvements in the desired facial areas.


As previously mentioned, the authors' technique specifically utilizes short (6 cm) threads. The use of shorter threads is motivated by the cultural differences in beauty standards between white and Asian populations. In Asia, high cheekbones or a prominent malar eminence are generally considered unattractive and have rarely been appreciated. In traditional thread lifting techniques, the threads traverse the malar eminence, which can accentuate the cheekbones. This has been a common and troublesome issue for Asians.


The use of short threads in the authors' new technique is designed to spare the malar area. By doing so, the risk of malar eminence accentuation or widening is significantly reduced. This makes the technique particularly well-suited for Asians, addressing a specific concern that is frequently encountered in this population. By adapting the technique to cultural preferences, the authors aim to provide more favorable and satisfying outcomes for Asian patients.


Efficacy of Vertical Thread Lifting

In their clinical practice, the authors typically perform a thread lift procedure with the patient positioned in a 45-degree head-down tilt position. This specific positioning, achieved through neck extension, allows for a more natural face-lift effect and enhances the effectiveness of thread insertion. This technique proves beneficial for practitioners of thread lifting.


Overall, the efficacy of vertical thread lifting using short, wedge-shaped PDO sutures was found to be favorable. Both patients (89.7%) and physicians (87.2%) reported satisfaction and improvement at the 6-month follow-up. Although the authors' data is limited and does not allow for an in-depth discussion on the longevity of the thread lift, they observed that the lifting effect persisted for over a year in several of their patients, as shown in Figure 6. This suggests that the results of the procedure can be relatively long-lasting.


Common Complications

The procedure was well tolerated by the patients, and no additional sedation was required as local anesthesia was sufficient. The most common complication observed was dimpling, which affected 5.1% of patients. This issue was managed through techniques such as soft tissue massage and subcision to alleviate the dimpling effect.


Furthermore, the authors encountered one case (2.6%) of malar eminence accentuation, despite implementing the vertical technique that aimed to minimize this specific complication. It is worth noting that adverse events commonly associated with the use of barbed sutures include pain, dimpling, visibility of threads, and foreign body reactions. These potential complications should be considered and addressed when performing thread lifting procedures.


Literature Gaps for Potential Studies

Suture suspension of the face, while not a novel technique, has gained significant attention with the emergence of the "lunch-time" face-lift concept. This procedure involves the insertion of sutures beneath the facial skin to address tissue descent and laxity. Unlike traditional face-lift procedures, it does not require incisions or tissue undermining. As the name suggests, it offers a remarkably short recovery period.


Despite its widespread coverage in popular media, the surgeons who produced this discussed study, discovered a surprising lack of information regarding the safety, effectiveness, and long-term results of this technique in the literature of plastic surgery and dermatology. This indicates a gap in the existing research and highlights the need for further investigation to evaluate the outcomes and longevity of suture suspension procedures for facial rejuvenation.


In this particular study, the authors utilized self-retaining bidirectional 6-cm wedge-shaped polydioxanone (PDO) sutures. These sutures are designed to provide strong traction in mobile tissues. PDO is a polymer that gradually hydrolyzes over time. Its strength decreases as the wound heals or as the skin becomes lax. Currently, absorbable bidirectional wedge-shaped sutures are approved primarily for wound approximation and soft tissue approximation. However, the results of this study suggest that the suture material may also have favorable applications in facial rejuvenation procedures.


Conclusion

There is currently no definitive consensus regarding the ideal number of threads and their optimal placement in thread lifting procedures. However, by gaining a better understanding of the critical vectors involved and taking into account cultural differences, it is possible to achieve more successful outcomes compared to traditional approaches.


The authors' vertical lifting technique offers several advantages over current methods. Firstly, the vectors used in this technique directly counteract the vertical sagging of the face, resulting in a highly efficient lifting effect. Additionally, this technique minimizes the risk of accentuating the cheekbones, which is particularly beneficial for Asian patients who typically prefer a more rounded cheek appearance.

By considering these factors and tailoring the approach accordingly, the authors' vertical lifting technique aims to provide improved results and meet the specific aesthetic preferences of different patient populations.


Based on the study results, vertical lifting using wedge-shaped PDO sutures is deemed an effective and safe procedure for facial rejuvenation in Asian individuals. However, appropriate patient selection is crucial to achieve optimal outcomes. This procedure is most suitable for relatively young individuals with a moderate degree of facial soft tissue laxity. It is not recommended for patients with significant sun damage (dermatoheliosis) or prominent wrinkles. Ideally, the patient should have a less prominent malar eminence, as this can help minimize the risk of accentuation during the procedure.


While the technique is best suited for Asian individuals, it can also be successfully utilized in Caucasian patients as a complementary approach alongside the conventional techniques currently practiced. Therefore, considering patient suitability and tailoring the procedure accordingly can lead to successful outcomes in both Asian and Caucasian populations.


Reference

Vertical Lifting: A New Optimal Thread Lifting Technique for Asians (2017)

Barbed sutures in aesthetic plastic surgery: evolution of thought and process (2013)

Barbed sutures in facial rejuvenation (2004)

Elevating the midface with barbed polypropylene sutures (2005)

 

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