The surgery was conducted with local anesthesia and propofol sedation. The two holes for inserting the canula in the chin area were made with an 18 gauge needle. A tumescent agent composed of 0.5% lidocaine and epinephrine was injected into the fat removal area with an 18 gauge canula. Usually 5–10 cc of tumescent fluid was injected into the cheek and chin area, and the laser canula was inserted. The 1444 nm Nd-YAG laser (AccuSculpt; Lutronic, Goyang, Korea) was used on multilayers for laser lipolysis such as the subdermis and superficial subcutaneous and deep subcutaneous layers. Usually, 500–800 J of energy was shot into one side of the cheek, and 500–1000 J was shot into the chin area. After the laser treatment, cold wet gauze was applied to prevent thermal damage. Then, liposuction was done with a 16 gauge canula. Liposuction was possible with the 16 gauge canula because fatty tissue was crushed into pieces by the laser. Liposuction was stopped when adequate reduction in fat thickness was achieved. Suction volume was usually the same or double the tumescent volume, ranging 10–20 cc. After liposuction, the canula insertion site was closed with 6–0 nylon. The sutures were removed 7 days after the surgery.

The barbed suture lift was carried out with 0–0 bidirectional cogged polydioxanone sutures. The barbed sutures were anchored under the deep temporal fascia and tympanoparotid fascia using Owl. Then, each end of the barbed suture was reinserted with a straight canula into the area to be lifted such as the paranasal and chin areas (Fig. 14.1). The barbed sutures were passed into the deep subcutaneous layer, which is immediately above the superficial musculoaponeurotic system area that we wanted to pull up. Usually, 6–10 threads were inserted into each cheek and anchored to the deep temporal fascia. Four to six threads were inserted to improve cheek drooping and deep nasolabial folds, and 2–4 threads were inserted to improve the jowl. The exposed threads were removed with pulling of the soft tissue to prevent postoperative thread exposure. Then, the skin was stretched to prevent dimpling with the patient in the sitting-up position. Dimpling was not detected well in the supine position, so checking this aspect in the sitting-up position is important. After all procedures were completed, elastic bandages were applied to the neck and cheek area to sustain the effect of the lift and to prevent swelling. The bandages and sutures were removed on postoperative 3 days and 7 days, respectively.

The most important thing in our elastic lift is exit point and thread returning point. Firstly, draw around the soft tissue bulge in the cheek; secondly, mark the point of maximal bulging. Thirdly, mark the exit point distal to the maximal bulge, keeping in mind the depth of subcutaneous needle penetration and direction of pull.

The elastic lifting procedures were performed under conscious sedation in isolated cases and under general anesthesia in simultaneous cases with facial bone contouring surgeries. The incision sites at both scalps were infiltrated with 2% lidocaine and 1:100,000 epinephrine. Two vertical stab incisions are made with No.15 blade at the level of the highest point of the ear helix. Then a sharp mosquito was used to dissect down deep to the temporal fascia. An Owl was used to anchor an elastic thread at the deep temporal fascia. The free-end of the elastic thread was pinched with a mosquito to prevent it from pulling inside. Then the Jano needle^® was inserted through the incision site opposite to the free-end. The needle was passed through the deep subcutaneous tissue plane and exits at target point. It is important not to pull out the needle entirely. There are five depth marks on the needle at each interval of 5 mm. So, the surgeon can adjust the distance from the needle exit site to the tissue which was actually to be lifted. The needle was pulled out until the last one or two depth marks were shown, and the elastic thread was pulled through the needle exit site as much as possible. Then the needle was rotated toward the incision site bearing the free-end. The needle was passed through the deep subcutaneous layer with the posterior tip now becoming anterior and pulled out completely at the incision site of the free-end. Now, the surgeon should evaluate if lifting layer was appropriate and lifting didn’t cause any dimpling, depression, or soft tissue bunching by pulling the elastic thread with adequate power. The elastic thread was knotted under tension and placed deeply in order not to be exposed. The same procedure was carried from the opposite incision site with opposite direction use of Owl. The two-stab incisions were sutured with No. 4–0 nylon (Fig. 14.2).

Both barbed thread and elastic thread can cause dimpling or depression. Too superficial placement of barbed thread and too narrow interval from the exit site to the end of remaining barbed thread can cause dimpling. The surgeon can prevent by insertion of thread in appropriate layers and cut away enough amount of the barbed thread end from the exit sites. In case dimpling already happened, gentle massage can solve the problem in most cases, but sometimes removal of barbed thread was the only way as a last resort. Elastic thread causes less dimpling because it has no barb on the surface. But too much traction force can make dimpling or depression at the target lifting site. The surgeon can avoid this complication by control of traction force and checking the result in a sitting position. In case dimpling or depression happens in elastic lifting, massage has little effect. Thus, removal of elastic thread is the only solution for these cases.

Although neurapraxia or nerve palsy happens extremely rare, its consequence might be significant. Laser-assisted liposuction gives much energy to subcutaneous plane. So, the marginal mandibular branch of the facial nerve can be damaged by the thermal energy. The patient who damaged his/her facial nerve can complain of lip twisting and the mouth corner pulled toward unaffected sides. Barbed thread lifting and elastic lifting can cause frontal nerve palsy because the canula and the needle passed through the dangerous area between the ear and eyebrows. When using Owl around the Lore’s fascia, the thread could encircle some branch of the facial nerve, resulting in transient weakness of facial muscle expressions.