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BRIEF REPORT
Year : 2022 | Volume
: 40
| Issue : 1 | Page : 44-47
The applications of real-time imaging with transillumination, ultrasound, and Doppler for thread lifting
Yu-Hsin Wang1, Ching-Sheng Yang2, Kuang-Cheng Chang3, Shyue-Luen Chang1, Chun-Yu Cheng1, Yau-Li Huang1
1 Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Dermatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Department of Aesthetic Medicine, Chang Gung Memorial Hospital, Taoyuan; Department of Aesthetic Medicine, Chang Gung Clinic, Taipei, Taiwan
2 Department of Dermatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
3 Renew Clinic, New Taipei City, Taiwan
Correspondence Address:
Dr. Yau-Li Huang
Department of Dermatology, Chang Gung Memorial Hospital, Linkou, No. 5, Fuxing St., Guishan Dist., Taoyuan 33305
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ds.ds_1_22
Thread lifting has gained popularity in recent years because of its minimally invasive properties. Regardless of the technique used, the key is threading in the optimal anatomical plane and suspending the correct target tissue. Failure to meet these objectives may result in chronic pain; contour irregularity; thread migration or exposure; and nerve, vessel, and gland injuries. The knowledge of facial anatomy alone is insufficient to corroborate the anatomical variations of a patient. Ultrasound-guided thread lifting can be performed because the trocar presents a hyperechogenic signal with bayonet and reverberation artifacts. Ultrasound is an effective tool because it can provide real-time images of the layers of the facial anatomy, fat pads, muscles, fascia, ligaments, superficial muscular aponeurotic system, arteries, and parotid duct. Transillumination, however, can be conducted to verify the presence of superficial vessels and prevent venipuncture and injury to homonymous arteries. The combination of transillumination and ultrasound provides three-dimensional information. In this study, to evaluate facial anatomy and guide threading, reconfirm the position of the thread, and prevent malpractices, practical strategies such as transillumination, ultrasound, and Doppler imaging are recommended for improving patient safety during, before, and after the procedure.
Keywords: Real-time imaging, thread lifting, transillumination, ultrasound
The certified use of thread lifting, by the U. S. Food and Drug Administration, for rejuvenation of ptotic skin of the face in 2004, has caused the development of various thread lifts techniques and threading methods. This is due to its minimally invasive properties and features such as speedy recovery, minimal downtime, absence of scars, and less extreme complications. Regardless of the technique used, the key is threading in the correct anatomical plane and suspending the correct target tissue. Failure to meet these objectives may result in chronic pain (11%), contour irregularity (2.8%–14.6%), thread migration or exposure (7.8%–11.2%), and nerve, vessel, and gland injury (0.02%).[1],[2],[3]
Furthermore, because most neurovascular structures are below the superficial muscular aponeurotic system (SMAS), the optimal zone of the trocar passage should be maintained at the subcutaneous and subdermal levels for accurate superficial thread lifting. Because thread lifting is blindly carried out and as the subcutaneous fat in temporal areas is thin (2.2 mm in average),[4] it is difficult to ensure that the trocar drives along the facial contour at a consistent depth, particularly in Asian subjects wherein the skull is larger than the face. In clinical practice, a surgeon usually lets the trocar go too deep, piercing the SMAS without realizing it. Furthermore, despite knowledge of facial anatomy, the anatomical variants of a patient are difficult to confirm. This study aimed to recommend the use of a dual-image device to improve patient safety in thread lifting.
MethodsThis study was approved by the Institutional Review Board of the Chang Gung Memorial Hospital (approval number: 202000871B0; approval date: 2020.05.27).
A vein viewer (Christie Medical Holdings, Inc., Memphis, TN, USA) and a handheld ultrasound device with a 10 MHz ultrasound transducer and color Doppler mode (LeSonoLU700L, Leltek, Inc., Taiwan) were used as auxiliary imaging tools for thread lifting. The examination of patients was performed before the thread lifting procedure. First, a vein viewer was used to locate the veins in the treatment zone to avoid venipuncture. Next, ultrasound was conducted to check planes, identify customized danger zones, and locate critical structures.
During the procedure, the trocar and the thread were placed in, using real-time handheld ultrasound imaging. When the trocar path was on the upper face, the ultrasound probe was vertically placed in the preauricular area. When the trocar path reaches the center face, the target for lifting, the ultrasonic probe was positioned diagonally along the line from the earlobe to the corner of the mouth. A reconfirmation ultrasound examination was performed when threads visible on ultrasound were employed [Figure 1].
Figure 1: A diagram illustrating how real-time imaging is applied in a 40-year-old female for facial thread lifting. First, the real-time imaging examination is performed before the procedure. The operator can outline the veins with transillumination (Vein Viewer, Christie Medical Holdings, Inc., Memphis, TN, USA) while planning the threading route to reduce the risk of venipuncture. Through the ultrasound (LeSonoLU700L, Leltek, Inc., Taiwan) with Doppler mode, one can identify the real-man anatomical layers, such as 10 layers in the temporal regions, and can illustrate the crucial structures that are prone to injury during threading. Next, during the procedure, the operator can insert the cannula precisely at a consistent depth and relative avascular plane with the guidance of ultrasound. Portion a, e: Transillumination of the upper and lower face. Portion b: Ultrasound image of the temporal area. Portion c: Doppler image of the temporal area. Portion d: Ultrasound-guided thread lifting, clinical image. Portion f: Ultrasound image of the buccal area. Portion g: Ultrasound-guided thread lifting, ultrasound image. SQ: Subcutaneous layer, STF: Superficial temporal fascia, IF: Innominate fascia, sDTF: Superficial layer of deep temporal fascia, TFP: Temporal fat pad, dDTF: Deep layer of deep temporal fascia, BFP: Buccal fat pad, TM: Temporalis muscle, TB: Temporal bone, FbSTA: Frontal branch of superficial temporal artery, FA: Facial artery, SV: Sentinel vein, FV: Facial vein, SMAS: Superficial muscular aponeurotic system. Results The dual image, when combined with color Doppler, can provide real-time information about the facial anatomical layers, fat pads, muscles, fascia, ligaments, SMAS, and vessels. Moreover, when the vein viewer was used while the ultrasound probe was placed vertically in the preauricular area, 10 anatomical layers and crucial structures in the temporal regions were shown. These regions included the subcutaneous fat layer, the superficial temporal fascia, the innominate fascia, the superficial layer of the deep temporal fascia, the temporal fat pad, the deep layer of the deep temporal fascia, the buccal fat pad, the temporalis muscle, temporal bone, sentinel vein (SV), and frontal branch of the superficial temporal artery. Moreover, as the trocar path progressed, the second ultrasound window with the ultrasonic probe was placed diagonally along the line from the earlobe to the corner of the mouth. This revealed the facial artery (FA), facial vein (FV), SMAS, and target buccal fat pad [Figure 1].
DiscussionUltrasound is suitable because it can detect trocars, cannulas, and threads in certain situations. The trocar displays a hyperechogenic signal with bayonet and reverberation artifacts, as shown in [Figure 1]. Moreover, the combined use of ultrasound and color Doppler imaging can provide real-time information of the facial anatomy and can guide threading. It can also be used to determine the depth, thickness, and volume of the target tissue as well as to distinguish between superficial and deep fat compartments for superficial and deep plane thread lifting.[5]
In addition, when making an entry point and during thread lifting, the SV, middle temporal vein, inferior palpebral vein, and FV are susceptible to venous injuries. Transillumination may include details in the third dimension to help locate some of these superficial vessels to prevent venipuncture and injury to the accompanying homonymous arteries.
Thread-lifting-associated nerve injuries require special consideration for two reasons. First, while there are several vector directions that can be chosen depending on the lifting targets, the trocar or cannula route can cross-facial nerve (FN) branches along all these vectors. The lifting targets include the vector that passes from the marionette line to the ear lobule, the vector that passes through the mandibular zygomatic arch temple, and/or the vector that passes through the nasolabial fold-zygomatic bone hairline. However, threads with cogs may hook or twine nerves and surrounding tissues, causing neuropraxia. Second, although the branches of the FN are difficult to detect with ultrasound, the surrounding vessels in the danger zones can help distinguish the branches. The SV, for example, indicates the temporal branch of the FN upon transillumination and FA/FV at the antegonial notch indicates the marginal mandibular branch of the FN.
Further, transillumination, ultrasound, and Doppler imaging can be used to establish the three-dimensional structure of facial anatomy. However, further research, accumulation of case data, and statistical analyses are required. In our experience, it was observed that the instances of loose embedding and the need for secondary correction were significantly reduced with the use of imaging-assisted thread lifting. Further, this experience demonstrates that the dual-image device is useful at three stages during the clinical process: before the procedure for anatomical evaluation, during the procedure for guidance, and after the procedure for reconfirmation and prevention of malpractices. In most cases, if the surgeon is well trained, he or she can proceed normally but benefit from preoperative anatomical assessment based on transillumination, ultrasound, and Doppler imaging. For select cases with a higher risk of complications, such as when the patient has too little subcutaneous fat or has received facial surgery, real-time imaging is conducted during, before, and after thread lifting to improve patient safety [Table 1].
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
References
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