# 📖 **Chapter 2.1 Surgical Approaches – Academic Knowledge** --- ## 1. Overview Surgical lifting remains the **gold standard** for moderate to severe skin laxity because it directly repositions deeper structures (SMAS, retaining ligaments, fat pads) and removes redundant skin. While non-surgical devices offer subtle improvements, surgery provides the **most dramatic and longest-lasting outcomes** (often 7–10 years). --- ## 2. Major Surgical Techniques ### (1) **Traditional Facelift (안면거상, Rhytidectomy)** - **Principle**: Excision of redundant skin + tightening of underlying SMAS (Superficial Musculoaponeurotic System). - **Incision**: Starts in the temporal hairline → preauricular crease → around earlobe → postauricular hairline. - **Dissection**: Subcutaneous flap elevation to expose SMAS. - **SMAS Management**: - **SMAS plication**: folding and suturing SMAS without wide dissection (faster, less invasive). - **SMASectomy**: excision of a strip of SMAS, then reapproximation. - **SMAS imbrication**: cutting SMAS and overlapping with sutures. - **Outcome**: Effective for midface, jowls, jawline, and neck. - **Longevity**: 7–10 years. --- ### (2) **Deep Plane Facelift** - **Principle**: Dissection occurs **under the SMAS**, mobilizing skin + SMAS + fat pads as one unit. - **Advantages**: - Strong lift of midface and nasolabial folds. - Natural, longer-lasting result. - Less skin tension → fewer visible scars. - **Disadvantages**: technically more demanding, higher risk of nerve injury. - **Indications**: patients with midface ptosis, deep nasolabial folds, significant jowls. --- ### (3) **Mini-Lift** - **Principle**: Limited incision and dissection, mostly addressing early jowls and mild laxity. - **Incision**: shorter (temple to ear), minimal skin undermining. - **SMAS**: usually plication or minimal imbrication. - **Advantages**: shorter downtime, less risk, can be performed under local anesthesia. - **Limitations**: modest results, best for younger patients (40s–50s). --- ### (4) **SMAS Lift (Superficial Musculoaponeurotic System Lift)** - Sometimes used interchangeably with rhytidectomy, but specifically emphasizes manipulation of SMAS. - **Approaches**: - Lateral SMASectomy: excising a strip laterally and suturing. - High-SMAS technique: more vertical vector lift, effective for midface. - **Significance**: Recognizes SMAS as the critical layer for long-lasting lift. --- ### (5) **Endoscopic Brow Lift** - **Principle**: Corrects brow ptosis and upper facial aging. - **Technique**: - Small incisions behind hairline. - Endoscopic visualization → dissection of forehead soft tissues → release of brow depressor muscles (corrugator, procerus). - Brow is elevated and fixed (sutures, screws, absorbable fixation devices). - **Advantages**: minimally invasive, less scarring, effective rejuvenation of upper third. --- ### (6) **Thread-Assisted Surgical Lifts** (not just “thread lift”) - In some hybrid surgeries, permanent suspension sutures are placed to reinforce deep lifts. - Distinct from office-based PDO/PLLA threads: these are often anchored to deep temporal fascia or periosteum. --- ## 3. Key Anatomical Principles - **Retaining Ligaments**: - Zygomatic, masseteric, mandibular, orbital. - Release is critical for effective mobilization of soft tissue. - **SMAS**: - Fibro-muscular layer connecting facial muscles and dermis. - Acts as a scaffold; tightening provides durable lift. - **Platysma**: - Important in lower face/neck lift. - Techniques include platysmaplasty (midline approximation, lateral suspension). --- ## 4. Complications (Surgical) - Hematoma (most common; 2–5%). - Nerve injury (temporary paresis 1–2%, permanent <1%). - Skin necrosis (higher in smokers). - Hypertrophic or visible scars. - Hairline distortion, ear deformities (“pixie ear”). --- ## 5. Patient Selection - **Best candidates**: - Age 50–70 with moderate to severe laxity. - Adequate skin elasticity. - Realistic expectations. - **Poor candidates**: - Significant comorbidities (bleeding risk, poor wound healing). - Unrealistic demand for “scarless” surgery. --- ## 6. Longevity and Outcomes - Traditional/deep plane facelift: **7–10 years**. - Mini-lift: **2–4 years**. - Brow lift: **5–7 years**. - Thread-assisted: **1–2 years** (adjunctive). --- # 📖 **Chapter 2.2 Non-surgical Approaches (with Shurink)** --- ## 1. Overview Non-surgical lifting modalities aim to **stimulate collagen remodeling, restore tissue tension, and improve contour** without excision. They are especially effective for **mild to moderate skin laxity**, and popular because of: - Minimal downtime - High safety profile - Applicability across skin types - Patient preference for non-invasive treatments However, their results are generally **less dramatic and less durable** than surgical approaches. --- ## 2. Major Non-Surgical Lifting Modalities --- ### (1) **Radiofrequency (RF)-Based Lifting** - **Mechanism**: Alternating current generates dermal heat (55–65°C) → collagen denaturation + fibroblast stimulation. - **Types**: - **Monopolar RF (Thermage)**: deep penetration, uniform dermal heating, cooling-protected epidermis. - **Bipolar RF**: more superficial penetration (2–4 mm). - **Fractional Microneedle RF (Morpheus8, Scarlet RF)**: needles deliver RF energy into dermis/subcutis. - **Indications**: fine wrinkles, mild-to-moderate laxity, periorbital tightening. - **Pros**: safe for all skin types, minimal pigment risk. - **Cons**: multiple sessions often required, results subtle. --- ### (2) **Ultrasound-Based Lifting (HIFU)** - **Mechanism**: High-Intensity Focused Ultrasound generates **thermal coagulation points (TCPs)** at 1.5, 3.0, and 4.5 mm depths. - **Unique feature**: Only non-invasive technology that can directly target **SMAS layer**. - **Devices**: - **Ultherapy**: FDA-cleared, gold-standard, extensive clinical data. - **Shurink**: Korean HIFU system, widely used in Asia, CE-certified. - Depth cartridges: 1.5 mm (superficial dermis), 3.0 mm (deep dermis), 4.5 mm (SMAS). - Faster shot delivery, often less painful, more cost-effective. - **Indications**: - Brow lift, jawline definition, submental tightening, mild midface lifting. - **Pros**: single session, results lasting 9–18 months, strong lifting of SMAS. - **Cons**: significant pain (requires analgesia/nerve blocks), less effective in severe laxity. --- ### (3) **Microwave-Based Lifting (Onda Coolwaves™)** - **Mechanism**: Microwaves at 2.45 GHz selectively heat adipocytes and dermis. - **Dual effect**: adipocyte apoptosis + collagen remodeling. - **Indications**: - Submental fat reduction, body contouring (abdomen, thighs), cellulite. - **Pros**: combined fat reduction + skin tightening. - **Cons**: less effective for pure facial laxity without fat component. --- ### (4) **Laser & Phototherapy** - **Fractional CO₂ Laser**: Ablative microthermal zones → neocollagenesis + resurfacing. - **Er:YAG, Nd:YAG (non-ablative lasers)**: dermal heating → collagen remodeling. - **IPL / LED**: improve pigmentation/texture; adjunctive, not true lifting. - **Indications**: fine wrinkles, skin texture, superficial laxity. --- ### (5) **Injectable Biostimulators & Regenerative Approaches** - **Sculptra (PLLA)**: stimulates collagen through controlled inflammatory response. - **Radiesse (CaHA)**: volumizing + collagen induction. - **PRP / Exosomes / Stem-cell conditioned media**: paracrine signaling → fibroblast activation, angiogenesis, ECM remodeling. - **Effect**: gradual volumetric restoration + indirect lifting. --- ### (6) **Thread Lifting** - **Materials**: PDO, PLLA, PCL. - **Mechanism**: - Mechanical lift by barbed threads anchoring into SMAS. - Collagen stimulation along thread tract. - **Indications**: midface and jawline laxity, mild-to-moderate cases. - **Pros**: immediate visible lift. - **Cons**: longevity 12–18 months; risks of dimpling, asymmetry, migration. --- ## 3. Comparative Overview (Including Shurink) |Technique|Depth Target|Key Effect|Longevity|Best Indication| |---|---|---|---|---| |**RF (Thermage, Morpheus8)**|Dermis (2–4 mm)|Collagen remodeling|12–24 mo|Fine wrinkles, superficial laxity| |**HIFU (Ultherapy, Shurink)**|Dermis + SMAS (1.5–4.5 mm)|Deep tightening|9–18 mo|Brow lift, jawline, submental| |**Microwave (Onda)**|Dermis + Fat (~1.5 cm)|Fat reduction + tightening|6–12 mo|Submental fat, body contour| |**Laser (CO₂, Nd:YAG)**|Epidermis + Dermis|Resurfacing + mild tightening|6–12 mo|Texture, pigment, fine wrinkles| |**Biostimulators (Sculptra, Radiesse)**|Dermis/SC fat|Collagen induction, volumizing|12–24 mo|Volume loss + mild laxity| |**Thread Lift**|SMAS|Mechanical reposition + collagen|12–18 mo|Midface/jawline mild laxity| --- ## 4. Key Clinical Insights - **Shurink vs. Ultherapy**: - Same mechanism (HIFU). - Shurink → faster, less expensive, commonly used in Korea/Asia. - Ultherapy → more clinical evidence, FDA-approved, longer average duration. - **Combination therapy is standard**: - Example: Shurink (SMAS tightening) + Thermage (dermal tightening) + Sculptra (volume restoration). - Layered, multimodal approach = more natural and sustained results. ---