Hello. Welcome to the ASPS Global Partners webinar series. This time, it is prepared by South Korea. Please submit your questions throughout the presentation using the Q&A at the bottom of your screen. We will answer as many questions as possible at the end of each presentation during the webinar. Okay. Next, please. I'm Dr. Hak Chang from Seoul National University and president of the Korean Society of Plastic and Reconstructive Surgeons. I will moderate this webinar today. All speakers are from South Korea and are board-certified plastic surgeons here. We have three speakers. The theme is related to lymphatics, keloid, and facelift using thread. Now, let's move on to the first speaker. I will introduce the first speaker, Dr. Kyung Jae Woo. He is now an associate professor at the Department of Plastic Surgery at Mokdong Hospital, IFAW Women's University. His specialty is lymphatic surgery and breast reconstruction. Dr. Woo, would you please give your presentation? Okay. Can you see my slide? Okay. No problem. Yes. Okay. Good evening and good morning, everyone. It's a great honor to have a talk in this ASPS webinar. I am K.J. Woo from South Korea, and the title of my talk today is Lymphatic Pathway-Based ICG Lymphographic Evaluation for LVA in patients with upper extremity lymphedema. Lymphatic venous anastomosis is a surgical procedure for creating lymphovenous shunt. As you can see in this video, lymphatic fluid drains into the vein when the LVA is successfully performed. The lymphatic fluid is drained through the sub-thermal veins, as you can see here, after the lymphovenous shunt. LVA is effective treatment when the lymphedema is caused by proximal obstruction of lymphatic system. In order to perform LVA, existence of functioning lymphatics is essential. The proximal obstruction of lymphatic system can be checked by thermal backflow, and the ICG lymphography is the most sensitive tool to evaluate the thermal backflow. It is well known that lymphatic vessels lose smooth muscle function and sclerotic changes undergo in lymphedema patients. However, the degree of lymphosclerosis has significant variation among patients. ICG lymphography is a useful exam to evaluate the function of lymphatic vessels. Lymphatic flow capacity can be checked after 30 minutes of ICG injection to the hand. As the lymphosclerosis becomes severe, lymphatic flow capacity will be reduced, and we found that ICG enhanced above the elbow level in 30 minutes. There will be always well-functioning lymphatic vessels, so flow velocity grade 3 and 4 will be a good indication for LVA. We found that ICG flow velocity grade was 3 or 4. Higher rate of well-functioning lymphatic vessels were found compared to flow velocity grade 1 and 2. When we also evaluated surgical outcomes according to lymphatic flow pattern in lymphocentrography, we found that better outcomes could be obtained when the lymphatic flow was more proximally maintained in lymphocentrography. Lymphatic vessel function is generally more preserved in early stage, early ISL stage. However, well-functioning lymphatics can also be found in some of the advanced stage ISL lymphedema. Therefore, LVA can be also effective in some of the advanced stage lymphedema. Although ICG lymphography is a gold standard exam, there is no anatomical landmarks for evaluation of lymphatic vessels. Also, there is no consensus regarding nomenclature of lymphatic vessels. Dr. Suamiero reported a wonderful study, which demonstrated superficial lymphatic pathways of upper extremity. Lymphatic pathways were classified anterior and posterior in this study. However, the courses looked complicated and there is no anatomical landmark that can guide evaluation of lymphatic vessels. Therefore, we performed anatomical study using ICG lymphography. The anatomical landmark for anterior lymphatic pathways were anterior axillary fold, center of cubital fossa, and palmaris longus. Injection sites were oller side of palmaris longus tendon and dorsal second web space. And the superficial lymphatic vessels were traced using ICG lymphography. The landmark of posterior form was center of cubital fossa and center of the dorsal wrist. We traced superficial lymphatic vessels in relation to the reference lines. This is an example of tracing in patient with lymphedema on her left arm. Distance from lymphatic vessels to the reference lines were checked at seven points. Anterior lymphatics ran close to the reference line of the forearm and then ran more medially to the reference line on the upper arm. Compared to anterior lymphatics, posterior lymphatics ran oller to the posterior reference line and showed more variation than anterior lymphatic vessels. The lymphatic pathways can be categorized into anterior and posterior and posterior oller lymphatic pathways. Contrary to anterior and posterior lymphatic vessels, posterior oller lymphatic vessels turned anterior in the mid forearm and near the elbow. When you look at Dr. Swamy's report, anterior and posterior lymphatic pathways can be found. In addition, posterior oller lymphatic pathways can be found that turns anteriorly and distorts the elbow joints and goes along with the anterior lymphatic vessels. Considering these lymphatic pathways, systematic evaluation of each pathway can be possible in ICG lymphography. This is an example of ICG lymphography of right arm lymphedema patient. Now compared to the normal arm, right arm showed complete obstruction of the posterior lymphatic pathway but functioning posterior oller lymphatic pathway. And right side photo shows that anterior lymphatic pathway also had complete obstruction. Therefore, LPA for posterior oller lymphatic vessel can be planned for this patient. So another example of patient with right arm lymphedema. ICG lymphography showed a good flow velocity, a grade 4 lymph flow velocity. In lymphocytography, a complete obstruction of right axillary lymph node was found. For this patient, three LPAs were performed, one anterior, one posterior, and one posterior oller lymphatic vessels each. This is an example of interoperative ICG lymphography. After injection of ICG to the polar wrist, anterior lymphatic vessels were traced. And it was marked using a red colored pen on the skin like this. As it goes to proximally, it has obstruction on the proximal forearm here. Here. And we can see no proximal flow of the lymphatic vessel. So this area will be a target for LVA for the anterior lymphatic vessels. And posterior lymphatic vessels were traced from the dosum of the hand. There are two injections was done to the web space. And it is traced approximately with the same manner. And you can see where the dermal backflow is and where the lymphatic flow has obstruction. So this posterior lymphatic vessel is marked here. If this is posterior oller lymphatic vessel, it will go oller side on the proximal forearm. This is the posterior lymphatic vessel and there is a backflow on the proximal forearm. And next, posterior ulnar lymphatic vessels can be checked along the course of posterior ulnar lymphatic pathway. This is elbow joint. You can see the lymphatic vessel is turning anteriorly near the elbow. This is another example of ICCA lymphography. The posterior lymphatic pathway was checked first for this patient. Here is the elbow joint. Now we can see there are two or three lymphatic vessels along the posterior lymphatic pathway. And the flow is well maintained below the elbow joint. And we can trace three lymphatic vessels here. And we can see it has no flow above the elbow joint. And anterior lymphatic pathway was checked next. This is a polar wrist. And there are two injection sites. You can see there is no lymphatic flow on the anterior lymphatic pathway. But we can see here the posterior ulnar lymphatic vessels coming from the dosum of the hand. And it turns anteriorly near the elbow. This is the elbow joint. And it goes above the elbow joint and goes up medially to the anterior lymphatic pathway or posterior lymphatic pathway. So here can be a target for LVA. So this patient underwent two LVA on the posterior lymphatic vessels, which was marked on the previous video, and one posterior ulnar lymphatic vessels. The lymphatic vessels of upper extremity usually have diameter of less than 0.5 millimeter. And let me show you a video clip showing end-to-end anastomosis of upper extremity. The size of lymphatics was 0.3 millimeter. And this is a lymphatics and intravascular stent using 60 nylon was inserted in the lymphatic vessel. And when selecting veins for LVA, a branch of subcutaneous vein is preferred for anastomosis because it has lower pressure and diameter is usually similar with the lymphatic vessels. And before the final tie, the stent is removed. And after anastomosis, any leakage from the branch of the vein is checked and it is tied or ligated. And we can check the lymphatic flow drains into the vein. This patient had right arm lymphedema, secondary to tuberculosis on the axilla. Two LVAs were performed and six months post-op, a significant improvement could be obtained. And another example of patient with breast cancer-related lymphedema on the right arm. At 1.5 years follow, circumference difference reduced and pressure feeling was improved. This is a patient with right arm lymphedema, which was aggravated after chemotherapy. And LVAs at two sites were performed. And two years later, nearly no circumference difference was found between normal and arm with lymphedema. In summary, superficial lymphatic vessels can be classified into anterior, posterior, and posterior online lymphatic vessels. And the classification of superficial lymphatic pathway can be used for better understanding of preoperative ICC lymphography in patients with upper extremity lymphedema. Thank you for your attention. Thank you, Dr. Woo. You presented the overview of the lymphedema and then your own ICC study, and then the wonderful case results. So far, there is no online questions. I'll give you some couple of questions. You mentioned the lymphatic flow velocity grade is important for the indication of the ICC. So you think the grade three or four is good candidate, right? Yes. So the poor velocity group, group one and two, so you don't even try to LVA in that cases, or just you move to another options in those cases? How do you do that? In case of flow velocity one, I don't recommend LVA because there is no lymphatic vessel. And in case of flow velocity grade two, it depends on the situation. But I think the outcome is not good as flow velocity three or four. So when there is one or two lymphatic vessel in flow velocity grade two, I can recommend LVA plus vascular lymph node transfer. Okay, thank you for your strategy for the advanced cases. Okay, thank you for Dr. Woo. We need to move the second presentation. And the next presenter is the Dr. Taehwan Park. He's a member of the Iowa Society and he's working now the Department of Plastic and Reconstructive Surgery, Tongtan Sacred Heart Hospital, Hanlim University. He's now an assistant professor. So would you start your presentation now, Dr. Park? Sure, sir. Good afternoon, everyone. I'm Taehwan Park from South Korea. First of all, thank you very much, Professor Chang, for introduction and invitation to this webinar. Today, I'll be talking about how to optimize the outcome of keloid with surgery plus hyperfractionated electromembrane radiotherapy. I have nothing to disclose. Most keloid patients have typical symptoms such as pain, pruritus, cosmetic concern and psychological issues. Whatever their main complaints are, we have to assess the proper context of keloid scar consider carefully what the patient desires. Treatment of keloids remains challenging and there's no single standard treatment option. From May 2021 to August 2023, we treated 600 keloids with surgery plus electron beam radiotherapy within 24 hours after surgery. So we are doing radiotherapy in post-op day one from Monday through Thursday. We also have a same day radiotherapy schedule on Tuesday, Thursday and Friday. So we are doing 30 to 40 cases per month. Initially, we used Tengri single fraction electron beam radiotherapy for all keloid cases without exception, but diversify the protocol and this is the updated radiation protocol that we now use. This Tengri single fraction electron beam radiotherapy for keloid dates back to 2014. The professor Chang Ha, who is the moderator of this webinar for the first time revealed this outcome of this protocol with his colleague from Seoul National University Hospital using 16 keloid in 12 patient during 20 months follow period. They found the recurrence among the period time period. So as I mentioned, we initially started to use Tengri single fraction electron beam radiotherapy for all keloid cases without exception and published the early outcome this May. You can read this article as a reference if you are interested in this resume. I'm gonna share a little bit of my surgical approach. The study published in 2015, our group showed the three distinct collagen architecture of keloid. So this schematic illustration shows the outermost keloid collagen, intermediate organizing collagen and near most proliferant core collagen. We wanted to know which part of collagen is related to keloid recurrence. So we conducted another study in 2018, confirming that remnant keloid tissue at the resection margin, especially at the proliferant core collagen is related to keloid recurrence. And this finding was statistically significant. So I try to keep the surgery as simple as possible one way or another. In this regard, direct linear closure is done in about 90% local diabetes use is only 10%. This 55 year old main patient with interstitial keloid was treated with a complete excision and a grade two fraction daily radiotherapy schedule. Immediate post-operative appearance, post-op day three, two months, six months, one year, two months follow up result. After radiotherapy, the only adjuvant therapy was having patient put silicone glycerin on the scar because we don't have any officially available stereotypes in our country. Based on my experience, if the vertical height of keloid is within six centimeters, primary closure is always possible without exception. Horizontally oriented multiple chest keloid can be excised in a single stage fashion. I used complete excision and 12 year single fraction radiotherapy for this case. This is follow up 10 months result and this is follow up one year result. On the other hand, in vertically oriented multiple chest keloid, we can decide where to treat in the first place depending on the symptoms of each lesion. In this case, I treated her uppermost chest and a multiple keloid in the first stage, leaving this circular chest keloid in the middle for the next operation. So after complete excision, direct linear closure is done, immediate post-op result, we applied closed incisional bag to optimize the outcome and 11 grade single fraction radiotherapy was done and post-op day one, three weeks, three months, eight months follow up result. 10 months after the initial surgery, we did second stage operation for the remaining part. After complete excision, direct linear closure is done and this is after marking the area to be irradiated. We also applied closed incisional negative wound pressure therapy to optimize outcome and 10.5 grade single fraction radiotherapy was applied. However, local flat coverage is beneficial in some cases as shown in this 20 year old female patient. This is follow up six months result. And I like to use conventional keystone flat for some year keloid. This case was treated as such, post-op day one, seven, 21. Although I didn't take a long-term follow-up picture, the outcome is really amazing in this case. Compared to conventional keystone flat, I sometimes I use omega variant keystone flat and this case was treated as such. And this is pre-op and post-op one year follow-up result. To prepare this webinar, I recorded this video clip last week, last Thursday. And this is pre-operative appearance and this picture was taken yesterday. So although it's a very simple procedure, I just show you how actually the procedure happens. So all your keloid surgery is done on the lopunny, are done on the lopunny without exception. I use 15 blades from incision to flap elevation and take out keloid tissue in a single mass without dividing them into multiple pieces. And I do not like to use laboratory to take out keloid tissue not to injure any underlying structure. And the only anatomical structure that we should be preserved during flap elevation is posterior branch of greater rectal nerve. And after checking the defect, flap is marked and after local injection, flap elevation is quite straightforward. So after simulating the fluid, simulating the forger and this is immediate post-operative result. And this picture is actually post-op day six result. This case was treated as such, pre-op and intraoperative appearance and post-op six months, post-op one year follow-up result. Another case, pre-op and post-op one year follow-up result. Pre-op and post-op one year follow-up result. Interestingly, this patient became pregnant at this time point. So we took these pictures on post-op 18 months. And so we confirmed that this 10-grade single fraction electron beam radiotherapy for keloid is very safe and effective even in pregnancy. We published this outcome in this APS journal last year. In some cases, I like to use pre-auricular local flap to reconstruct pericardial root portion of helix. And it is very useful when the patient underwent open surgeries using local tissue to fit their helical keloid. I think the best outcome can be achieved in helical keloid cases following constricted ear retroflexive surgery. I think this is a very good option. And two local flaps are used for sizable ear keloid. This is very reliable flap and this post-op one year follow-up result. Sometimes primal closure can yield very good aesthetic outcome in a well-selected case. Another case I did primal closure for helical keloid after sacrificing some ear cartilage and achieved a good aesthetic outcome. And most of the yellow keloid could be post-primal without exception. And we suggested this classification in 2012 in Dermatology Surgery Journal with my professor Chang, Chunyang Chang. So let me switch gears back to chest keloid. So how would I put this patient? Most of us would probably think of corticosteroid injections but what if the conventional steroid injections does not affect your control of this keloid scar but patients still desire to treat it? I came up with a triple combination therapy including intralesional excision with a punchy device and intralesional steroid injections and single fashion radiotherapy. This is a case of a 3D depth approach and this is an intraoperative appearance and 10.5 year single fashion radiotherapy of supply. This is post-op one year follow-up result and this is follow-up 15 months follow-up result. So this is the case I did. First case I used these techniques and he told me he had no symptoms for more than one year and was extremely happy with it. He even wanted me to share this picture with many other plastic surgeons. This is another chest keloid treated with the same approach for pre-op and post-op one year two months follow-up result. So this approach is indicated in treating intractable keloid and responsive to conventional steroid injections or traditional scar visions are not visible for some reason as shown in this case. Even this approach can be successfully applied this widespread massive seemingly unbearable keloid. I first treated his left shoulder on the local anesthesia with IV sedation. The intra-vascular procedure was done and single fashion radiotherapy of 10.5 year was applied and this is follow-up six months result compared to right shoulder. We achieved a great aesthetically improved outcome and I was amazed to see how this simple procedure can change a person's life and their family's life and their attitude, their lives as well. And however, this approach entails not only several punches on the surface of keloid but also eradicating the entire proliferant core beneath the keloid surface through a punch device or a sharp medicine valve. And as you see, this approach can be combined with complete excision as seen in this case. So this case was treated with a combination of these while his upper most chest keloid were excited completely, lower two lesions were excited by a punch device and injection was done and 11 grade single fraction radiotherapy was applied. And this is post-op 10 months result. And this is post-op one year follow-up result. This is another test, another case, 30 year male patient with left chin keloid. I did complete excision also did, as you see, four punchings were done into your side of the lung on the tubular incision and 11 grade single fraction radiotherapy was applied. This is post-op one year follow-up zone. His sex treatment is right chin as well. Instead of doing complete excision on this side, I did partial excision with a puncher device. This is appearance immediate after radiotherapy. And this is post-op 10 months follow-up zone. So sometimes developing surgery can help patient get symptom relief and a better quality of life. So I think keloid surgery should be planned in the most accomplished manner in the simplest way and hyper-fractional radiotherapy such as single fraction or two fractions is very effective for keloid. Thank you. Thank you, Dr. Park. I'm surprised the wonderful result and then brave surgery and the radiotherapy for intractable keloid. So far we don't have the online question. I'll give you some couple of questions. Let me ask you first, you show the surgery and the radiotherapy. So do you use the conservative treatment for keloid? Usually, you try to use the surgery and then the radiotherapy for some patient, you need to use the conservative local therapy. So how's your portion of that? Most of patient who are indicated for surgery, I just go forward with surgery plus radiotherapy 100%, but in some cases who have fear of getting worse after surgery, in that case, I just using injection therapy using triamcinolone, acetonide mostly, but 50% of triamcinolone, acetonide, but another 50% would be 10% of 5-FU and 90% of steroid injection. So, but the composition would be, overall, the composition would be 50-50%. Okay, good. And then, oh, here's the one question. Yeah. He's asking, what are your thoughts about the steroid injection in combination with surgery and what's your protocol for that treatment modality? Systematic plus surgery. Yes, that is a good question. Especially for facial keloid, radiotherapy is limited. So to treat facial keloid, I always use surgery plus steroid injections. That's the standard treatment option. But other than that, if the mass itself is protruding and symptoms are severe than it looks like, in that case, I always go with surgery plus radiotherapy. But surgery plus triamcinolone, acetonide, it can be a good, but some cases like anterior chest wall, if you use surgery plus steroid injections, it recurred and I don't think that is a good option for recurrence-prone sites, such as anterior chest wall or suprapubic area or some shoulder area. I don't like to use surgery plus injection therapy for those high-prone sites. But other than that, like if you treat buttock or abdomen or some lower extremity, I think surgery plus intralateral strain injection would be a reasonable option. Can you tell me the detail of your injection protocol? Only steroid or steroid plus 5-FU or something? I asked patient whether they would like to add some chemotherapy to it first. If they agree, I use 10% of 5-FU and 90% of steroid injection. That would be the ideal. I got the ideal outcome with that protocol. And the maximal dose is two cc. If the patient have high surface area of keloid, we have to mix it or dilute it to more saline so we can make it like four cc or six cc. But anyway, I always use 50 milligram per week. That's the maximal dose I use for steroid injection. And 5-FU, just 0.1 or 0.2 cc. So you only use the 5-FU and saline, right? Yes. You don't combine these steroid? I combine steroid. Combine steroid. Only? So nine to one ratio, 90% of steroid and 10% of 5-FU. That's a very good option. And I recommend using that instead of just 100% steroid. Okay. Great. Okay. And then you're using the surgery and the radiotherapy and then you show the recurrence due to the keloid remaining. I think the chest wall, it's possible to excise every air everywhere, but like the earlobe, sometimes it's very hard to remove everything. So you always check the keloid specimen. So would you experience any recurrence due to the remnant keloid? So my, yeah, that's a great question. And I think some authors suggested filaflab, meaning that using the skin covering the keloid, they cover like 90%, they remove the keloid scar, but they use a skin covering the keloid and use that tissue as a method of one of the way to cover that defect. But I don't think that is a reliable option. If you follow up the patient one or two years, they recur. So just remove all the keloid and cover that defect with local tissue or some other option would be much better in terms of keloid recurrence. And I always get rid of keloid tissue 100%. If you touch that tissue with a manual hand, or if you see it's just a surgical loop, you can recognize that you actually did remove everything, keloid tissue. So I recommend removing all the tissue, keloid tissue 100%. Even all recurrent here. So you try to excise everything and then use using local tissue and then radiotherapy. Yes. Okay. So thank you very much for your nice presentation. Yeah, we move to the final presenter, Dr. Youngjin Park. He's now running his own Gangnam Samsung Plastic Surgery Center. And he's a representative doctor of that clinic. So would you please start Dr. Youngjin Park? Can you see it? Yeah, sure. Okay. Good afternoon. In Korea, good morning. Honorable audience and host of this webinar. My name is Youngjin Park at the Gangnam Samsung Plastic Surgery Center, Seoul. Today, I wanna give a presentation about threat using facial lifting by the concept of structure, reinforcement and repositioning. Instead of enhancement, I changed it to reinforcement. It may be the appropriate expression. Okay. With aging, there is obvious change of facial soft tissue and skin structure. Ideal solution for such dropping is the ratio adjustment of repositioning and surface volume. However, traditional conventional facelift requires a much invasiveness. From my experience, three years after conventional facelift, there was prominent relapse. Much curious about what happened to her. Even six years after from the second operation, her result was worse than I expected. It was because of her underlying disease, diabetes and hypotension. So from this experience in such cases, I thought it would be the best way to let her have a frequent minimal invasive procedures by short intervals. There has been many trials of less invasiveness of anti-aging procedures. Among them, threat is regarded as one of the most effective one in terms of fast recovery, acceptable result and requires easy surgical skills. Before looking into the details, let me explain the threat generation for lifting procedures. Among them, I wanna show you most effective ones, Consultina designed cog threads and jamba threads. About 20 years ago, Dr. Shulamanit from Georgia, at the time Russia had the success of threat lifting commercially. After that, there came some modifications. With the emergence of observable PDO in the threat lifting, the need for solving drooping end resumination had been explosively increased. Then we could meet various innovative designs and materials like a cavity containing jamba threads or polycarprolactin. First, the opto-thread and then modification to temporal anchoring and large cones by Silasoft and then molding cogs from PDO and polycarprolactin. Now, cavity containing jamba thread. If I would summarize the cog design, the sum of the tangent stress in the pitches of cogs in the Consultina is similar to the bigger contrast. It has another advantage of easy tissue wrapping in the cog pitches, which gives the better and longer effective lifting and least discomfort with more tangent. My concept is composed of a structural reinforcement and repositioning of a droop tissue using various kinds of threads and multiple vectors, lateral and medial vectors. I would explain the aging by the illustration or with aging, it is a weak underlying structure. New concept is by structural reinforcement of weak structures with a combination of several different shape threads. Basically anchoring points are strong retaining ligaments from inferior temporal septum to mandibular cutaneous ligaments. Pier has a meaning of anchoring, suspension by bobbed threads, lateral and medial oblique and truss means a suspension supporting the lifting structure maintained with using cavity containing thread jamber. Suspension bridge is the motive of my concept in the structural lifting. All vectors are recommended for the best result. Vertical, lateral oblique, medial oblique, horizontal. The multiple threads should be placed in the multi layers. For the ideal result, multiple targets are also indicated from mid cheek fat, jowling and so on. But it should not confine to a certain tissues like SMAS. My procedure is not suspension only. I would like to emphasize the trussing. The trussing, trussing and it should not be too much deep below SMAS for fear of injuring the nerves and vessels. I wanna show you the video clip. Usually it is performed under IV anesthesia with the local solutions. Usually, the first entry point is from one centimeter above the lateral canthus. It's for anchoring from the inferior temporal septum to the mouth corner, dense area, dense fibrous area. Another entry point is from a little lower than the first one and then to the mandibular canthus ligament. Nowadays, there is a least chance of temporal anchoring by tying to the temporal area because of using taut retaining ligaments. This is another entry point to the mandibular canthus ligament. And now, I want to emphasize the medial squeezing from macular cutaneous ligament to the pre-ortical dense fascia-like structures through the masseter cutaneous ligament. This is pretty much important procedure for getting the best result. As I explained before, the trussing is pretty much important, which can be the structural reinforcement of weak structures. For two years, from 2016, 73 patients were evaluated until 24 months. The average age was over 50s, and most of them are female and orientals, except the 10 other races. And we evaluate it with a guide score. If it is over 3, we thought it is improved. So, 85% were satisfied with the result two years after the procedures. Long result was maintained till 24 months over 3 guide score, but much improvement state was maintained till one year. So, the patients regarded the best result lasted about one year or so. From our evaluation, we could get the objective effective lifting maintained for more than two years by our technique. From this data, we can give reference guidelines about when the patients can consider redoing. It's a deep meaning, I think, and there was some misunderstanding of my technique. The reviewers thought the maximum usage can produce good results. My original title was Threat Using Facial Lifting by the Structural Reinforcement and Repositioning with 4M. Multiple Threats, Multiple Layers, Target Factors. I'm sure this new concept can be spread to all doctors from all over the world from now on. Now, take a look at the results. 38-year-old female, she received my Threat Lifting Technique. Her main concern was jowling and mid-cheek drooping by the expression of prominent nasolabial depression. One month after, still have some swelling or edema. However, four months, the jowling and mid-cheek drooping was completely improved. Six months, even almost one year. And almost one and a half year, such improvement was maintained. Quarterly showed no relapse. And two years later, she got some weight, much better accumulation on her face. However, still, although there is a little relapse, but the improvement was maintained above guide score three. Nowadays, patients evaluate them by selfie, so that it can be another objective evaluation without fake or scam. Six months after, she sent this selfie. Another lady, 68-year-old female, she received folate blepharoplasty accompanied by my Threat Lifting Included Forehead. Six months, even one year after, she got maintained mid-cheek improvement. Except dimple and swelling, not so much irreversible complications occurred. This kind of cavity-containing threads helps establish the collagen column or stick, which make forming the collagen network, it has big meaning of reinforcement. According to the Pedial Biodegradation, we can guess how long the result will last. By SCAR softening mechanism, it can last for more than one year. If it is accompanied, combined by structural reinforcement, sometimes needs more, six months for another softening. Essential conditions and mechanism in structural lifting are observable thread lift is by fibrotic union of surrounding tissues. Deep tissue lifting only cannot produce the effective result. Tight tissue placation by even non-observable threads cannot guarantee the longevity. Weak retaining ligament should be reinforced, as well as volumetric enhancement is required too. For accomplishing such goals for volumetric enhancement and structural reinforcement, new cavity-containing threads are released with the name of JEMBR. This has a big role at the weak mid-shank ligament, as well as weak sporting structures, especially by the concept of reinforcement. Now, if I would conclude my topic, structural reinforcement and repositioning of aging tissues can guarantee the effective outcomes of anti-aging with the least invasiveness. To achieve above goals, if we use the technique of multi-layers, multi-targets, multi-vectors, and multi-threads, it can give a big satisfaction to both patients and doctors. Thank you very much for your attention. Next time, I can give another presentation about nose job with observable threads and leg lift. If possible, see you again. Thank you very much. Thank you. Thank you, Dr. Youngjin Park. Yes. Yeah. I'm surprised with your long time experience with thread lift and nice results. Okay. Now, so far, there's no online questions, so I'll give you some questions. Okay. Yeah. You used the multi-vector, multi-layer here, the thread. So, how do you decide how many threads in position? Maybe it depends on the patient, but yeah, you have some strategy for that. Yeah. In terms of cog lifting, like this way, lateral oblique, medial oblique, the minimum is usually five pieces in each side. And then, for the structural enforcement of the weak structure, the cavity-containing thread, two, or make a kind of triangle. Two, one, one. It can be four. And here, depending on the extent of jowling, usually three to five. So, it can be less than 10. However, for the sporting, we insert two or three more. So, it can be more than 10 pieces in each side. 10 pieces. If I will summarize it, cogs can be more than five. The cavity-containing thread should be more than 10. So, pretty much expensive for private clinics. Yeah. For private clinics, yeah, it's pretty much expensive. But we have to charge more than that. Okay. Yeah. I think that you experienced the conventional facelift surgery, and then you disappointed the result of the facelift. Longevity, especially longevity. Yeah, longevity. You moved to the thread lift, right? Mm-hmm. So, you showed a good result about the facelift. Mm-hmm. What about the neck drooping or neck area? Is it also affected by thread lift? We have to modify it. Yeah. As you see, you already saw some results by elastic thread, like elastic or some others. It also gives a good result. However, basically, if there are too many redundant skins, doctors or patients cannot be satisfied with that. So, I mean, with the least amount of, not the least, some scar contracture can induce some prominent neck lines. That's all. That's all we can do using the threads. With much drooping or much fat accumulation, it cannot be solved by thread lift. Conventional facelift is strongly recommended in such a situation. Okay. There are another online question. Mm-hmm. It's asking, what type of the facelift technique were you using with the disappointed results? Deep plane or SMAS application? From deep plane, extended SMAS elevation, or whichever it may be, if there is a patient with underlying disease, as I showed you, like diabetes or some hormonal disease, in such a situation, the result cannot last longer and longer compared to the ordinary health people. So, you mean bad result after the facelift depends on the patient's condition? Condition, health condition. Yeah, he's talking about comorbidity of the patients influence the result of the facelift. Okay. And then any scarring change? Okay. There's another question. If the patient wants to have the facelift after thread lift, does scar change can make the surgery more complex? Oh, not so much, not so much. In case of PDO, it doesn't much influence on the conventional facelift. However, in case of polycaprolactone, which cannot be biodegraded in a short time, it can last more than two to five years. Using such delayed biodegradable material can influence on the much scarring. Usually not much scar. Yeah, yeah, right. Not so much. No problem for the facelift surgery. Okay. It's almost time. We have enough questions and answers. Okay. So, let me close this ASPS webinar session. Thank you for joining us, approved by the Korean Society of Plastic and Reconstructive Surgeons. And thank you for three speakers. Thank you very much. Thank you. Thank you. See you next time.

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keloid treatment

facelift techniques

thread lifting

reconstructive surgery