Received: 21 February 2024 Accepted: 28 February 2024

DOI: 10.1111/srt.13650

ORIGINAL ARTICLE

SMAS repositioning technique utilizing cog thread: Anatomical

perspectives

Gi-Woong Hong1 Soo-Bin Kim2 Soo Yeon Park3 Jovian Wan4 Kyu-Ho Yi2,5

1
Samskin Plastic Surgery Clinic, Seoul, South
Korea Abstract
2
Division in Anatomy and Developmental Introduction: Face-lifting surgeries were once common among individuals over 60
Biology, Department of Oral Biology, Human
years old due to skin laxity, but recent trends favor thread lifting in this age group.
Identification Research Institute, BK21 FOUR
Project, Yonsei University College of Dentistry, Understanding dynamic changes in facial anatomy during postural shifts is essential.
Seoul, South Korea
Method: Fresh cadaver studies have demonstrated the passage of threads through
3
Made-Young Plastic Surgery Clinic, Seoul,
South Korea
the superficial musculoaponeurotic system (SMAS) layer, confirming the efficacy of
4
Asia Pacific Aesthetic Academy, Hong Kong, the technique. Proper insertion depth targeting SMAS repositioning, rather than
Hong Kong superficial skin layers, is crucial.
5
Maylin Clinic (Apgujeong), Seoul, South Korea Result: The natural movement of tissues secured by thread (N-Cog and N-Fix, N-
Finders Inc., Korea) insertion results in lifting effects. However, complications may
Correspondence arise if threads affect deeper facial muscles, leading to discomfort. Fibrous septa play a
Kyu-Ho Yi, Division in Anatomy &
Developmental Biology, Department of Oral
significant role in guiding thread placement, with different densities influencing thread
Biology, Yonsei University College of Dentistry, maneuverability and tissue response during lifting.
50–1 Yonsei-ro, Seodaemun-gu, Seoul, 03722,
Korea.
Conclusion: Procedures targeting SMAS repositioning using threads aim to main-
Email: [email protected] tain the new position of relocated tissues. Understanding structural variations in
facial regions informs thread selection and placement. Aligning threads with tissue
movement and the intended SMAS layer positioning is vital to prevent complica-
tions. Balancing thread insertion depth and tissue traction is critical for successful
outcomes. Modern thread lifting techniques prioritize SMAS repositioning, enhancing
lifting effects while ensuring procedure safety and efficacy.

KEYWORDS
facial anatomy, facial retaining ligament, SMAS repositioning, thread lifting

1 INTRODUCTION was widely believed that achieving effective results solely through lift-
ing techniques employing threads or sutures was challenging in this age
As individuals enter their middle to late years, typically surpassing the group. However, in recent years, there has been a shift toward perform-
age of 60, wrinkles tend to deepen, and skin sagging becomes more ing thread-lifting procedures in individuals within this age bracket. The
pronounced. Consequently, there was a historical necessity for face- commencement of this practice stemmed from a fundamental change
lifting surgeries, involving the pulling and excision of excess skin, owing in the conceptualization of thread-lifting techniques.2
to the increased laxity of the skin and underlying tissues.1 Formerly, it Previously, the conventional approach involved a straightforward
upward traction of the lax skin and subcutaneous tissues.3–5 Presently,
Gi-Woong Hong and Soo-Bin Kim contributed equally to this study.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2024 The Authors. Skin Research and Technology published by John Wiley & Sons Ltd.

Skin Res Technol. 2024;30:e13650. wileyonlinelibrary.com/journal/srt 1 of 8

https://doi.org/10.1111/srt.13650
2 of 8 HONG ET AL .

F I G U R E 1 The figure illustrates alterations in facial skin and soft tissue concerning positional changes. Panel A presents a lateral profile view
in a sitting position, while panel B depicts the lateral profile view in a supine position.

the mindset has evolved to a technique where, when patients are entirely resolved, there are noticeable changes in the appearance of
placed in a reclined position, subtly lifting the chin or slightly lowering the face. The facial structure appears less saggy, the texture of the
the head results in the migration of lax tissues of the midface and lower skin and connective tissues improves, deep wrinkles become shallower,
face toward the firmer structures around the head, ears, and jawline. and individuals tend to look naturally younger than their actual age,
The primary objective of thread lifting is now perceived as securing acquiring a softer and more amiable facial impression.12,13 Addition-
these migrated connective tissues to the firm underlying structures to ally, considering the potential exacerbation of aging-related changes
prevent them from reverting to their original positions.6–8 over time if thread-lifting procedures were not undertaken, the abil-
ity of this approach to slow down facial changes associated with aging
assumes considerable significance.
2 SMAS REPOSITIONING TECHNIQUE Moreover, in performing a natural thread-lifting procedure that
takes into account tissue movement concerning posture, an important
The study of fresh cadaveric movements of facial skin and tissues con- aspect to consider is the depth at which the inserted threads reside.
cerning postural changes reveals that transitioning from a seated to a The preference for different techniques in thread lifting may lead some
supine position not only alters the positioning of the cadaver’s head but individuals to opt for the insertion of multiple relatively thin threads
also induces overall tension in the facial skin and soft tissues.9 The skin into the subcutaneous tissue, favoring a lighter pulling approach. Many
and connective tissues around the head and ears are drawn, causing a individuals referring to this approach often mention a plane within the
visible change in the shape and angle of the periorbital area and nasal subcutaneous fat tissue that allows easy insertion of threads without
tip. Notably, the transformation of the lower face tissues is intriguing resistance.14
as it demonstrates that, with postural changes, the lax skin and tis- When discussing the explanation of dual-plane filler procedures, the
sues, including those around the submental area, do not solely migrate author often highlights that, except for the inner aspects of the face,
toward the head and ears but also remain along the firm structures where vertically oriented fibrous septa firmly attach the subcutaneous
encompassing the chin, anterior jawline, and the angle of the mandible. fat and skin to the underlying SMAS (superficial musculoaponeurotic
This persistence contributes to the natural delineation of the chin and system) to protect the facial structure and enable facial expressions
jawline, resulting in tauter skin. This phenomenon can be attributed to through the movement of facial muscles, there is not ample space for
the presence of resilient structures such as the insertion of the men- filler injection.15 This leads to the question of how such a space, suit-
talis muscle at the chin, the mandibular ligament along the boundary of able for performing thread lifting procedures with ease, is created
the chin and jawline, and the angular tract fascia anterior to the SCM during these procedures.
muscle within the inner angle of the mandible.10,11 These unyielding The reason why threads can be smoothly inserted into the subcu-
structures play a role in the phenomenon wherein lax tissues, when taneous tissue is due to the presence of spaces between the fibrous
shifted toward firm structures, produce a naturally effective lifting septa connecting the skin and the SMAS layer. Despite the firm
effect, aligning with the author’s perspective (Figure 1). attachment of these tissues through fibrous septa, the presence
When observing the outcomes of thread-lifting procedures based of these spaces allows threads to pass through. Assuming that all
on these principles in elderly patients, it becomes apparent that while other conditions remain constant, the structural density difference
severe skin sagging and deep wrinkles caused by aging may not be in these fibrous septa alone leads to variations in the firmness of
HONG ET AL . 3 of 8

FIGURE 2 The figure demonstrates the distinction in fibrous septa between the superficial and deep fat layers.

the subcutaneous fat tissue in upper, middle, and lower regions. If in achieving prolonged lifting effects by merely dissecting and pulling
we consider fibrous septa as thin fibrous tissues, the area passing the skin and subcutaneous tissues.21 Even skin pulled by thread inser-
through the SMAS layer appears densely packed initially, resembling tion eventually reverts to its original position, firmly connected to the
thick branches of a tree, gradually thinning out as they ascend and SMAS layer, and forcing excessive skin tension may engender various
spreading out as they approach the dermal tissue.16,17 To firmly issues.
anchor the skin, the fibrous tissues heading towards the skin again Nevertheless, even in recent descriptions of thread-lifting proce-
disperse evenly and densely, exhibiting a pattern resembling numerous dures, there is a tendency to emphasize that the direction of insertion
closely divided thin branches. Consequently, fibrous septa passing after cannula insertion should primarily target the subcutaneous tissue
through the SMAS layer appear robust and firm due to the dense underneath the skin to avoid complications and hindrances. In practice,
clustering of fibrous tissues, while those situated in the middle of the threads are inserted closer to the SMAS layer along the upper or lower
subcutaneous fat layer comprise finer branches, rendering them less surfaces of the SMAS, and even if some threads become attached
rigid. The retinacular cutis located closer to the dermis consists of very to the SMAS, they are so robust that, except for regions such as the
thin but densely distributed branches, creating a perceptibly robust head or ear, moving the cannula does not encounter severe resistance.
structure. Upon withdrawing the inserted cannula and pulling the thread caught
Moreover, the density of fibrous septa within the subcutaneous tis- in the tissues, including the SMAS layer, it is observable that the skin
sue and the resulting strength vary across facial regions. Areas where and connective tissues, including the SMAS layer, respond well to the
ligaments or ligament-like tissues hold firmly exhibit dense fibrous pull. This phenomenon is due to the deep fat layer beneath the SMAS,
septa, creating a rigid sensation when threads pass through.18 In con- composed of obliquely oriented fibrous septa, unlike the superficial
trast, areas where fibers of ligamentous tissues are loosely gathered fat layer, allowing smoother movement of facial muscles. This area
allow threads to pass more smoothly.19 For instance, the zygomatic does not impede the movement of the SMAS layer due to its loose
ligament, regarded as one of the most robust ligaments in our face, configuration and lack of firm attachment to the SMAS layer above,
generates substantial resistance as it traverses the lower portion of forming a space that allows movement, referred to as a “moving plane”
the zygomatic arch due to the density of fibrous septa within the beneath the SMAS due to its anatomical characteristics. Additionally,
subcutaneous tissue (Figure 2).20 when inserting or moving the cannula, it is possible to avoid injuring
The insertion of threads through the middle layer of subcutaneous important internal structures by controlling the angle of the cannula
tissue, while inducing a perception of initial skin movement due to and not delving too deeply into the loose space below the SMAS layer
pulling and gathering, still maintains the attachment of the skin and (Figure 2).
SMAS layer via fibrous septa. Consequently, forcefully pulling only the Therefore, to maximize the natural repositioning effect on tissues
skin and subcutaneous tissue while the SMAS layer remains unmoved and achieve optimal lifting and tightening outcomes during thread
leads to a temporary sensation of tension initially, which eventually dis- lifting procedures, the author suggests targeting not the skin or
sipates as the skin, connected to the unaltered SMAS layer, returns dermal layers but rather the SMAS layer or the surrounding tissues.
to its original position. Therefore, rather than excessive skin tension, By focusing on pulling these areas, the procedure aims to enhance the
a more desirable lifting effect involves a sensation of the skin layer lifting and tightening effects through natural tissue repositioning. This
adhering moderately toward the head and ear, ensuring sustained approach is feasible due to the presence of a “moving plane” beneath
procedural effectiveness. the SMAS layer, allowing a certain degree of movement and traction
In cosmetic surgery, the reason for dissecting and pulling the SMAS of the SMAS layer, as previously discussed. The author refers to this
layer during face-lifting procedures ultimately stems from the difficulty thread-lifting technique, which utilizes repositioning of the SMAS layer
4 of 8 HONG ET AL .

F I G U R E 3 The figure delineates the shifting plane beneath the superficial musculo-aponeurotic system (SMAS) layer for cogged thread lifting
(N-Cog, N-finders Inc., Seoul, Korea).

F I G U R E 4 An approach entails placing the patient on a tilting table oriented against gravity, facilitating the concentration of the superficial
musculo-aponeurotic system (SMAS) and reticular cutis toward the temple prior to thread insertion. Panel A demonstrates the face’s inclination in
the antigravity orientation, while panel B showcases the consolidation of the reticular cutis and SMAS (N-Fix, N-finders Inc., Seoul, Korea).

using threads, as the “SMAS Repositioning Technique with Thread before inserting the threads (Figure 5). It is advisable to confirm the
Lifting.” (Figure 3). absence of nerve compression or other issues by applying pressure
with the palm for approximately one minute before thread insertion.
By establishing a dense position of the SMAS and reticular cutis before
3 CLINICAL APPLICATION thread insertion, the threads can maintain this shape while producing a
lifting effect (Figure 6).
There are generally two approaches to this procedure. One involves
positioning the patient on a tilting table in the antigravity direction,
allowing the SMAS and reticular cutis to be densely located toward 4 DISCUSSION
the temple before inserting the threads (refer to Figure 4 and Video
S1). In the video demonstration, N-Finders product called N-Cog and In fresh cadaver studies conducted for thread lifting procedures, obser-
N-Fix, which are the main thread of this SMAS repositioning con- vations reveal that, without intentionally inserting threads close to
cept. This method offers the advantage of pre-assessing the effects of the skin, practitioners aim to mimic the depth of insertion in actual
thread insertion as the shape is already established, thereby reducing patients. Delicately inserting the cannula to the same depth as dur-
the risk of developing dimples. Additionally, it minimizes the likeli- ing procedures and subsequently placing threads, upon dissecting the
hood of adverse effects such as bleeding or nerve paralysis by avoiding skin, shows that in a significant number of cases, threads are found
excessive pulling on nerves or blood vessels. to traverse along or partially penetrate the SMAS layer. In instances
Another approach would be, in the absence of a tilting table utiliz- where the skin and subcutaneous tissues are thin, it is observed that
ing gravity, an alternative method involves manually pushing the tissue threads are predominantly inserted along the underside of the SMAS
toward the temple on the skin surface using the palm of the hand layer. (Figure 7).
HONG ET AL . 5 of 8

F I G U R E 5 In addition to the method utilizing gravity, another approach involves manually pushing the tissue towards the temple on the skin
surface using the palm of the hand, creating a dense positioning of the reticular cutis towards the temple before inserting the threads.

ment of the skin and subcutaneous tissues occurs in accordance with

this relocation, demonstrating the lifting effect. This understanding
involves the concept that when the SMAS layer is relocated, the skin
and subcutaneous tissues connected to the SMAS naturally move
alongside the periSMAS tissue. Hence, there is a shift toward per-
forming thread-lifting procedures even for individuals of relatively
advanced age, emphasizing the changing approach toward implement-
ing thread-lifting procedures for older individuals nowadays.
Clinically observed phenomena indicate that when the nodules of
the thread impact the dermal tissues beneath the skin surface, it often
results in the appearance of dimples or irregularities on the skin. Con-
versely, if the nodules of the thread catch and pull within the deep facial
muscle layer, it may lead to awkward facial expressions and cause dis-
comfort or pain when moving the face. During actual procedures, when
passing through the fat compartments just above or below the SMAS
layer, practitioners often experience a smooth movement of the needle
F I G U R E 6 Ensuring a compact alignment of the superficial
musculo-aponeurotic system (SMAS) and reticular cutis before or cannula without resistance. However, inserting the needle or can-
inserting the threads enables them to sustain this configuration while nula into the deeper fascial layers of the facial muscles results in less
eliciting a lifting effect (N-Cog, N-finders Inc., Seoul, Korea). movement upon manipulation and leads to patient discomfort or pain.
When a needle or cannula is properly inserted just above or below
the SMAS layer, or within the SMAS layer, raising the needle or can-
The possibility of threads penetrating the SMAS layer itself stems nula reveals that the layer of skin and subcutaneous tissue above it
from the structural composition of the SMAS when examined in lifts uniformly to a certain thickness equal to the length of the needle
detail. Rather than being a single thick layer of muscle, the SMAS or cannula. To determine the appropriate depth for the procedure, a
consists of a superficial fascia comprising three layers.22 Within this useful method involves utilizing the pinch technique, where the prac-
structure, the SMAS is not merely a thick muscular layer; instead, titioner uses their non-dominant hand (usually the left hand) to grasp
it consists of a thin and resilient membranous layer sandwiched and pull the tissue to measure its thickness. Studies employing the
between upper and lower fatty layers, forming a superficial fascia pinch technique generally demonstrate that intentionally thinning and
(Figure 2). elevating the skin tissue with the tips of the thumb and index finger
As mentioned earlier, the skin and SMAS layer are firmly connected often results in mainly lifting the subcutaneous tissues above the SMAS
through vertically oriented fibrous septa and retinacular cutis. There- layer, with minimal disturbance to the SMAS layer itself, which is barely
fore, when threads pass through the SMAS or its surrounding areas, touched on the surface (Figure 8) When using the broader and thicker
and by pulling the SMAS layer around the moving plane beneath the part of the finger pad, rather than just the tips of the thumb and index
SMAS, a natural lifting effect is achieved. Consequently, the move- finger, to grasp and lift the tissue in the outer cheek area, it can lead to
6 of 8 HONG ET AL .

FIGURE 7 The figure showcases cogged threads inserted along the supra SMAS plane (N-Cog, N-finders Inc., Seoul, Korea).

F I G U R E 8 The figure illustrates the technique of shallow pinch for subcutaneous tissue traction (panel A) and deep pinch for superficial
musculo-aponeurotic system (SMAS) layer traction (panel B).

a somewhat rounded elevation of the skin and subcutaneous tissues, subcutaneous tissue (Figure 9). Therefore, when inserting needles or
including the SMAS layer. cannulas for thread lifting, as long as the tissue is not pushed too deeply
It is crucial to note that on the lateral side of the face near the ear, beneath the grasped tissues, the probability of the thread going deep
the SMAS layer is thicker and firmer compared to the inner aspects of under the SMAS layer is low.
the face. When lifting tissue in this area, despite grabbing and elevating However, in the inner aspects of the face, the SMAS layer is thinner,
the tissue firmly, the SMAS layer may not elevate significantly above, and the deep fat layer is thicker. Carelessly grasping and pinching too
but rather the tissue being held might only slightly lift just beneath the thickly in this area can cause the SMAS layer and even the deep fat layer
HONG ET AL . 7 of 8

F I G U R E 9 The figure displays variations in superficial musculo-aponeurotic system (SMAS) thickness and tightness concerning anteior face
(A) and lateral face (B).

underneath to be inadvertently lifted together. This could result in the depth of wrinkles, and the patient’s preferences. In some cases, a
thread being positioned deeper than intended, possibly perforating the combination of multiple threads may be suitable. When employing
mucous membrane inside the mouth. Moreover, if the thread grasps SMAS repositioning-based thread lifting, an essential considera-
the tissue too thickly, the ultimate efficacy of the procedure might be tion is determining the direction in which the tissues are stretched,
compromised. Therefore, caution is strongly advised to prevent these guiding the insertion direction of the threads accordingly. Once the
potential complications. thread insertion direction is established, decisions need to be made
The early stages of thread lifting involved the belief that maxi- regarding the entry point of the threads, thread thickness, quantity,
mum pulling and tensioning of the skin and subcutaneous tissues using insertion depth, and awareness of important anatomical structures
thread cones were necessary to maintain some residual effect even and tissues prone to thread entanglement. These considerations
as the threads naturally loosened over time. However, with improve- are fundamental regardless of the facial area targeted for thread
ments in thread shapes and qualities for lifting and the enhancement lifting.
of lifting materials, there’s no longer a strong necessity to excessively
tension tissues during the initial stages. It is now recognized that the ACKNOWLEDGMENTS
contemporary concept of thread lifting focuses less on the forced lift- This study was conducted in compliance with the principles set forth in
ing of superficial skin and subcutaneous tissue but rather on the natural the Declaration of Helsinki.
repositioning of deeper tissue layers such as the SMAS and its sur-
rounding tissues. After tissue repositioning, it is crucial to stabilize the CONFLICT OF INTEREST STATEMENT
relocated tissues to prevent them from moving back to their original I acknowledge that I have considered the conflict of interest statement
positions. Hence, the tension applied by the threads, capable of with- included in the “Author Guidelines.” I hereby certify that, to the best of
standing the direction of gravity and maintaining the tissues in their my knowledge, no aspect of my current personal or professional situ-
adjusted position, becomes vital. ation might reasonably be expected to significantly affect my views on
In the past, U-type long threads were frequently used for this pur- the subject I am presenting.
pose, but nowadays, there’s a wide variety of PDO threads available
in different thicknesses and shapes. Advancements in manufac- DATA AVAILABILITY STATEMENT
turing techniques and procedural instruments have facilitated the Data sharing is not applicable to this article as no new data were
use of convenient I-type threads for various enhancements beyond created or analyzed in this study.
lifting the outer jawline, including addressing issues like eyebrow
drooping, eye hollows, forehead lines, marionette lines, and neck STATEMENT OF HUMAN AND ANIMAL RIGHTS, OR
sagging. ETHICAL APPROVAL
The choice of threads depends on factors such as the thickness This article does not contain any studies with human partici-
and weight of the patient’s skin and tissues, the extent of sagging, pants or animals performed by any of the authors.
8 of 8 HONG ET AL .

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