Facelift surgery is a cornerstone of facial rejuvenation, yet the optimal technique remains debated. This prospective cohort study compared outcomes and complication rates between the deep plane and superficial musculoaponeurotic system (SMAS) plication facelift techniques. A total of 166 patients undergoing primary facelift surgery by a single surgeon between January 2019 and December 2024 were prospectively enrolled. Patients were allocated to the deep plane (n = 45, 27.1%) or SMAS plication (n = 121, 72.9%) groups. Data collected included demographics, operative characteristics, aesthetic outcomes, patient satisfaction, recovery duration, and complications. The median patient age was 49years (IQR 42.7-56), with most being female (95.2%) and overweight (46%). Baseline characteristics were comparable between groups. Facial rejuvenation was rated as excellent in 70.5% of SMAS cases versus 29.5% of deep plane cases (p = 0.67). Patient satisfaction was high in both groups (p = 0.09), and recovery duration was similar (median 25.5 vs. 30days, p = 0.65). Overall complication rates did not differ significantly (21.6% vs. 28.7%, p = 0.39), including transient facial nerve weakness (11.1% vs. 12.4%, p = 0.70). Concurrent ancillary procedures were similarly distributed between groups (93.3% vs. 95.9%, p = 0.79). Logistic regression identified no significant predictors of outcome or interaction effects. Deep plane and SMAS plication facelifts demonstrated comparable early postoperative outcomes with no significant differences in patient satisfaction, rejuvenation ratings, recovery, or complication rates within a median follow-up of three months. These findings should be interpreted in the context of short-term follow-up, unequal group sizes, and the absence of validated outcome instruments. Both techniques appear safe and effective in the early postoperative period, with results largely influenced by surgical expertise and patient selection rather than technique alone LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Facelift surgery has evolved from superficial skin excisions to anatomically guided reconstruction of the deep facial and cervical layers. Modern deep-plane, extended deep-plane, and deep-neck techniques address the functional superficial muscular aponeurotic system (SMAS)-platysma unit, the retaining ligaments, and deep cervical structures. Preservation-based approaches, the crevasse technique, and recent endoscopic modalities emphasize structural integrity and natural vector repositioning. This article reviews the historical evolution of facelift, the anatomical principles, classical and contemporary techniques, and the newest modifications and emerging innovations, outlining future directions in cervicofacial rejuvenation.

This study aimed to investigate safety and effectiveness of using a modified hairline preserving incision (the Okumus incision) in face-lift surgery, particularly in terms of temporal region aesthetic outcome. A total of 400 female patients (mean age: 49years, range 38 to 72years) who underwent rhytidectomy using modified hairline preserving incision (the Okumuş incision) through a temporozygomatic approach were included in this study. The Okumus incision was evaluated in terms of objective assessment by the investigator using the Global Aesthetic Improvement Scale (GAIS), patient-reported outcome (appearance after treatment, satisfaction with the treatment), complications and temporal region aesthetic outcome (temporal hairline distortion, anterior temporal scarring, alopecia, or sideburn irregularity). At postoperative month 12, GAIS scores indicated exceptional improvement in 98% of patients and 98% of patients reported that they were very satisfied with the treatment in terms of temporal region aesthetic outcome. No cases of temporal hairline distortion, sideburn irregularity, or visible anterior temporal scars were observed. All complications including widening of temporal scalp scars (4.2%), delayed wound healing (5.2%) and hypertrophic scarring (2.7%) resolved without long-term functional or aesthetic sequelae. The Okumus incision offers a hairline-preserving, cosmetically superior alternative for female patients undergoing facelift, without compromising safety or efficacy. Providing a unique balance between the comprehensive exposure of a classical facelift and the aesthetic advantages of short-scar techniques, it enables retention of the full surgical access for cheek and midface rejuvenation while reliably preserving the temporal hairline and avoiding the stigmata of visible temporal scars. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The senior author has combined buccal fat suspension with facelift surgery to restore youthful cheek volume and contour. This technique consistently produces softening of the nasolabial fold as a secondary benefit. However, no existing anatomic model adequately explains this effect. This study was designed to identify the anatomic mechanism by which buccal fat suspension softens the nasolabial fold. Buccal fat suspension was reverse-engineered on fresh cadaveric specimens. Four consistent effects on the middle third of the cheek were identified, which generated four targeted anatomic questions. These questions were addressed through layered and cross-sectional dissections of 20 hemifaces from 10 fresh cadavers (mean age 68.2 years). The study identified a functional "buccal sling." Traction on the buccal fat and its capsule transmits tension through these structures to the transverse facial septum. This tension repositions the deep medial cheek fat medially, thereby softening the nasolabial fold. Buccal fat suspension is not merely a lift; it re-establishes the buccal sling and inferior cheek border, while recreating the shape and contour of a youthful, attractive "Nefertiti cheek." Hoxworth suggested that attenuation of the buccal capsule is the initiating factor in jowls. Building on the prior work of Mendelson and Matarasso, the authors propose the "Buccal Cascade" as a bottom-up model of midfacial aging in which progressive attenuation of the buccal capsule ultimately leads to malposition of the deep medial cheek fat and pseudoatrophy.

Complete release of the retaining ligaments during deep plane face and neck lift is essential for durable rejuvenation. This step demands particular caution to avoid nerve injury, however, as branches of the facial nerve course in close proximity to the retaining ligaments. During ligament release, surgeons currently rely on uncodified visual and tactile clues or separate neuromonitoring equipment which introduces an instrument change between identification and division. We describe a three-sign sequential identification framework in which the LigaSure vessel sealing system (Medtronic, Minneapolis, MN) serves as both the diagnostic probe and the division instrument, eliminating the need for an instrument change during ligament release in deep plane facelift. First, the Visual Assessment Test evaluates fiber direction and tissue character. Second, the LigaSure Tweak Test distinguishes excitable nerve from nonresponsive ligamentous tissue. Third, the Skin Tethering Test applies gentle traction to confirm a ligament's dermal insertion through visible skin dimpling. A structure is divided only when all three signs align with a ligamentous identity. This framework synthesizes individually described anatomic identification clues into a structured, reproducible, and teachable approach for what is described as the most challenging step of deep plane facelift.

Facial rejuvenation techniques must meet modern demand for natural results with minimal visible scarring. Traditional facelifts often fail to correct midfacial descent and multivector ptosis, especially in younger patients without significant skin laxity. We describe a multiplanar, triaxial facelift approach combining subperiosteal, subfascial, and sub-SMAS (superficial musculoaponeurotic system)/subplatysmal dissection through hidden incisions. This study aimed to evaluate the clinical effectiveness and safety of a scar-concealing, multiplanar facelift approach that integrates forehead lift, transoral midface lift, and limited-scar lower face and neck lift techniques. The objective was to determine whether this combined strategy provides consistent midfacial elevation and natural facial harmony while maintaining minimal visible scarring and low postoperative morbidity. This retrospective study included 216 female patients who underwent surgery between June 2021 and January 2024. The technique uses intraoral, retroauricular, and scalp incisions to enable multiplanar access. Midfacial repositioning was performed through dual-plane transoral fixation, while lower facial and cervical contouring was achieved via subplatysmal and sub-SMAS dissection. The mean surgical duration was 167 minutes, with an average follow-up of 18.5 months. Patients demonstrated consistent midfacial elevation, improved contour, and enhanced overall facial harmony on postoperative clinical assessment and standardized photographic comparison. Complications were minimal and transient, including temporary facial nerve weakness and localized dimpling, all of which resolved without permanent sequelae. Our scar-concealing multiplanar facelift approach provides a reliable and anatomically sound option for comprehensive facial rejuvenation, achieving consistent midfacial elevation and natural facial harmony with minimal visible scarring. The technique demonstrated durable esthetic improvement with a low complication rate, supporting its safety and effectiveness for appropriately selected patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Facial asymmetry, particularly rotational asymmetry, represents a significant aesthetic concern that impacts facial harmony and perceived attractiveness. Traditional approaches to facial rejuvenation often employ symmetrical interventions, which may fail to address the underlying rotational patterns. This study investigates the efficacy of asymmetrical thread lifting using JETEMA threads (Epiticon, Bi-thread, JETEMA, Korea) for correction of facial rotation. To evaluate the effectiveness of standardised unilateral thread placement in the nasolabial fold area for correction of facial rotational asymmetry and establish a consistent approach for treatment of clockwise facial rotation patterns. Forty-five patients (32 females, 13 males; mean age 41.3 years) presenting with facial rotation were treated with asymmetrical insertion of JETEMA threads. Two threads were inserted using a reverse technique on the affected side of the face (left side for clockwise rotation, right side for counter-clockwise rotation) targeting the nasolabial fold area. Assessment of facial rotation was conducted using standardised photography and a newly-developed 4-point Facial Rotation Grading Scale (FRGS) before treatment and at 6-month follow-up. Patient satisfaction and improvements in rotation grade were evaluated. Improvement in facial symmetry was observed in 89% of patients (40/45) at the 6-month follow-up based on the study-specific Facial Rotation Grading Scale (FRGS). All severe cases (Grade 3, n = 11) improved to mild rotation (Grade 1), while most moderate cases (Grade 2, n = 26) improved to Grade 1, with the exception of 5 patients. Patient satisfaction scores averaged 8.3/10. These findings should be interpreted with caution due to the use of a non-validated assessment scale and the absence of objective measurement tools. Unilateral thread lifting using a standardised reverse technique may represent a promising minimally invasive approach for correction of facial rotational asymmetry. However, given the methodological limitations, including the use of a non-validated grading system and short-term follow-up, further studies incorporating validated assessment tools and objective measurements are required. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Polydioxanone (PDO) thread-lift is a minimally invasive technique used for facial rejuvenation. However, high-quality evidence regarding the incidence of complications and its predictive factors remains scarce. In this study, we aimed to determine the incidence of complications following PDO thread-lift procedures, identify the independent predictors for complications, and construct a clinically applicable risk-scoring model. In this multicenter retrospective study, we analyzed 2000 randomly selected cases of PDO thread lifting performed at 105 clinics between November 2020 and December 2023. Age, sex, thread count, and incidence of postoperative complications were evaluated. Multivariate logistic regression and receiver operating characteristic curve analyses were used to identify predictors and validate model performance. A weighted risk score was developed using thread count and age as covariates. The overall complication rate was 12.4%. The most common adverse events were skin retraction (6.35%), asymmetry (2.9%), and pain (1.75%). Multivariate analysis identified thread count (odds ratio [OR]: 1.12 per thread, 95% confidence interval: 1.09-1.15) and older age (OR: 2.14 for 40-49; 3.38 for 50-59; 5.08 for ≥60) as independent predictors of postoperative complications. A risk score combining these variables demonstrated strong discrimination (area under the curve = 0.747), with a cutoff of 9 points, yielding a sensitivity of 90.3% and specificity of 46.9%. This study presents the first large-scale, validated, PDO-specific scoring model for predicting complications after thread lifting. By enabling objective preoperative risk stratification, the model supports safe, evidence-based, and personalized aesthetic treatment planning. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Facelift surgery is becoming increasingly common in men. Certain male- specific characteristics necessitate a tailored approach to achieve a natural, stigma-free outcome. The sideburn area in men requires special attention to avoid visible scars and to maintain its position, preventing an unaesthetic and feminized appearance. The author describes his personal approach to managing the sideburns in men undergoing facelift surgery and provides a literature review of techniques used in this region to avoid postoperative stigmas. The technique used by the author allows for the maintenance of both the width and position of the male sideburns, with scars camouflaged within the hair and beard regions. Temporal flap rotation and excess skin resection in the male sideburn area have proven effective in maintaining a natural, stigma-free result. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have demonstrated substantial therapeutic benefits for patients with Type 2 diabetes mellitus and/or obesity. Their use has recently expanded rapidly across diverse patient populations. However, GLP-1 RA-associated changes in body composition and skin quality, including premature skin aging and alterations in body contour, may create functional and aesthetic concerns for patients. Effective strategies to address these visible and unwanted effects are needed. To summarize preclinical and clinical evidence supporting the potential role of AP31, a novel multifunctional micropeptide, in mitigating skin-laxity effects relevant to patients treated with GLP-1 RAs. Preclinical studies have evaluated the biological activity of AP31 across multiple aging-related end points, including inflammatory pathways, extracellular matrix integrity, and age-associated gene expression. In addition, clinical studies have assessed AP31-containing regimens in middle-aged women, with outcomes focused on visible markers of skin aging such as firmness, elasticity, fine lines, wrinkles, facial contour, and structural support. Preclinical investigations demonstrated that AP31 reduced proinflammatory markers, increased key extracellular matrix components, and favorably modulated genes associated with intrinsic skin aging. In clinical studies, AP31-containing regimens produced rapid and visible improvements in multiple parameters of skin aging, including enhanced firmness and elasticity, reduction in fine lines and wrinkles, improvement in jawline definition, global facial lift, and reduced prominence of nasolabial folds. AP31 shows promising biological and clinical activity in improving visible signs of skin aging. While current findings are encouraging in the context of normal aging, randomized controlled trials are warranted to further establish the efficacy of AP31 for patients experiencing skin-related changes associated with GLP-1 RA use.

Various techniques have been evolved throughout the history of facelift surgeries, some being conservative while others radical, endangering facial nerves for better results. While plication techniques tighten the SMAS via sutures, SMAS flap techniques enable full mobility of the face for a stronger lift and enhanced longevity. Regardless of the technique, the midface is among the first on the "dissatisfaction list" with recurrences and insufficient lifting reported. True midfacial mobility is possible with complete release of the zygomatic ligaments and proper stabilization of the SMAS, or with subperiosteal midfacial repositioning techniques. The SMAS flap techniques (particularly an extended composite or high-SMAS) can elevate the midface effectively; however, the midfacial lift is more in a lateral vector. Suture-based techniques that lift the midface through the temporal approach on the other hand lift the midface in a more vertical vector; however, their means of stabilization are weaker as a consequence of cheese-wiring outcomes. The objective of this paper is to introduce into literature a SMAS flap technique utilizing 2 SMAS slings to elevate and stabilize the face, neck and midface in a three-vector, strong and effective yet long-lasting way. The technique was performed in a selective group of the author's facial rejuvenation patients (n=72) from 2019 to 2025 age 39-75. Inclusion criteria were a sagging midface, no prior power-based procedure and primary facelift candidates. A modified composite facelift and necklift was performed under general anesthesia with elevation and preparation of two sling SMAS flaps additional to the classical high-SMAS flap vector. The transversely elevated superior sling flap was flipped and transported through the temporal tunnel to the superior temporal space. This flap was secured to the medial portion of the deep temporal fascia for the purpose of elevation and fixation of the midface to the temple. The vertical prepared inferior sling flap was rotated behind the ear and secured to the mastoid fascia for the purpose of lifting the neck (platysma) and demarcating the mandibular angle and jawline. SMAS elevation and release of the retaining ligaments enables full mobilization of the face required for a proper and efficient facelift surgery. Deep neck work on the other hand enables decompressing and controlling the sagging tissues of the neck and tightening of the platysma muscle. The double-sling SMAS flaps enable a strong, effective and long-lasting stabilization of the SMAS to the temple and the mastoid fascia in addition to the classical oblique vector. Midfacial elevation and stabilization are in a more vertical vector, the lower face in an oblique vector and the neck in a transverse vector, hence ensuring a natural facial rejuvenation. The double-sling composite facelift technique enables mobilization of the SMAS and stabilizes it via "true" SMAS flaps in three different vectors simultaneously (specifically lifting the midface in a more vertical vector). This technique achieves effective rejuvenation with sub-SMAS dissection and retaining ligament release; prolonged longevity with SMAS flap stabilization; and post-surgery quick recovery due to limited skin dissection in the composite facelift approach. Case series/surgical technical paper. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The lateral and buccal cheek regions present unique challenges in facial rejuvenation due to their dynamic nature and the significant distance between target tissues and potential anchor points. Understanding the relationship between tissue descent patterns and facial movement is crucial for achieving optimal outcomes. This narrative review examines anatomic considerations and technical approaches using epiticon® (JETEMA Co., Ltd., Korea) for lateral and buccal cheek thread lifting. The analysis is based on previously published studies and anatomic descriptions focusing on facial layers, retaining ligaments, and neurovascular structures relevant to thread placement. The results demonstrate that successful outcomes depend on understanding tissue mobility patterns, proper thread selection, and precise vector planning. Careful consideration of facial dynamics and anatomic variations, such as the strength and location of retaining ligaments, is crucial for achieving natural-looking results. The integration of anatomic knowledge with technical expertise represents the cornerstone of successful lateral and buccal cheek thread lifting. Proper assessment of facial dynamics and individual anatomic variations remains crucial for achieving optimal and lasting results in these challenging facial regions.

Periorbital aging is driven by early, compartment-specific volume loss that is accentuated by the region's thin, soft tissue and complex retaining ligament network. This article presents a structured, anatomy-based approach to periorbital fat grafting that targets five key anatomic regions: the tear trough, medial superior orbital rim, lateral brow, temple, and lateral canthal region. This technique provides a reproducible framework for safe and natural periorbital rejuvenation, either as a standalone procedure or in conjunction with blepharoplasty, browlift, and facelift surgeries.

Prior studies have reported higher hematoma rates in male facelift patients, often attributed to thicker skin, more robust subcutaneous vasculature, elevated baseline blood pressure, and greater incidence of alcohol and tobacco use. This study aimed to evaluate postoperative hematoma rate and overall outcomes between matched male and female facelift patients treated by a single surgeon using standardized hematoma prevention protocols. A retrospective analysis was performed on consecutive patients who underwent facelift surgery from 2014 to 2024. Male and female patients were matched by age, BMI, primary vs. secondary status, local tranexamic acid (TXA) use, and comorbidities (hypertension, diabetes, smoking). Operative characteristics and postoperative complication profiles were compared. 541 patients were included (34 male, 507 female). Minor hematoma occurred in 0% of males versus 2.0% of females (P=1), with no hematomas requiring operative evacuation. Males had longer operative times (456 vs 407 minutes, P<0.001) and higher EBL (≥100 cc 34.8% vs 2.9%, P<0.001). Propensity matching yielded 68 patients (34 male, 34 female). In the matched cohort, males again had longer operative time (457 vs 422 minutes, P<0.001) and higher EBL (≥100 cc 34.8% vs 6.9%, P=0.02). There remained no difference in hematoma rate between gender (0% vs 2.9%, P=1) and overall complications were similar. Despite increased operative time and EBL, male patients experienced similar hematoma rates compared to matched female counterparts. These findings suggest that, with modern surgical protocols, historical disparities in male facelift patient outcomes can be meaningfully reduced.

Minimally invasive thread lifting has emerged as an effective strategy for soft tissue repositioning and facial rejuvenation; however, currently used absorbable threads generally lack intrinsic antimicrobial functionality, which may increase the risk of postoperative infection. Here, we report a biodegradable antibacterial lifting thread based on a nanocellulose/MOF composite system. The thread was fabricated via a green wet-spinning strategy using carboxymethylated cellulose nanofibrils (CCNF, prepared with cellulose derived from Astragalus residue) and sodium alginate (SA) as the structural matrix, while tetracycline hydrochloride-loaded ZIF-8 nanoparticles were incorporated to provide sustained antibacterial activity. The resulting antibacterial CCNF/SA thread (AB-CCNF/SA) exhibited a uniform morphology and a tensile strength of 80 MPa. The porous ZIF-8 carriers enabled efficient drug loading and controlled release, providing effective antibacterial activity against Staphylococcus aureus and Escherichia coli. Meanwhile, the composite threads showed favorable biodegradability, with approximately 45% degradation within 56 days, together with excellent cytocompatibility as demonstrated by fibroblast viability above 90%. In vivo studies further revealed inflammatory responses comparable to those of commercial collagen threads, confirming the good biocompatibility of the system. Overall, this work establishes a strategy for integrating nanocellulose structural materials with MOF-enabled antibacterial drug delivery, providing a multifunctional platform that combines mechanical support, biodegradability, and sustained antibacterial activity for minimally invasive soft tissue lifting and related biomedical implant applications.

Temporal hairline thread lifting is widely used for minimally invasive repositioning of midface soft tissues. Vascular complications are uncommon but may be serious, including superficial temporal artery (STA) pseudoaneurysm and arteriovenous fistula after thread-based procedures. The STA courses within the superficial temporal (temporoparietal) fascia may be vulnerable when threads are advanced in the superficial subcutaneous plane. A cadaveric temporal hairline cogged thread lifting pattern was simulated. The interfascial space between the superficial temporal fascia (STF) and deep temporal fascia (DTF) was delineated by injection of dyed gelatin. Cogged threads were advanced along planned vectors either (1) within the superficial subcutaneous plane or (2) within the interfascial (STF-DTF) plane. After layered dissection, the relationships between threads and STA branches were documented, and dynamic vessel deformation during thread traction was assessed. Dyed gelatin reliably expanded the STF-DTF interfascial compartment, demonstrating that STA branches course superficial to the interfascial space within or immediately adjacent to the STF. Threads placed in the subcutaneous plane could occupy the same layer as STA branches and, when tensioned, could visibly compress the vessel. In contrast, threads maintained in the interfascial plane were separated from the STA by the STF and did not produce visible arterial compression during traction. A clinically relevant failure mode was identified: a thread initially deep to the STF could migrate superficially, crossing an anterior STA branch near the lateral temporal region. For temporal hairline cogged thread lifting, maintaining the planned deep plane (interfascial STF-DTF) may reduce the likelihood of superficial temporal artery contact or compression compared with superficial subcutaneous advancement. Importantly, this study highlights a clear clinical takeaway: consistent maintenance of the interfascial plane should be prioritized to minimize vascular risk. However, depth shifts can occur, emphasizing the need for strict plane control, cautious advancement near expected STA trajectories, and consideration of ultrasound mapping in high-risk regions.

The growing popularity of filler injections, thread lifts, and energy-based devices for facial rejuvenation poses new challenges for deep plane or subSMAS facelifts. The use of a nerve integrity monitor (NIM) may help address these challenges. However, data on the application of NIM in facelift procedures remains limited. This study aims to describe the use of NIM in facelifts and to compare outcomes between procedures performed with and without NIM assistance. This was a prospective study conducted from January 2024 to August 2025. Patients undergoing extended subSMAS facelift who had previously received filler injections, thread lifts, or facelifts were eligible for inclusion. Participants were divided into either the NIM or non-NIM group. A step-by-step dissection algorithm using NIM during facelift surgery is presented. A total of 200 patients were included in the final analysis. The incidence of neurapraxia was significantly lower in the NIM group 0 (0%) compared to the non-NIM group 6 (6%), p = 0.029. Dissection time was also significantly reduced in the NIM group (32.86 [26.25, 38.00] minutes) compared to the non-NIM group (63.5 [55.0, 75.0] minutes), p < 0.001. The use of a nerve integrity monitor in facelift surgery was found to reduce both the rate of neurapraxia and operative time.

Subangular Deep Fascia Fixation for Submental U-Shaped Cogged Thread Lifting.

ABSTRACTBackgroundThe use of polydioxanone thread has grown substantially for facial soft‐tissue repositioning and collagen biostimulation, with a well‐established safety profile and favorable tissue integration.AimsTo describe the reverse knot technique, a novel method for the implantation of polydioxanone suspension threads.Patients/MethodsWe present an original polydioxanone thread‐lifting technique designed primarily for patients with a “heavy face.” The reverse knot technique positions the knot in the anterior portion of the face, below the zygomatic cutaneous ligament, whereas anchoring the distal end of the thread in the temporal fascia, creating a lever mechanism that enhances lifting of the middle and lower thirds of the face.ConclusionsThe technique provides immediate and effective midface soft‐tissue support, representing a minimally invasive alternative for face lifting and resulting in high patient satisfaction and minimal morbidity. The procedure should be performed by professionals experienced in thread lifting, as positioning the knot in the medial portion of the face increases support but also raises the risk of localized depressions at the knot site.

This review redefines facial "ligaments" as fibrous pseudo-ligaments that compartmentalize and support facial tissues, enabling mobility and maintaining contour. Their density and tensile strength vary across facial subunits, critically influencing the outcomes of minimally invasive procedures like fillers and thread lifts. Significant interethnic differences exist; Caucasians often exhibit flatter malar eminences, while Asians tend to have broader faces with prominent zygomas, leading to divergent presentations of "sunken cheeks." Consequently, procedural strategies must differ. For Asians, augmenting the sub-arch hollow refines contour and provides an efficient lift, whereas Caucasian patients typically require augmentation of the malar eminence and zygomatic arch itself. Effective treatment requires a biomechanical understanding of these ligamentous structures and their ethnic variations.