Wrinkle improvement procedure guide

For forehead wrinkles, glabellar wrinkles, crow’s feet, under-eye wrinkles, and mouth-area wrinkles,

a simple and natural correction can be performed using fat grafting, fillers, Botox, and lifting procedures

with minimal side effects.

Wrinkle areas that can be corrected

① Fine lines or deep wrinkles on the forehead
② Crow’s-feet expression lines or non-expression lines around the eyes
③ Nasolabial folds around the mouth
④ Cheek sagging or wrinkles
⑤ Glabellar “cheon” lines or depressions
⑥ Hollow under-eye wrinkles
⑦ Other facial wrinkle lines
⑧ Neck sagging or wrinkle lines

Facial wrinkles by area

Four treatment principles that improve satisfaction with wrinkle correction

Choose a treatment method that is simple and allows a quick return to daily life
Choose a method with low treatment cost
Choose a treatment method with no side effects or sequelae
Choose a method with excellent results that can maximize satisfaction

Wrinkles are treated by combining the following six methods—fat grafting, botulinum toxin (Botox), fillers (Juvederm), skin booster injections, Endotine lifting, and HIFU (ultrasound fat-dissolving lifting)—depending on the patient’s condition.

Forehead wrinkles

For fine wrinkles, botulinum toxin (Botox) and fillers (Juvederm injections) are used together to correct forehead wrinkles, or only one method may be used alone.

Botox temporarily paralyzes the frontalis muscle of the forehead so that expression lines cannot form, while fillers (Juvederm) correct fine lines in a relaxed, expressionless state.

However, in the case of deep wrinkles, fat grafting is needed for correction.

Surgical methods

Endotine fixation

If the forehead skin is stretched and the wrinkles are sagging, they can be corrected with frontalis muscle surgery.

This method involves making a small incision in the scalp, fixing the Endotine anchor pin to the bone, and then pulling the scalp and securing it to the Endotine loop.

It has the effect of pulling the frontalis muscle and lifting sagging eyebrows upward, but its effect on smoothing wrinkles is limited.

Injection therapy

◇ Botox

For expression lines, botulinum toxin (Botox) is injected to temporarily paralyze the frontalis muscle and prevent facial expressions.

The effect is temporary, and after about 3 to 6 months the medication wears off and facial expressions return to normal.

However, it does not improve wrinkles in a relaxed, expressionless state.

◇ Filler (Juvederm)

For expressionless wrinkles or fine lines, forehead wrinkles can be simply corrected with filler (Juvederm).

While Botox corrects expression lines, fillers are effective for improving wrinkles that appear when the face is relaxed.

Unlike Botox, fillers tend to accumulate in effect as treatment is repeated.

Fat grafting

Effective for deep wrinkles.

When wrinkles are deep, Botox or fillers are often not sufficient.

In such cases, fat grafting can correct forehead contour irregularities or depressions while also softening the wrinkles.

Glabellar wrinkles

For fine lines or expression lines, fillers or Botox may be used for correction, and for deep wrinkles or depressions, fat grafting is used.

Sometimes fat grafting is performed while using Botox as an adjunct.

Surgical methods

Corrugator muscle resection

Beneath the eyebrows is a muscle called the corrugator that creates glabellar wrinkles, and these wrinkles can be removed by selectively resecting this muscle.

For resection, an incision must be made in the scalp and the procedure performed while confirming the area with an endoscope.

The disadvantages are significant swelling and, after muscle removal, a depression in the area where the muscle was located.

If the procedure is done incorrectly, it may damage the sensory nerves of the forehead and cause sensory impairment.

Due to the burden of surgery, this is not a commonly performed method.

Injection therapy

◇ Botox

It is mainly used for expression lines and is not effective for wrinkles in a relaxed state.

◇ Filler (Juvederm)

It is mainly used for thin, expressionless wrinkles, and after treatment the expression lines vary depending on facial movement habits.

It should be used only for fine lines; it is less effective for thick wrinkles.

Fat grafting

Effective for deep wrinkles.

When wrinkles are deep, Botox or fillers are often insufficient.

For deep glabellar wrinkles or depressions, fat grafting is recommended.

Combination treatment methods

◇ Combined Botox and filler treatment

Botox and filler are used together so that expression lines are corrected with Botox and relaxed-state wrinkles are corrected with filler.

◇ Combined Botox and fat grafting treatment

Botox and fat grafting can also be used together. While the transplanted fat is settling, Botox paralyzes the expression muscles so that wrinkles do not form during the graft take process.

Because the take rate is better than with fat grafting alone, the wrinkle-improving effect is greater.

Crow’s-feet wrinkles

Wrinkles that appear in a relaxed state are corrected with filler, and when expression lines are severe, Botox is used together.

The difference between filler and Botox is that wrinkles in a relaxed state are effectively corrected with filler, while Botox is used for expression lines that appear when smiling.

The mechanism of Botox is to paralyze the expression muscles so that facial expressions cannot be made.

Surgical methods

Orbicularis oculi muscle resection

This method involves making an incision in the temporal area, dissecting the skin, and resecting the orbicularis oculi muscle that creates expression lines around the eyes.

Because of the cost and the need for general anesthesia, it is a burdensome surgery and is not commonly used today.

Before Botox became widely used, it was used to address expression wrinkles around the eyes, but now it has mostly been replaced by Botox or fillers and is rarely performed.

Injection therapy

◇ Botox

It works by paralyzing the orbicularis oculi muscle around the eyes so that expressions cannot be made, so it is mainly used for expression lines and is not effective for wrinkles in a relaxed state.

Its effect lasts about 3 to 6 months, after which the expression lines return to their original state.

◇ Filler (Juvederm)

It is mainly used for wrinkles in a relaxed state, and because it does not paralyze the muscles like Botox, expression lines do not change after treatment.

The recurrence of wrinkles depends on facial movement habits.

However, even if wrinkles return, they do not return to their original state and recur only mildly, so the more the treatment is repeated, the more the effect accumulates and the wrinkles continue to become lighter.

Combination treatment methods

◇ Combined Botox and filler treatment

Botox and filler are used together so that expression lines are corrected with Botox and relaxed-state wrinkles are corrected with filler.

Using both together is more effective than using filler alone, but it is more costly.

Under-eye wrinkles

If there is a hollow wrinkle line under the eyes, fillers should not be used.

If filler is used under the eyes, side effects such as unevenness or a pale skin tone can occur, so in the case of hollow under-eye wrinkle lines, correction should be done only with fat grafting.

Even if there are fine lines, fillers often have the opposite effect, so fillers should not be used even for very fine wrinkles.

Fat grafting

For under-eye wrinkles, fillers are often not enough.

Fat grafting can correct the hollow area while also softening wrinkles.

Mouth-area wrinkles and nasolabial folds

For nasolabial folds around the mouth or lines at the corners of the mouth, fine wrinkles may sometimes be corrected with fillers, but in most cases wrinkles are corrected with fat grafting.

Surgical methods

AlloDerm insertion

AlloDerm, a processed human skin tissue material, may also be used for grafting.

Its advantage is that, because it is a biological material, there are almost no side effects.

However, it is difficult to precisely correct wrinkle lines, and because a large amount is absorbed, the treatment effect is not very strong.

Another disadvantage is that AlloDerm is expensive.

It is not commonly used today.

Injection therapy

◇ Botox

Botox is often used on the forehead, around the eyes, and between the eyebrows, but if used around the mouth, it can cause unnatural mouth movement and awkward facial expressions, so in principle it is not suitable for treating mouth-area wrinkles.

◇ Filler (Juvederm)

It can be used for very fine lines.

However, it is less effective for thick wrinkles, and if a large amount is injected, there is a higher possibility of side effects.

Since nasolabial folds are usually not very fine lines, they are not often corrected with filler and are often used as an adjunct to fat grafting.

Fat grafting

This is the best method for correcting mouth-area wrinkles.

Because the amount of fat to be grafted can be adjusted according to the depth and shape of the wrinkles, it is an effective treatment method.

Most mouth-area wrinkles are corrected with fat grafting,

and in some cases, fillers are used as an adjunct when fine wrinkles are also present.

Cheek fullness Endotine

Endotine lifting method for improving cheek sagging

1. Design the temporal area and cheek area.

2. Perform local anesthesia and sedation anesthesia.

3. Make a horizontal incision of about 2 cm in the temporal area.

4. Perform dissection above the periosteal layer.

5. Use an endoscope to check for any bleeding in the dissected area.

6. Insert the Endotine and pull it upward.

7. Secure the Endotine to the fascia with sutures.

8. Suture the scalp.

9. Apply elastic tape.

Endoscopic Endotine lifting procedure for improving cheek sagging

1. Design according to the accurately diagnosed surgical plan.

Design the incision area and check the position and length where the Endotine will be inserted.

Sedation anesthesia and local anesthesia are performed.

Because sedation anesthesia is used together, there is no pain at all.

2. After the temporal incision, dissect above the muscle.

Because the incision is small and located in the scalp, there is no scar or hair loss.

After the incision, dissection is performed above the fascia with blunt-ended scissors without bleeding.

3. Insert the Endotine after confirmation with an endoscope.

After dissection, an endoscope is used to check that the dissection is accurate and that there is no bleeding.

After dissection, the Endotine is inserted to lift the sagging cheek.

4. After fixing the Endotine to the fascia, close the incision.

Secure the Endotine firmly to the fascia and suture the scalp.

Apply elastic tape to prevent swelling and sagging.

Remove the tape after 2 to 3 days, and hair washing is possible from 4 days after surgery.

The stitches are removed after 7 days.

Example of cheek Endotine lifting

HIFU lifting

HIFU lifting has different indications from Endotine lifting, and it can be applied to areas with a large volume of fat, areas where Endotine lifting is difficult, areas where fine lines need to be smoothed, or areas requiring lifting in a small region.

It is mainly applied to sagging in the front cheek and around the mouth. It is also applied to sagging in the neck, fine lines around the eyes, and fine forehead wrinkles, and can also be used to correct areas where too much fat has remained after fat grafting.

The procedure time is short, the effect is immediate, recovery is quick, and daily life is possible on the day of treatment.

Effects of fat grafting for wrinkle removal

Tunneling refers to creating space just beneath the skin with a micro-needle for the fat to go into. Because a space is made as if drilling a tunnel and the fat is then injected, even after all of the fat has been placed, it does not sag in the direction of gravity or become lumpy.

Rather than injecting a large amount into one area with the tunneling technique, we perform three-dimensional micro fat grafting with 100% concentrated fat evenly and uniformly across multiple layers.

A delicate and meticulous injection method allows for customized design.

Fat grafting also includes a process called “tunneling,” which ensures maximum contact with the surrounding abundant blood vessels so that nutrients can be continuously supplied.

Because the tunneling technique includes the dissection process of the wrinkles, fat is grafted beneath the dissected wrinkle, so the wrinkle improvement is clearer than with fat grafting performed at other clinics.

Fat grafting method for wrinkle removal

① Fat is collected from areas where your own fat is abundant, such as the lower abdomen, waist, or thighs.

• Because local anesthesia (painless sedation anesthesia) is used, there is no pain at all.

• A thin liposuction cannula is used to collect the fat into a syringe.

② The collected fat is spun in a centrifuge to obtain pure concentrated fat.

The purpose of centrifugation is to obtain pure concentrated fat, reduce side effects after grafting, and increase the fat take rate.

③ The centrifuged fat is subjected to a second concentration process to remove water and oil.

By removing water and oil, nearly 100% concentrated fat is obtained.

④ The fat is transferred again into a fine 1cc syringe and grafted into the desired area.

Advantages of wrinkle correction with fat grafting

The procedure is simple.
Because no foreign materials such as fillers (Restylane, Radiesse, Artecoll) are used, there is no concern about side effects.
Because the procedure is performed without incising the skin, there is no concern about scarring.
Because it uses autologous tissue, the result looks natural.
There is little swelling or bruising.
You can return to daily life immediately after the procedure.
Because the fat tissue takes hold, the effect can be maintained for a long time.

Long-lasting effects of fat grafting

Some people say fat grafting has no effect because much of the fat is absorbed, but if it is performed correctly, a satisfying result can be achieved.

Once the transplanted fat takes hold, it is no longer absorbed and remains as your own fat tissue for life, so it is considered one of the safest and most effective methods.

On average, two sessions of fat grafting can provide a semi-permanent, satisfying wrinkle improvement effect.

Precautions when using fat grafting for wrinkle correction

• Because some of the fat is absorbed, one treatment may be insufficient.

A repeat procedure may be needed after 2 to 3 months.

• It is difficult to apply to fine lines around the eyes or under the eyes.

Number of fat grafting sessions for wrinkles

For most areas, including nasolabial folds around the mouth, satisfying results can usually be achieved with an average of about two sessions of fat grafting.

The interval between treatments is 2 to 3 months, and when a repeat procedure is needed, the fat that was collected at the time of the first graft can be thawed and used.

Side effects of fat grafting

Because fat grafting uses your own fat, there are almost no side effects unlike commercial filling materials (fillers).

Other than slight swelling and bruising after the procedure, it can be said that there are no side effects.

Therefore, it can be considered one of the safest cosmetic procedures.

However, this refers to properly performed fat grafting. If the procedure is done against the principles, side effects may occasionally occur, such as an uneven appearance, hardening caused by fat necrosis, inflammation, or an awkward appearance due to excessive injection.

These issues depend on the practitioner’s experience and skill and are not inherent problems with fat grafting itself.

Therefore, if the procedure follows the correct principles, these side effects are very rare.

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Facial wrinkles are corrected using the appropriate method depending on their depth and degree.

It cannot be said that any one specific method is better.

Sometimes better results are achieved when two or more procedures are performed together.

Certified plastic surgeon Dr. Shin Duhan, with over 20 years of experience, personally examines and personally performs the surgery ~