English edition

index

RecordBoard-certified plastic surgeonCo-director, UVOM Plastic SurgeryDepartment of Plastic and Reconstructive Surgery, School of Medicine, Catholic University of DaeguSix peer-reviewed papers, first author on five

Scope of practice

Three operations, one clinical problem

Material that will not resolve, bone that has been moved, and tissue that has to be put back where it belongs.

Principal workFacial foreign body removal

Filler, grafted fat and threads that did not resolve, now inside scar and adhesion. The plan starts from what has to stay.

Read this sectionBone and tissueEndoscopic malarplasty

Moving the zygoma is the first half. Whether the fat and the SMAS above it follow is the second.

Read this sectionWhat followsDeep plane facelift

The operation that follows removal, once a space held open for years is emptied.

Read this section

Clinical pathway

How a case is assessed and planned

The same sequence for every patient, whether seen in Seoul or first reviewed from abroad.

1

A written reading before the flight

Photographs and previous imaging are reviewed in writing before a date is set, so a long journey is not made for an examination that could have been anticipated.

2

Examination, ultrasound, CT where bone matters

The plane a material sits in, how far it has spread, whether it is inflamed, and where it meets normal fat and nerve.

3

A plan stated as what stays

How much can come out, what must be left, which plane to work in, and whether it is one operation or two.

4

Surgery, and the order after it

Swelling, settling, and the lift or graft that may follow months later rather than on the same day.

Assessment

Knowing what is in there

Most people arrive without a product name, a receipt or a record. Identification begins instead with what can still be measured: the plane a material sits in, how far it has spread, and what the tissue around it has become.

• Ultrasound shows the plane, the depth and the extent.
• CT is added when bone, the orbit or the deep midface is in question.
• A missing product name does not prevent assessment.

Open this section

Operative judgement

How much comes out

Opening is not the difficult part of a removal. The difficult part is deciding, against the anatomy actually in front of you, how much can safely leave and what has to stay.

• Complete removal in a single operation is often not the goal.
• The boundary with normal fat is found in theatre, not on a scan.
• Nerve risk decides how far the dissection goes.

Open this section

After the operation

What remains after removal

Removal leaves a space. What fills it, what sags into it, and how long the face takes to settle are the questions that decide whether the operation was worth having, and they are settled before it rather than after.

• A space held open for years does not close on its own.
• Hollowing and laxity are estimated before surgery, not discovered after it.
• Fat grafting and lifting have their own intervals.

Open this section

Before surgery is considered

What an injection can and cannot undo

Not every route to a deposit is surgical, and not every non-surgical route reaches the material.

Operative routes

Four ways in, chosen by where the material is

The clinic describes four routes to a facial deposit. Which one is used is decided by the plane, the extent and what lies beside it, not by preference.

Route 01Cannula aspiration

A blunt cannula through a small entry point, used where the material is still soft and sits in one plane.

It cannot separate material that fibrosis has bound to the tissue around it.

Route 02Ultrasound-assisted

Imaging at the chairside and during the operation, to follow the deposit through the plane it actually occupies rather than the plane it was injected into.

It shows where a material is and how it behaves, not what it is made of.

Route 03Endoscopic

Direct vision through a remote incision, for the temple, the forehead and the deep midface, where the field is far from any acceptable scar.

It does not reduce the dissection needed once the boundary is reached.

Route 04Open

An incision over the deposit, where the material is encapsulated, calcified or lying against a structure that must be seen to be preserved.

It leaves a scar, which is why it is chosen for the deposits that justify one.

Operating time

60 to 120 minutes, by region

Anaesthesia

Sedation

Sutures

Removed at five to seven days

Return to ordinary activity

About one week

Tissue settling

Up to six months before the result is judged

Operative information as the clinic states it. It describes the usual course, not a commitment for any individual.

The surgeon

Chang Min Kang

A board-certified plastic surgeon and a co-director of UVOM Plastic Surgery. The clinic lists his practice as endoscopic malar reduction and the removal of injected material.

Qualification

Board-certified plastic surgeon

Position

Co-director, UVOM Plastic Surgery, Gangnam-gu, Seoul

Listed practice

Endoscopic malar reduction; removal of injected material

Published work

Six peer-reviewed papers, first author on five, carried out in the Department of Plastic and Reconstructive Surgery, School of Medicine, Catholic University of Daegu

The full accountPublished work

The atlas

Outreach going out, patients coming in

The clinic has run medical outreach since 1999. Patients now travel the other way, into Seoul.

The full record 0places The record 0Outreach countries 0Direct routes

Drag to turn the globe, scroll to zoom, tap a marker to hold it. The first layer is the clinic's outreach record. The second marks cities with scheduled service to Incheon and the flight time from each; it describes the journey, not patient numbers.

6Peer-reviewed papersFirst author on five. Breast reconstruction, gluteal ptosis, nasal bone fracture.12Outreach countriesThe clinic’s institutional record since 1999, in three forms.78Questions answeredEach written to be read on its own, with its limits stated.18SectionsThe whole record, including what it does not contain.

Published work

Six papers, cited as method

The subjects are breast reconstruction, gluteal ptosis and nasal bone fracture. They are not evidence for the outcome of a facial operation, and are not presented as such.

The archive2017Objective outcomes of closed reduction by type of nasal bone fracture

Arch Craniofac Surg

PMID 289133002017Operation result and patient satisfaction after nasal bone fracture

Arch Craniofac Surg

PMID 289132992017Postoperative pain control by intercostal nerve block

Aesthetic Plast Surg

PMID 287914412018Volume change of a pedicled latissimus dorsi muscle flap

J Reconstr Microsurg

PMID 300997362018Buttock lifting with a new classification of gluteal ptosis

Aesthetic Plast Surg

PMID 296109542021Volume change of muscle and fat portions, measured separately

Plast Reconstr Surg Glob Open

PMID 33868878

Materials

What gets injected, and what it becomes

Nine families behave differently over time, look different on ultrasound, and need different routes out.

All nine in fullHyaluronic acid

Answers to hyaluronidase, which is why it is tried first and why failure is informative.

Polycaprolactone

Ellansé and related products are not broken down by hyaluronidase.

Calcium hydroxylapatite

Bright and shadowing on ultrasound; it can be mistaken for calcified graft.

Poly-L-lactic acid

Stimulates collagen, so what remains is often the reaction rather than the product.

Collagen-based injectables

Some carry permanent microspheres in a resorbable vehicle.

Permanent materials

Silicone, paraffin and non-medical injections bound into the tissue around them.

Grafted fat

Survives unevenly; hardens, calcifies, forms oil cysts, or settles elsewhere.

Lifting threads

The thread may have absorbed while the tissue reaction along its track has not.

Unknown composition

No record of what was injected. Assessment still proceeds; shortcuts do not.

Common concerns

In the words people use

Ten complaints that bring people here, each with what it usually is, what answers it, and what it is not.

All ten in full

Most often it is injected material that is still there. Hyaluronic acid under the lower lid can persist well past its stated duration, and semi-permanent and permanent products longer again. Grafted fat can survive as a firm collection. Prolapsed orbital fat and a swollen lymphatic channel produce a similar silhouette from outside.

Usually a delayed inflammatory reaction around material that has been in place for months or years. Triggers described in the published literature include influenza-like and other upper respiratory infections, dental treatment, vaccination, facial trauma, and further injection into a site that already contains material.

Material that has spread unevenly, was placed too superficially, or has provoked fibrosis around itself. Over-grafted fat can harden or calcify. What is felt is usually a mixture of the substance and the tissue the body has built around it, which is why the lump is often firmer than the product ever was.

Several different things are described in these words. A thread, and the fibrous track it leaves behind, run in a line and are felt as a cord. Filler placed along the mandible can firm up. A band that tightens on speaking is muscle rather than material. Descent of the soft tissue in front of the chin produces a ridge that reads as a band.

A reaction to something beneath the skin that flares and settles. Recurrence in one fixed place points to a fixed cause in that place, and that cause is usually material. Thin skin over a superficial deposit also reddens more readily than skin elsewhere.

Descent, added volume, or both together. Material injected into the cheek adds weight to tissue whose support is already loosening. After contouring surgery the soft tissue does not always follow the bone. And the cheek that looks heavy is often the one whose support has given way rather than the one that has gained bulk.

Scar, in most cases. Tissue that has been injected, inflamed or operated on becomes bound to the layers around it, and a bound layer feels tight. Numbness reflects a sensory nerve that has been stretched, compressed within scar or injured, most often the infraorbital nerve in the mid-cheek, or the supraorbital and supratrochlear nerves in the forehead.

A foreign body granuloma, or a delayed inflammatory nodule. Cells gather at material the body can neither break down nor ignore, and collagen is laid down around the whole. The result is a firm mass made partly of the original substance and partly of tissue that was not there before.

Where filler was placed, this is usually the Tyndall effect. A gel sitting shallow beneath thin translucent skin scatters light and reads as blue or grey rather than as a flesh-coloured ridge. The lower lid has the thinnest skin on the face, so it appears here more than anywhere else.

This is the ordinary starting position for a removal rather than an unusual one. Clinics close. Records were never handed over. The word filler covered several different materials, and more than one of them may have gone into the same cheek on different days.

The practice

Why this is the work

The full account

UVOM Plastic Surgery is on Dosan-daero in Gangnam-gu, Seoul, and has two directors. Dr. Chang Min Kang’s part of the practice is the face that already has something in it: material injected years ago that has hardened, inflamed or distorted the tissue around it, and the slackness left behind when it comes out. The work is facial and under-eye foreign body removal, endoscopic malarplasty read from the soft tissue side, and deep plane facelift as the operation that follows removal.

01Where the work came from

Cleft lip and palate came first, and it is a particular education. It is rarely one operation. By the second or third procedure the anatomy has already been altered, by growth, by scar, and by whatever the previous repair decided, so the plan has to be made from what is actually in front of you rather than from a diagram. The result is not judged by shape alone. It is judged by whether the lip seals, whether speech develops, and by the twenty years that follow. A photograph taken at six months answers none of that.

A surgeon who begins there learns two things early: that the interesting problem is usually the second or third one, and that what the patient says about the result is evidence rather than a courtesy. That disposition carried through reconstruction and into the work of the present, which is faces hardened, lumped, inflamed or scarred years after something was injected into them.

02Why these patients are still unwell

Not every injected material answers to a dissolving agent. Hyaluronic acid filler responds to hyaluronidase, and where the material genuinely is hyaluronic acid that injection is often the right first move. Polycaprolactone-based products such as Ellansé are not broken down by it at all. Neither are calcium-based or collagen-based semi-permanent fillers, nor grafted fat, nor lifting threads.

Steroid treatment is the other common route, and it behaves in a way that is easy to misread. It can reduce inflammation and shrink a nodule. The lump becomes smaller, the face looks better for a while, and the material that provoked the reaction is exactly where it was. When the effect wears off the nodule returns, this time inside skin that is thinner than it was.

So patients arrive after several rounds of treatment somewhere else, and by then the work is not filler removal in the sense the phrase is normally used. The material sits inside scar and adhesion, the boundary with normal tissue has blurred, and facial nerve branches, the infraorbital nerve, vessels and the orbital septum run through or beside the field that has to be opened.

03What is settled before the operation

As much of the decision as possible is made before anyone is in theatre. Ultrasound shows the plane and the depth of the material, whether it is a discrete nodule or diffuse, whether inflammation is active around it, and where it lies in relation to normal fat and to the structures that have to be preserved. CT is added where bone is part of the question: previous contouring surgery, erosion of bone beneath an old implant, the position of the malar complex.

Neither will name the product that was injected. The clinic’s stated protocol is to say so to the patient rather than to gloss it. What imaging settles is the geography, and the geography is what a plan can honestly be built from.

Opening the face is not the hard part. The hard part is deciding how much can come out, what has to be left, and which plane to work in, judged against the anatomy actually in front of you.

04Removal is not the end of it

A space that has been occupied for ten years does not close by itself. Take the material out and what is left is the shape of the problem: hollowing where volume used to be, skin that has been stretched and no longer retracts, fibrous irregularity, and deep tissue that had already descended and was being held up by the filling.

This is why the facelift came back into the work, and why it belongs here as the operation that follows removal rather than as a separate speciality. The two halves are one problem. Preserve normal structure while removing, then re-organise what has been left slack. Reconstruction taught him how to rebuild. The facelift taught him how to re-position. Foreign body removal is where the two meet.

05Who this practice is for, and who it is not for

In concrete terms, the consultations that make sense here tend to begin in one of these situations.

• Material injected years ago whose product name is unknown or uncertain, now causing hardness, swelling, discolouration, visible irregularity or pain.
• Hyaluronidase given once, twice or more with no lasting change, which usually means the material is not hyaluronic acid.
• A nodule that quietens after a steroid injection and returns some months later, each time inside a thinner envelope of skin.
• A face that has had contouring surgery, fat grafting, threads and filler in some order, so that the normal planes no longer match a standard map.
• Hollowing, laxity or surface irregularity that appeared after material was removed somewhere else.
• A cheek that descended after malarplasty, where the question is the soft tissue rather than the bone.

It is not for everyone, and the exceptions are worth naming rather than left to a consultation. Where infection is active, stabilising it comes before any removal. Where the material is known to be hyaluronic acid and hyaluronidase has not yet been tried, there is no reason to begin with an operation. Where a deposit is quiet and causing no symptom, the risk of dissecting it out may be larger than the problem.

There is a further case, harder to put politely. Anyone who wants a single appointment, a single operation and a guaranteed number will be better served elsewhere. What is on offer here is an assessment that separates the face into layers before it proposes anything, a plan that states what will be left before it states what comes out, and a willingness to say that part of the work should wait.

Where to start

Six entry points

01The surgeonCleft lip and palate, reconstruction, facelift, foreign body removal. Four operations that look like four specialities and are one preference: the patient whose anatomy has already been altered by somebody else.02The measured practiceSix peer-reviewed papers on the breast, the buttock and the nasal bone. The subjects have almost nothing in common. The method does: an impression replaced by a number, a time axis, or a division into layers.03Facial foreign body removalNot every injected material answers to a dissolving agent. What can be established beforehand, the routes used to reach material lying in scar, and why the aim is to reduce what causes trouble rather than take everything out.04Knowing what is in thereMost people arrive without a product name. Ultrasound establishes the plane, the depth and the spread; CT is added where bone is part of the question. Neither will name the product, and the clinic’s stated protocol is to say so.05What remainsA space occupied for a decade does not close by itself. Hollowing, laxity and firm scar are part of the operation rather than complications of it, and the sequence that corrects them is decided before the removal, not after.06Published workPain recorded at four fixed moments. Nasal bone reduction read from CT. Flap volume divided into muscle and fat. Six papers, first author on five, cited here as method and never as proof that a facial operation works.

If you have been to several places and still have the complaint

A first consultation is an examination and a reading, not a decision. Bring any record of what was injected, the dates, previous imaging, and photographs from before the first treatment.

What happens at a consultation Seventy-eight answers