method
Read the six papers by subject and they look like an accident: breast reconstruction, a buttock lift, broken noses. Read them by method and they are one piece of work carried out six times. Each takes a sentence a surgeon says routinely and refuses to accept it, replacing the impression with a number, a time axis or a division into layers.
01Why the subjects are scattered
There is nothing mysterious about the range. A plastic surgeon in training operates across the whole body, and research follows the rota: breast reconstruction in one year, facial trauma in another. What does not follow the rota is the design of the studies, which is consistent across all six and which was a choice.
Five of the six carry his name first. First authorship is the position given to the author who did the work and settled how it would be done, which is the reason it matters here. The design of these studies is his, and the design is the part that carries over into a consulting room.
The shape is the same every time. Take a sentence surgeons say without thinking. The pain settles quickly. It healed well. The volume holds. It has dropped. Then decline to accept the sentence, and put in its place something that can be compared against somebody else’s version of the same claim.
The dates matter less than the sequence. The pain and nasal bone studies come first, in 2017. The volume studies follow in 2018 and 2021. Each question is a little harder than the one before it. Measure something at fixed times. Then measure it against what the patient thinks of it. Then follow it for years rather than months. Then divide it into its parts and follow those separately.
02Pain, at four fixed moments
The 2017 pain study followed 44 patients who had breast augmentation with an implant and received an intercostal nerve block. The comparison was not made on impression, or on how much analgesia was asked for. A pain score was taken on arrival in the recovery room, and again at thirty, sixty and one hundred and twenty minutes.
Four points on a time axis do something a single summary cannot. They separate pain that starts low and stays low, from pain that starts low and climbs as a block wears off, from pain that begins high and settles. Those are three different clinical situations, and the phrase comfortable afterwards covers all three without distinguishing them.
03Reduction, by type of fracture
In the same year he assessed 313 patients who had undergone closed reduction of a nasal bone fracture. The outcome was read from CT rather than from inspection, and the patients were grouped by fracture type, so that the question stopped being whether the operation works and became which fractures end up where.
Grouping by type is a small change with a large consequence. A single average across 313 patients would have said that closed reduction is broadly satisfactory, which is true and unusable. Sorted by type, the same data says something you can act on at the moment of decision: this configuration reduces predictably, that one does not, and here is where residual displacement tends to remain.
04The same cohort, asked a second question
The second nasal paper is drawn from the same 313 patients. It is a separate publication, and the two should never be added together into a larger series. It sets the operative result against the patient’s own satisfaction a month afterwards.
The two correlated, most closely in lateral impact type I fractures and least closely in comminuted fractures. The part worth keeping is that the question was put at all. The patient’s own judgement was collected as its own measurement and set against the imaging, rather than inferred from it.
A measurement is useful in proportion to how clearly you know what it is a measurement of. CT tells you where the bone is. What the person makes of the face they are living with is a separate question, and in that paper it was asked separately.
05Volume, on a time axis
In 2018 he tracked the volume of a pedicled latissimus dorsi muscle flap on CT after partial breast reconstruction: eleven patients, followed for five years. The design is the point. Tissue volume was not assessed once, at the moment it looked settled. It was followed.
Anything measured once is a photograph. Anything measured repeatedly is a trajectory, and a trajectory can be extended forwards. A surgeon who has watched transferred tissue change over two years plans differently from one who has seen it at three months and called it a result.
06A layer, and then the parts of the layer
The 2021 study went further. In 16 patients the latissimus dorsi myocutaneous flap was no longer treated as one thing. The muscle portion and the fat portion were measured separately over time, and they did not change at the same rate.
That is the most transferable habit in the six papers, and it transfers as a habit rather than as a result. Tissue that looks homogeneous on the table is a composite. Its components change at different speeds. Anything built out of it will therefore change shape over time, not merely size, which is a different thing to plan for.
07Ptosis, divided into stages
The sixth paper, on which he is a co-author rather than first author, describes buttock lifting with an elastic thread and proposes a new classification of gluteal ptosis. The lift is not the relevant part. The classification is.
Descent is usually recorded as a word: mild, moderate, severe. A staged classification forces a decision about what separates one stage from the next, and once that decision is written down, two surgeons can disagree about a particular patient in a useful way, because they are at least disagreeing about the same thing.
| Measured | Axis or division | Study population |
|---|---|---|
| Postoperative pain | Four fixed time points after surgery | 44 breast augmentation patients |
| Reduction of a nasal bone fracture | CT assessment, grouped by fracture type | 313 nasal fracture patients |
| Operative result against satisfaction | Imaging outcome set against the patient’s own rating | The same 313 patients |
| Flap volume | Long-term follow-up on CT | 11 partial breast reconstruction patients |
| Flap volume by component | Muscle portion and fat portion measured separately | 16 breast reconstruction patients |
| Gluteal ptosis | A staged classification | Buttock lift patients; co-author |
08What these papers do not show
They do not show that any facial operation works. Not the facelift, not malarplasty, not foreign body removal.
The populations were the breast, the buttock and the nasal bone. None of the six examined an aesthetic operation on a face. The volume studies were carried out in breast reconstruction patients, and a latissimus dorsi flap in a reconstructed breast is not a mid-face. The ptosis classification was written for the buttock, and gluteal descent is not facial descent: the anatomy, the supporting structures and the forces acting on them are all different. The nasal bone papers examine a functional reconstruction after trauma, not a cosmetic result.
The breast and buttock studies are cited here as method, and as nothing else. They do not validate a facelift, a malarplasty or a removal. Anyone describing this practice as a facelift verified by volume research, or as a removal technique proven by published data, has misread the record. The accurate sentence is narrower and it is true: this is a surgeon whose research background is the separation of tissue into layers, components and time points before it is judged.
09How the habit shows up in a consultation now
The translation into practice is less abstract than it sounds. It appears as an order of operations, and the order is the whole of it.
- Establish what is present, and in which layer. For injected material, ultrasound comes first: it shows depth and plane, whether the material is a discrete nodule or diffuse, whether inflammation is active around it, and where it lies in relation to normal fat.
- Add CT where bone is part of the question. Previous contouring surgery, erosion of bone beneath an old implant, the position of the malar complex and the extent of a deformity are not soft tissue problems and are not answered by ultrasound.
- Separate the findings before combining them. Bone, injected material and soft tissue descent are written down as three findings rather than one complaint. A face may have all three, and the treatments for them are not interchangeable.
- Name what must be preserved. Normal fat, the nerve branches crossing the field, the skin envelope and whatever support structures remain are identified before any removal plan exists.
- Decide what will be left, and only then how much comes out. The volume remaining after removal, the skin that will no longer be filled and the support that will have to hold the result are estimated first. The extent of removal follows from that estimate rather than preceding it.
- Decide whether this is one operation or several. Active inflammation, material spread widely through several layers, and compromised skin perfusion all push the work into stages.
The fifth step is the one that reverses the usual order, and it is the clearest inheritance from the volume studies. The intuitive way to plan a removal is to ask how much can be taken out. The measured way is to ask what the face will consist of afterwards, and then to remove the amount consistent with that answer.
From the patient’s side this looks like a longer first appointment than expected, and a plan that arrives in parts. The ultrasound is done in the room rather than booked for another day. The findings are given as a list, because that is what they are: material at this depth and in this plane, inflammation active or quiet, normal fat here that should stay, a nerve running through the field that has to be worked around. The proposal comes last, and it is often smaller than the one people arrive expecting, because it is confined to the part of the material that is producing the symptom.
Many decisions in aesthetic surgery are made from a photograph and from experience. Experience is a real instrument and nothing here is offered as a substitute for it. The difference a measurement makes is narrower than it sounds: it lets a plan be written down in a form somebody else could check, including the patient, and it makes the point at which the plan was wrong visible afterwards instead of arguable.
10Where measurement stops
Instruments have limits, and stating them is part of using them properly.
- Ultrasound shows the plane, the depth and the pattern of a material. It does not reliably name the product, and it is least reliable where several materials were injected at different times and fibrosis has since developed around them.
- CT shows bone and the extent of a deformity. It does not show whether a facial nerve branch has been displaced by scar, which is the thing you most want to know before dissecting through one.
- The response to hyaluronidase is informative, since material that does not change is unlikely to be hyaluronic acid. It is one piece of evidence and not a diagnosis.
- No imaging measures how a person feels about their own face. That is why the 2017 satisfaction study asked the patients directly rather than reading it off the scan.
Which returns the argument to where it began. Measurement is not the point of this practice. It is the discipline that keeps a plan honest up to the moment when the only question left is whether the person in front of you will be better off. That question is answered by judgement, and it is answered in conversation.
Four terms used on this page
- First author
- The author who carried out the study and settled its design. Dr. Kang holds this position on five of the six papers.
- Co-author
- A contributing author in another position. He is a co-author, not first author, on the gluteal ptosis paper, and that is stated wherever the paper appears.
- Study population
- The group of patients in which a finding was actually observed. A finding does not travel to a different population because the tissue looks similar.
- Methodological background
- Research cited for how it was done rather than for what it found. Every citation of these six papers on this site is of that kind.