Simple MACS-lift

Two purse string sutures are used to correct the jowls, the marionette grooves and the neck. They are anchored to the deep temporal fascia above the zygomatic arch, 1 cm in front of the auricular helix. The first suture runs as a narrow vertical U-shaped purse string towards the mandibular angle, incorporating the posterior border of the platysma muscle. Following liposuction of the neck, tying this suture under maximum tension produces a strong vertical lift on the lateral part of the platysma, correcting the cervicomental angle. The second purse string suture starts from the same anchoring point above the zygomatic arch and runs obliquely in the direction of the jowls as a wider O-shaped loop. Tying this suture corrects the jowls, the marionette grooves and downward slanting corners of the mouth (Fig. 12.1).

Fig. 12.1 Schematic drawing of the MACS-lift, demonstrating the extent of the skin undermining and the position of the purse-string suture loops. The skin incision is marked in red, the extent of the skin undermining in pink, and the suture loops in dotted black lines.

Extended MACS-lift

An additional point 2 cm below the lateral canthus is marked preoperatively with the patient sitting. This is the inferior limit of the third purse string suture and is included in the skin undermining. This suture also originates from the deep temporal fascia, but at its anterior aspect, lateral to the orbital rim. It provides strong correction of the nasolabial fold, enhancement of the malar region, lifting of the midface and shortening of the vertical height of the lower eyelid (Fig. 12.1).

In both the S-MACS and X-MACS the skin is redraped in a completely vertical direction and skin excess above the temporal hairline incision is resected. As there is no lateral traction on the skin, there is no dog ear at the level of the earlobe, eliminating the need for a post-auricular extension of the incision (Fig. 12.2).

Fig. 12.2 Vertical skin redraping and resection during a MACS-lift. No postauricular extension of the incision is required.

In an extended MACS lift, suspending the malar fat pad causes bunching of skin in the lateral part of the lower eyelid and the paracanthal zone and further skin excision in this region is necessary. This skin resection is safe because of the support on the lower eyelid provided by the third purse string suture. This led to the development of the pinch blepharoplasty: skin excess is evaluated by pinching with forceps and is excised via a lower eyelid blepharoplasty incision combined with a paracanthal extension. Between four to eight millimeters of skin can be safely resected.

The MACS-lift achieves powerful improvement in submental and upper neck laxity, sharpening of a blunted submental angle, jaw line definition, restoration of mid facial volume and correction of the nasolabial fold.

Whether to perform a simple or extended MACS-lift is determined primarily by whether the patient needs correction of the upper half of the nasolabial fold and the midface. The third suture, suspending the malar fat pad, offers powerful correction of these features. It also enhances the volumetric restoration of the midface and provides structural support of the lower eyelid. This means that a third suture can also be indicated in patients with a flattened malar mound and laxity of the lower eyelids.

Only patients with no major medical problems or cardiovascular risk factors are selected for this outpatient office-based surgery. The decision whether to perform a MACS-lift under local or general anesthesia depends on both the surgeon’s and patient’s preference.

In classical teaching, smoking is considered an absolute contraindication to facelift surgery. As a result of the limited subcutaneous undermining and the absence of multiplanar dissection, we only consider smoking a relative contraindication to performing a MACS-lift.

Preoperative relaxation

An intramuscular injection of 2.5 to 5 mg of Midazolam (Dormicum®, Versed®) is administered prior to surgery depending on the weight and anxiety level of the patient.

Preoperative marking

With the patient in a sitting position, their neck is flexed to create a double chin. This area is marked, and the lower part of the jowls is included. Both areas will be liposuctioned. When an extended MACS lift is performed, a point 2 cm below the lateral canthus is also marked, as this will be included in the skin undermining.

Infiltration

Infiltration follows the sequence of procedures: first the upper eyelids, followed by the submental area, and finally the cheeks. (For the anesthetic solution see Table 12.1.)

Table 12.1 Anesthetic solution for MACS-lift

In the submental area an average of 30 to 40 mL is infiltrated in the preplatysmal fat until a moderate degree of tumescence is achieved.

Preoperative marking: incision

See Fig. 12.1, red line.

Marking starts at the lower limit of the lobule, progressing upwards in the pre-auricular crease. At the level of the incisura intertragica a 90° backwards turn is made to preserve the integrity of this anatomical landmark. The marking then follows the posterior edge of the tragus, heading towards the helical root.

At the superior limit of the ear the marking follows the small hairless recess between the sideburn and the auricle and then turns downwards to follow the inferior edge of the sideburn. In men, the marking descends approximately 1.5 cm before crossing anteriorly.

It continues forwards in a zigzag pattern, 2 mm within the lower and anterior aspect of the sideburn. In this part of the incision the knife is beveled at an angle almost tangential with the skin, cutting hair shafts perpendicularly (Fig. 12.3). This maneuver allows hairs to grow through the scar. After hair regrowth the scar will be hidden within the hairline and becomes virtually invisible. The purpose of the zigzag is to increase the length of the temporal incision making it a similar length to the cheek flap, reducing potential dog ear formation.

Fig. 12.3 Cross section through the sideburn and temporal skin incision. Above: in case of an incision parallel to the hairshafts the scar will always lie in front of the hairline. Below: in MACS-lifting a beveled incision is made just within the hairline, orienting the blade very obliquely. The hairshafts are divided, leaving the hair follicles behind. These hairs will grow through the scar hiding it in about 6–8 weeks.

In the simple MACS-lift the incision extends to the level of the lateral canthus. In an extended MACS-lift the incision continues to the level of the tail of the eyebrow.

Preoperative marking: undermining

See Fig. 12.1, pink line.

The mandibular angle is palpated with the index finger and marked. The undermining extends from the lowest point of the incision at the lobule, to the mandibular angle, and then curves anteriorly 5–6 cm in front of the ear. In an extended MACS-lift, the undermining includes the malar eminence.

Suction lipectomy

We use a 3 mm spatula cannula, with one opening. The opening is directed away from the skin to avoid dermal damage. Two or three stab incisions enable feathering of the marked area. Liposuction is performed in a preplatysmal plane under tactile guidance from the nondominant hand. At the completion of the procedure, the cannula should be just visible beneath the skin.

Exceptionally pre- and/or subplatysmal fat needs to be directly excised through a 3 cm submental incision. Wide undermining of the neck skin should be performed simultaneously to facilitate skin redraping.

In cases where microfat grafting is planned, the submental fat can be harvested with a special grating cannula (Fig. 12.4: “ToVer cannula,” Wells-Johnson, Tucson, AZ) which delivers fine-particle fat (1 mm diameter). If insufficient donor fat is present in the submental area, further fat can be harvested from the abdomen or love handles, using other cannulas (Fig. 12.5: “Becker Grater Round” cannula with 1 mm holes, Wells-Johnson, Tucson AZ).

Fig. 12.4 “ToVer cannula”, Wells-Johnson, Tucson, AZ.

Fig. 12.5 “Becker Grater Round” cannula with 1 mm holes, Wells-Johnson, Tucson, AZ.

Microfat grafting

Fat is prepared and injected as soon as possible after harvesting. We sieve it through a fine-meshed sterile cloth, rinsing away blood and oil with normal saline. The fat is injected with 18 G fat grafting cannulas (Fig. 12.6: Wells-Johnson, Tulip).

Fig. 12.6 Microfat grafting cannula by Tulip Medical Inc.

Microfat grafting is most frequently performed in the malar area (5–15 mL/side), nasojugal groove (0.5–2 mL/side), the nasolabial groove (2–4 mL/side), the marionette grooves (2–4 mL/side), and for lip augmentation.

The skin puncture is made with a 16 G pink needle, and does not require closure after the procedure.

In patients with a sharply demarcated nasolabial or marionette groove, further undermining is performed after fat injection, using a V-dissector cannula.