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.

Flap creation

We blindly undermine the skin subcutaneously with Gorney-type facelift scissors. The points of the scissors are directed upwards allowing visual and palpable control of the flap thickness. Most of the scissor dissection is done by spreading. Care is taken to create a sufficiently thick flap to mask small irregularities of the underlying tissues.

Anchor point

The sagging facial soft tissues are suspended by purse string sutures that are woven into the SMAS, which is not undermined. The anchor point for these sutures is the deep temporal fascia above the zygomatic arch, at a safe distance from the frontal branch of the facial nerve (Fig. 12.7).

Fig. 12.7 The placement of the anchor points is 1.8 cm posterior to the course of the frontal branch of the facial nerve for the 1st and 2nd loops (posterior black dot), and 2.0 cm anterior to it for the 3rd loop (anterior black dot).

The first purse-string suture: the vertical loop

See Fig. 12.1, dotted black line.

Using iris scissors we make a 0.5 cm diameter window in the subcutaneous tissue, 1 cm above the zygomatic arch and 1 cm anterior to the helical rim, exposing the deep temporal fascia. A 1-0 PDS suture on a CT-3 needle is used.

The first bite starts where we visualize the deep temporal fascia and pass down to the temporal bone. The needle is angled towards the tragus to avoid damaging the frontal branch of the facial nerve branch. Firm bites (1 to 1.5 cm long and 0.5 cm deep) of the SMAS tissue, which includes parotid fascia in the upper and platysma in the lower , are taken. It is important to confirm that every bite of the needle takes a substantial piece of SMAS, to prevent the suture from pulling through.

Suturing goes down to the lower limit of the skin undermining. At this point, two or three solid bites in the superior edge of the platysma muscle are taken (Fig. 12.8A). Then, suturing changes direction, turning upwards, back towards the starting point. This creates a narrow U-shaped purse string loop with a width of approximately 1 cm. The knot is then tied under maximum tension.

Fig. 12.8 Intraoperative picture, left side: with the 0-PDS suture at least 1–2 firm bites are taken in the superior border of the platysma.

The second purse-string suture: the oblique loop

Fig. 12.1, dotted black line.

The second suture originates at the same starting point on the deep temporal fascia. It forms a wider loop, directed towards the jowls, at an angle of 30° to an imaginary vertical line. This loop is more O-shaped than U-shaped, to prevent linear traction on the subcutaneous tissues, which could be visible through the skin.

The loop follows the anterior border of skin undermining in the lower part of the cheek. Short 1 cm bites are taken in the SMAS. The knot is again tied under maximum tension.

The third purse-string suture: the malar loop

Fig. 12.1, dotted black line.

The third suture has a separate anchor point on the deep temporal fascia, just lateral to the orbital rim. This is anterior to the course of the frontal branch of the facial nerve. A window is made in the orbicularis oculi muscle to identify the underlying deep temporal fascia.

A deep bite is taken and the purse string suture is oriented obliquely towards the malar fat pad, which is recognizable by its more fibrous consistency than the surrounding subcutaneous fat. At the point marked preoperatively on the skin, 2 cm below the lateral canthus, the direction of the suture is reversed, now passing in an upward and lateral direction. This loop has a narrow U-shape and ends at the anchor point. This knot is also tied under maximum tension.

After placement of the purse-string sutures, the windows in the SMAS and the orbicularis oculi muscle are closed with 4-0 Vicryl® to prevent the knot being palpable. If any irregularities of the subcutaneous tissue are noticed they can be corrected by further suturing or trimming with scissors. Some skin dimpling may also have to be released at the edges of the skin undermining.

Skin redraping and resection

One of the most important features in this short scar facelift is the vertical redraping of the skin. As the vector of the SMAS suspension is almost completely vertical, redraping and excision of skin in the same direction reinforces the underlying subcutaneous sculpturing effect.

Classically in facelift surgery there is always a horizontal component to the skin redraping. This causes skin redundancy around the earlobe, requiring a post auricular extension of the incision (Fig. 12.9, Fig. 12.10B).

Fig. 12.9 Computer simulation of two methods of skin redraping during a MACS-lift: when redraped obliquely backwards (left) the skin forms a dog-ear below the earlobe, which needs to be corrected by extending the incision and skin redraping behind the ear. When redraped vertically (right), no dog ear occurs at the earlobe, and the minor cranial dog ear is easily corrected by minimal extension of the temporal incision.

Fig. 12.10 Intraoperative picture: vertical skin redraping during a MACS-lift. The skin excess is mainly vertical, there is only a minimal horizontal skin redundancy due to the vertical lifting vector. There is no horizontal dog ear at the earlobe therefore no postauricular extension or skin resection is necessary.

Skin resection on the cheek flap is carried out in a curvilinear fashion. The zigzag border of the temporal hairline incision expands to incorporate this linear cheek flap, compensating for any incongruity and reducing possible dog ear formation. The earlobe is then set back into the cheek flap (Fig. 12.2).

Closure is with buried interrupted 4-0 Vicryl® sutures.

The horizontal limb of the incision is then closed with a running 5-0 nylon horizontal mattress suture, taking larger bites on the cheek flap to adjust for any difference in length.

A small hollow silicone drain is placed at the lowest point of the incision. This discharges into the loose postauricular dressings during the first 24 hours, after which both are removed.

The remainder of the wound is closed with interrupted 6-0 nylon sutures.

In cases where a short-scar temporal lift is added (see below), skin resection is postponed. The temporal lift corrects some of the excess paracanthal skin, reducing dog ear formation at the hairline incision.

The short-scar temporal lift

In most vertical facelifts, including the midface lift, skin excess may appear in the paracanthal region. This may accentuate pre-existing temporal hooding. The short-scar temporal lift with galeapexy, described by Alain Fogli is a useful solution to this problem.

We have had great success using this technique, adding some modifications in the planes of undermining and the vector of skin redraping.

The principle involves subcutaneous lifting of the lateral third of the eyebrow, using the galea as a vehicle and an anchor for the forehead skin. The dissection is subgaleal in the cranial part, and subcutaneous in the caudal part. The transition from the subgaleal to the subcutaneous plane lies at least 2 cm above the tail of the eyebrow, to protect the frontal branch of the facial nerve.

The pinch lower lid blepharoplasty

After performing an extended MACS-lift, the malar mound is moved vertically creating skin excess in the lower eyelid. This excess is estimated by pinching with forceps and is marked with methylene blue. A pinch blepharoplasty is performed via a classical lower eyelid blepharoplasty incision. The skin is released from the orbicularis, redraped and the excess resected. Closure is with a running 5-0 nylon intradermal suture.

Dressing

The incisions are dressed with sterile fluffy gauze and held in place with a noncompressive bandage. For the first 4 hours, an ice-cooling pack is applied to minimize swelling and bruising.

Dressings are removed on the first postoperative day. The wounds and the patient’s hair are washed. No further dressings are required and the patient may then shower.

Case 1 (side and frontal view)

Fig. 12.C1 Case 1 A, C Preoperative. B, D Postoperative.

This 45-year-old woman presented complaining of her “harsh” stare, loss of volume in the lower half of her face and mild laxity in her upper neck and submental region. On examination she has moderate jowling, early submental laxity without platysmal bands, marionette grooves (mainly visible on profile), with emptiness of the midface and cheeks. There is moderate herniation of the lower eyelid orbital fat, and an upper eyelid dermatochalasis with the loose skin resting on the upper eyelashes, and herniation of the medial fat pad. The position of the eyebrows is satisfactory. Also observe the glabellar frown line.

Treatment consisted of:

This was performed under local anesthesia with intramuscular midazolam sedation (3 mg) and took 2 hours. The patient was discharged home 2 hours after the completion of surgery.

The postoperative result one year later is shown. The frontal view demonstrates restoration of the lower facial shape, with a well-defined mandibular border, correction of the jowls, the marionette grooves and replenishment of the cheek volume. The herniation of lower eyelid fat has been corrected. Note the absence of upper eyelid dermatochalasis and the smooth glabella.

On profile, the flat submental area, the well-defined mandibular border and the sharp cervicomental angle are also obvious. Note the good scar quality and the natural temporal hairline.

Case 2 (frontal and view)

Fig. 12.C2 Case 2 A, C Preoperative. B, D Postoperative.

This 56-year-old woman requested rejuvenation of the lower and middle third of the face. She presents with platysmal bands, a lax submental and upper neck region, jowls, marionette grooves, downward slanting corners of the mouth, upper lip rhytids, marked nasolabial folds and emptiness of the midface with hollow lower eyelids. She also has empty upper eyelids but her eyebrow position is satisfactory. Note the inframalar depression in the view.

Treatment consisted of:

This procedure was done under local anesthesia with intramuscular midazolam relaxation (2.5 mg) and took 2 hours 10 min. The patient was discharged 2 hours postoperatively.

The 1-year postoperative result shows correction of the platysmal bands, neck and submental laxity, sharpening of the cervicomental angle and the mandibular border, correction of the jowls, marionette grooves and downward slanting corners of the mouth. There is also improvement in the perioral rhytids, the nasolabial fold and midface volume. Note the augmentation of the malar area, which produces a youthful appearance, especially on the view. There is also blending of the lid–cheek junction and a reduction of the vertical height of the lower eyelid.

Case 3 (side and frontal view)

Fig. 12.C3 Case 3 A, C Preoperative. B, D Postoperative.

This 58-year-old patient presented with obvious signs of facial aging, after a 60 kg weight loss resulting from a Scopinaro bowel reduction. She shows marked ptosis of the facial skin envelope with jowling, platysmal bands and marked perioral rhytids. Surgery was performed under local anesthesia with intramuscular midazolam sedation and consisted of:

The 1 year postoperative view is shown. It demonstrates a natural correction of the aged facial features. The improvement in the submental area and angle were achieved without opening the neck.

An additional postauricular incision was necessary to remove skin folds.

Case 4 (frontal and view)

Fig. 12.C4 Case 4 A–D

This 49-year-old man requested facial rejuvenation. He presents with thick heavy skin and generalized facial ptosis. He has some fatty infiltration of the submental area and ptotic jowls. He also has deep nasolabial grooves and heavy overlying folds. The midface has descended and there is a distinct crease between the cheek and lower eyelid, which bulges from the eyelashes to the infraorbital rim. The upper eyelids are hollow and the eyebrow is heavy and low set. The tail of the eyebrow has dropped causing lateral crowding with two to three deep horizontal creases in the lateral area. The patient also has deep frontal wrinkles.

Surgical treatment consisted of:

This procedure was done under local anesthesia with intramuscular midazolam (4.5 mg) and took 2 hours 40 minutes. The patient was discharged 2 hours following surgery.

The patient is shown 9 months later. He illustrates correction of the cervicomental angle, definition of the mandibular border, improvement of the jowls, with suspension of the submandibular glands by vertical tightening of the platysma muscle. The nasolabial groove has been reduced and the midface shows almost complete eradication of the lid-cheek junction. The malar volume is enhanced and this effect can be best appreciated on the view. In this, the effect of the temporal lift can also be seen. The tail of the eyebrow has been raised about 1 cm but the beard and sideburn remain in an anatomical position. Note the quality of the 4 cm horizontal scar from the temporal lift.

Case 5 (frontal and view)

Fig. 12.C5 Case 5 A–D

This 53-year-old woman is seeking minimally invasive facial rejuvenation. She wears her hair short and does not want any scars behind her ears. Clinical examination reveals laxity in the neck with platysmal bands, jowls, marionette grooves, fine perioral rhytids on thin lips, a marked nasolabial fold and an empty deflated midface with obvious demarcation between the lid–cheek junction. She also requested correction of her nasal hump and hanging columella.

Treatment consisted of:

The surgery was performed under general anesthesia and took 3 hours. The patient remained overnight and was discharged the following day.

The postoperative results are shown years after surgery. There is correction of the cervicomental angle, the jowls, marionette grooves and nasolabial folds, with an obvious improvement in the midface. This is most obvious in the view where the flat zygomatic area has been transformed into a youthful malar prominence. There is blending of the lid–cheek junction. The upper and lower lips have been naturally augmented and the fine rhytids have been eradicated by the laser treatment. The rhinoplasty has had a complementary effect on the rejuvenating surgery. Microfat grafting has produced the additional augmentation necessary in this thin deflated patient. This cannot be achieved by classical facelift procedures alone.