Minimal Access Cranial Suspension Lift

The Scar Solution Natural Scar Removal

Scar Solution By Sean Lowry

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Patrick Tonnard, Alex Verpaele

49.1

Introduction

When different surgical techniques in plastic surgery and especially in facial rejuvenation surgery are compared, one is tempted to look only at the end result and not at the global risk-benefit ratio that should be considered with any intervention. Some interventions can lead to superb final results but this at the cost of a possibly high complication rate and a long postoperative recovery period. It is not always the most aggressive and extreme surgery that delivers the happiest patient. There is a delicate subjective balance between the final result and the morbidity of the procedure that will determine the degree of the patient's happiness.

In the last decade of the twentieth century, facial aesthetic surgeons became increasingly convinced of the importance of shifting facial volumes rather than putting traction on the skin. The concept of volumetric rejuvenation gained worldwide acceptance. The restoration of facial volumes is more important than the amount of skin resected and the tension on the skin and superficial musculo-aponeurotic system (SMAS).

All traditional facelift designs have an oblique vector of traction on the SMAS which can be decomposed into a horizontal and a vertical component (Fig. 49.1). The horizontal component of this vector of traction on deep tissues and skin does not really rejuvenate the face. It rather flattens the face and puts it under tension.

In recent years, more emphasis has been put on reorienting this vector in a more vertical direction.

The working hypothesis of minimal access cranial suspension (MACS) lifting is as follows: The only re-

Superficial Muscular Aponeurotic System
Fig. 49.1. Traditional facelift designs have an oblique vector of traction on the superficial musculo-aponeurotic system (SMAS) which can be broken down into a horizontal and a vertical component. In recent years more emphasis has been placed on reorienting this vector in a vertical direction

juvenating vector applied on the deep tissues as well as on the overlying skin is the vertical one.

In the MACS lift the horizontal vector of traction is omitted, making this procedure a pure vertical vector facelift on deep tissues as well as on skin. It is aimed at obtaining an antigravitational volume redistribution in the upper neck and face by suspending the soft tissues of the face, working in the superficial subcutaneous plane without any deeper undermining. The skin excess is redraped in a vertical direction and resected in the temporal region and lower eyelid.

Temporal Suspension Lift
  1. 49.2. Simple minimal access cranial suspension (MACS) lift. a The incision starts at the lower limit of the earlobe, runs preauricularly to the temporal hairline following this along the sideburn up to the level of the lateral canthus. The skin is undermined in a subcutaneous level approximately 5 cm in an anterior direction. The mandibular angle is the inferior limit of the undermining. The arrow indicates the vector of the traction. b Position of the vertical, narrow purse-string suture and the 30° wide purse-string on the nonundermined SMAS with anchoring to the deep temporal fascia
  2. 49.2. Simple minimal access cranial suspension (MACS) lift. a The incision starts at the lower limit of the earlobe, runs preauricularly to the temporal hairline following this along the sideburn up to the level of the lateral canthus. The skin is undermined in a subcutaneous level approximately 5 cm in an anterior direction. The mandibular angle is the inferior limit of the undermining. The arrow indicates the vector of the traction. b Position of the vertical, narrow purse-string suture and the 30° wide purse-string on the nonundermined SMAS with anchoring to the deep temporal fascia

49.2

The Technique: Simple and Extended MACS Lifting

The general principle of the MACS lift is the vertical suspension of sagged facial soft tissues with permanent or slowly resorbable purse-string sutures strongly anchored to deep temporal fascia through a preau-ricular and temporal prehairline incision.

Two variations of the procedure were designed:

  1. The simple MACS lift(S-MACS), where two purse-string sutures are placed for correction of the neck and the lower third of the face (cervicomental angle, jowling, marionette grooves).
  2. The extended MACS lift (X-MACS), where a supplementary third purse-string suture is placed to suspend the malar fat pad. This suture will have an extra effect on the nasolabial groove, the midface and the lower eyelid.

In the simple MACS lift, two purse-string sutures are used for correction of the neck, the jowls and the marionette grooves. They are both 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 to the region of the mandibular angle catching the lateral border of the platysma muscle. Tying this suture under maximal tension produces a strong vertical pull on the lateral part of the platysma muscle, correcting the cervi-comental angle of the neck region, which has been liposuctioned previously. 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. This suture corrects the jowls, the marionette grooves and the downward slanting of the corners of the mouth (Fig. 49.2).

When performing an extended MACS lift, an additional undermining of the skin over the malar region is performed. A point dropped 2 cm below the lateral canthus has been marked with the patient in the standing position. It will be included in the skin undermining and is the inferior limit of the third purse-string suture. This suture originates as well from the deep temporal fascia, but in its anterior part, lateral to the lateral orbital rim. It provides a strong correction of the nasolabial fold, an enhancement of the malar region, a lifting of the midface and a shortening of the vertical height of the lower eyelid (Fig. 49.3) .

In both the simple MACS lift and the extended MACS lift the skin is redraped in a pure vertical direction and the excess of skin above the temporal hairline incision is resected. As no lateral traction on the skin is applied, there will be no dog-ear at the level of the earlobe, eliminating the need for a retroauricular dissection (Fig. 49.4).

As a consequence of lifting the malar fat pad in the direction of the lateral orbital rim, a bunching up of skin in the region of the lateral part of the lower eyelid and the paracanthal zone becomes apparent. A skin excision in the subciliary and paracanthal region hence becomes mandatory. This pure skin resection is easy and safe because of the good structural support of the lower eyelid provided by the third purse-string suspension suture. This observation has led to

Pre Auricular Fat

Fig. 49.3. The extended MACS lift. a Preoperative marking of the preauricular and infracapillary incision, which is extended along the temporal hairline with supplementary undermining of the malar region and different vectors of traction (arrows)

on the midface soft tissues. b Position of a third narrow purse-string suture, in addition to the two purse-string sutures described in Fig. 49.2, between the anterior part of the deep temporal fascia and the malar fat pad

Fig. 49.3. The extended MACS lift. a Preoperative marking of the preauricular and infracapillary incision, which is extended along the temporal hairline with supplementary undermining of the malar region and different vectors of traction (arrows)

on the midface soft tissues. b Position of a third narrow purse-string suture, in addition to the two purse-string sutures described in Fig. 49.2, between the anterior part of the deep temporal fascia and the malar fat pad

Suture Malar Fat
  1. 49.4. a When lateral skin redraping is performed, as in classic facelifts, a dog-ear appears at the earlobe which necessitates redraping by retroauricular flap dissection. b Vertical skin redraping, in contrast, will not produce a dog-ear under the earlobe and will avoid the necessity for retroauricular dissection
  2. 49.4. a When lateral skin redraping is performed, as in classic facelifts, a dog-ear appears at the earlobe which necessitates redraping by retroauricular flap dissection. b Vertical skin redraping, in contrast, will not produce a dog-ear under the earlobe and will avoid the necessity for retroauricular dissection the development of the principle of pinch blepharo-plasty: the excess of skin is evaluated by pinching the skin between the teeth of forceps and is excised via a lower-eyelid blepharoplasty incision with paracanthal extension. Four to eight millimetres of skin can easily be resected especially in the paracanthal region without the risk of ectropion or scleral show.

49.3

Indications and Contraindications

The appeal of the MACS lift lies mainly in the fact that it offers a stable and natural facial rejuvenation by a simple and safe procedure of 2-2.5 h which can be performed under local anaesthesia on an outpatient basis. In comparison with a classic facelift, the MACS lift has a quicker recovery and a lower morbidity. Last but not least the final scar is significantly shorter.

The MACS lift provides a powerful correction of submental and upper-neck laxity, correction of a blunted submental angle, restoration of a well-defined jaw line by correction of the jowls, restoration of the midfacial volume and correction of the nasolabial fold.

The decision whether to perform a simple or an extended MACS lift is not purely determined by the age of the patient. The main consideration to make is whether the patient needs a correction of the upper half of the nasolabial fold and the midface. The third suture, suspending the malar fat pad, gives a powerful correction of these features. It also enhances the volumetric restoration of the midface and provides a very strong support of the lower-eyelid skin. This means that the indication for the third suture can be extended to patients with a flattened malar mound and laxity of the lower eyelids. This is not only determined by age, but also by the facial bony anatomy.

In classical teaching smoking is considered an absolute contraindication for facelift surgery. Because of the limited subcutaneous undermining and the absence of multiplanar dissection, we consider smoking more as a relative contraindication.

As a general rule only, patients without a major medical history or cardiovascular risk factors are selected for outpatient office-based surgery. The decision whether to perform the MACS lift under a local or under general anaesthesia depends on the surgeon's and the patient's preference.

49.4

Operative Technique 49.4.1

Submental Infiltration

The sequence of infiltrations follows the sequence of the procedures. This means first the upper eyelids if treated, followed by the submental area, and then followed by one cheek infiltration.(For the anaesthetic solution see Table 49. 1)

For the submental suction lipectomy an average of 30-40 ml is infiltrated in the preplatysmal fat until a moderate degree of tumescence is reached.

Peroperative Marking: Incision

The marking starts at the lower limit of the lobule, going up in the preauricular crease. At the level of the incisura intertragica the marking makes a 90° turn

Table 49.1. Anaesthetic solution for minimal access cranial suspension lift

100 ml

0.9 % NaCl

20 ml

2% lidocaine

10 ml

10 mg/ml ropivacaine

2 ml

8.4% sodium bicarbonate

0.2 ml

10 mg/ml levorenine

10 mg

triamcinolone

  • From Tonnard PL., Verpaele AM. The MACS-lift Short Scar Rhytidectomy. St. Louis: Quality Medical Publishing, 2004.
  • From Tonnard PL., Verpaele AM. The MACS-lift Short Scar Rhytidectomy. St. Louis: Quality Medical Publishing, 2004.

backwards to preserve the integrity of this anatomical landmark. The marking then follows the posterior edge of the tragus, ascending 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 downward to follow the inferior implantation of the sideburn. In men the marking descends approximately 1.5 cm before turning anteriorly to cross the sideburn.

The marking runs further forward in a zigzag pattern, 2 mm within the lower and anterior implantation of the sideburn. In this part of the incision, the knife is inclined to an angle almost tangential with the skin so as to cut hair shafts perpendicularly (Fig. 49.5). This manoeuvre will allow hair to grow through the scar. After hair regrowth, the final scar will be hidden a few millimetres within the hairline and become virtually invisible. The purpose of the zigzag pattern is to increase the length of the temporal incision for better congruence with the length of the cheek flap, thereby reducing dog-ear formation.

In the simple MACS lift the incision will extend to the level of the lateral canthus. In an extended MACS lift the incision goes up to the level of the tail of the eyebrow. The total length of the incision will usually not exceed 7-9 cm, depending on the dimensions of the auricle (vertical branch of the incision) and the width of the sideburn (horizontal branch of the incision).

Fig. 49.5. Incision in the skin perpendicular to the hair shafts will allow hair regrowth through the scar and through the skin in front of the scar. This will hide the scar within the hair-bearing skin, making it less conspicuous

Peroperative Marking: Undermining

The mandibular angle is palpated with the index finger and marked as the lowest point of the undermining. The extent of the undermining is marked starting from the lowest point of the incision at the lobule, directed towards the marking of the mandibular angle, and then curving anteriorly to 5-6 cm in front of the ear. In the case of an extended MACS lift, the undermining of the malar eminence is included in the demarcation.

Suction Lipectomy

We prefer to use a 3 mm spatula cannula, with one opening. The opening is never directed towards the skin to avoid dermal damage. Two or three incisions are used to crisscross the marked area optimally. The lipectomy is performed in a preplatysmal plane under tactile guidance of the nondominant hand. A maximal lipectomy is performed, so that in the end the cannula is visible just beneath the skin.

Flap Creation

The skin is undermined blindly with Rees-type facelift scissors. The dissection is performed in a subcutaneous plane. The points of the scissors are directed towards the skin to have visual and palpable control over the thickness of the cheek flap. Most of the dissection is done by spreading manoeuvres with the scissors. Care is taken to create a flap of sufficient thickness to mask small irregularities of the underlying layer.

The First Purse-String Suture: the Vertical Loop

This suture will be fixed to the deep temporalis fascia at a point 1 cm above the zygomatic arch and 1 cm in front of the helical rim. An extra dose of local anaesthetic is injected at the anchor point down to the temporal bone, withdrawing the needle and infiltrating all layers of tissues.

With the iris scissors in the spreading mode a 0.5-cm-diameter window is made in the subcutaneous tissue to visualise the deep temporal fascia. It should be identified as a distinct white shiny layer.

A 2-0 permanent suture on a big V-7 needle is used to perform the suspension of the sagged facial and neck soft tissues. Monofilament polypropylene (Pro-lene), poly(tetrafluoroethylene) (Gore-Tex) or braided nylon (Mersilene) can be used, as well as a slowly resorbable PDS O suture.

The first bite starts in the window where we visualise the deep temporal fascia and goes down to the temporal bone. The needle is oriented towards the tragus so there is no danger of damaging any facial nerve branch. Firm bites 1-1.5 cm long and 0.5 cm deep are taken in the SMAS tissue, which consists of parotid fascia in the upper two thirds and platysma in the lower third. It is essential to confirm that every bite of the needle takes a substantial part of SMAS tissue, so that the suture will not pull through.

The suturing goes down towards the region of the mandibular angle until the lower limit of the undermining. In this region direct visualisation by means of a head light or a lighted retractor is helpful. After placing 2 or 3 firm bites in the lateral part of the platysma muscle, the suturing is turned upwards and continued towards the starting point. This creates a narrow U-shaped purse-string loop with a width of about 1 cm. Some skin dimples may have to be freed at the borders of the undermining.

The Second Purse-String Suture: the Oblique Loop

The second suture originates from the same location on the deep temporal fascia. This purse-string suture forms a wider loop, directed towards the region of the jowls, at an angle of 30° with the vertical. This loop is more O-shaped instead of the U-shaped vertical loop to prevent linear traction on the subcutaneous tissue, which could be visible through the skin.

The loop follows the borders of the anterior undermining in the lower part of the cheek. Short bites of maximum 1 cm are taken in the parotid fascia and the SMAS tissue.

The Third Purse-String Suture: the Malar Loop

The third suture has a separate anchor point on the deep temporal fascia, just lateral to the lateral orbital rim, which is in front of the course of the frontal branch of the facial nerve. Here a window is made in the orbicularis muscle down to the deep temporal fascia by spreading the iris scissors. This suture should also have a narrow U shape to prevent bulging of subcutaneous tissue in the highlighted zygomatic area. It runs to the malar fat pad, which was preoperatively located by a point marked 2 cm below the lateral can-thus.

A deep bite is taken anchoring the suture to the deep temporal fascia. The purse-string suture is oriented obliquely downwards and medially. The malar fat pad is recognisable by a more fibrous consistency than the surrounding subcutaneous fat. At the preop-eratively marked point, referring to the malar fat pad, the direction of the suturing is reversed, now in an upward and lateral direction. The loop has a narrow U shape, grabbing firm parts of tissue with every bite of the suture. The suture ends at its starting point in the window made in the orbicularis muscle.

The knot is tied under maximal tension. The window in the orbicularis muscle is closed with 4-0 Vicryl to prevent knot palpability in the lateral orbital region. Again some skin dimples may have to be freed with the scissors at the borders of the malar 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 nearly purely vertical, the redraping and resection of the skin in the same direction will seal the underlying suspension effect. Because the earlobe is pulled upward by the suspension sutures, it will have to be set back in the cheek flap, taking the place of any dog-ears.

In classic face lifting there is always a horizontal component of skin redraping. This causes a skin excess in the earlobe region, necessitating a retroauricu-lar incision for skin redraping.

The skin resection on the cheek flap is carried out in linear fashion and will be sutured to the zigzag border of the temporal hairline incision. The zigzag incision will now open up when coapting with the linear cheek flap, thereby compensating for the incongru-ence in length of the both borders and reducing possible dog-ears.

Closure with interrupted 4-0 Vicryl buried sutures is started from the superior end of the incision downwards. This is important to avoid dog-ears in this section.

The horizontal limb of the incision is sutured with a running 5-0 nylon horizontal mattress suture, taking bigger bites on the cheek flap side than on the temporal side to compensate for the final incongru-ence in length between both sides. A small hollow silicon tube is inserted for drainage at the lowest point of the incision. It will drain into the loose retroauric-ular dressing during the first 24 h, after which it is removed together with all dressings. The rest of the suturing is done with running and separated 6-0 nylon sutures.

49.4.10

The Pinch Lower Blepharoplasty

This is routinely added after performing an extended MACS-lift procedure as the lifting of the malar mound creates a skin excess in the lower-eyelid region (Fig. 49.6).

The concept of the pinch blepharoplasty of the lower eyelid is the safe removal of excess skin in the paracanthal and lateral subciliary region after providing strong structural support of the lower eyelid through suspension of the malar fat pad with the third purse-string suture of the extended MACS-lift procedure.

The skin excess is estimated by a pinching manoeuvre with forceps and marked with methylene blue. The pinch blepharoplasty is performed via a classic lower blepharoplasty incision. The skin is freed from the orbicularis muscle, is vertically redraped without any tension and resected. The skin is closed with a running 5-0 nylon intradermal suture.

References

  1. Baker, D. C. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and application. Aesth. Surg. J. 21:14, 2001.
  2. Camirand, A., Doucet J. A comparison between parallel hairline incisions and perpendicular incisions when performing a face-lift. Plast. Reconstr. Surg. 99:10, 1997.
  3. Coleman, S. R. Facial recontouring with lipostructure. Clin. Plast. Surg. 24:347, 1997.
  4. Connell, B. F., Semlacher, R. A. Contemporary deep layer facial rejuvenation. Plast. Reconstr. Surg. 100:1515, 1997.
  5. Little, J. W. Three-dimensional rejuvenation of the midface: Volumetric resculpture by malar imbrication. Plast. Reconstr. Surg. 105:267, 2000.
  6. Owsley, J. Q., Fiala, T. J. Update: Lifting the malar fat pad for correction of prominent nasolabial folds. Plast. Recon-str. Surg. 100:715, 1997.
  7. Tonnard, P., Verpaele A. The MACS-lift hort Scar Rhytid-ectomy. St Louis, Quality Medical Publishing, 2004.
  8. Tonnard, P., Verpaele A., et al. Minimal access cranial suspension lift: A modified S-lift. Plast. Reconstr. Surg. 109:2074, 2002
Smas Imbrication
  1. 49.6. a-c Frontal, three-quarter and profile views of a 56-year-old woman with a general sagging of the midface, marked nasolabial folds, marionette grooves and jowls, and moderate submental skin laxity with visible platysmal bands. d-f Results 8 months after an extended MACS lift (three sutures) with liposuction of the submental area, lower-lid pinch blepharoplasty, and upper-lip resurfacing with an erbium laser. Note the general triangularisation of the face in frontal
  2. 49.6. a-c Frontal, three-quarter and profile views of a 56-year-old woman with a general sagging of the midface, marked nasolabial folds, marionette grooves and jowls, and moderate submental skin laxity with visible platysmal bands. d-f Results 8 months after an extended MACS lift (three sutures) with liposuction of the submental area, lower-lid pinch blepharoplasty, and upper-lip resurfacing with an erbium laser. Note the general triangularisation of the face in frontal view, the correction of the neck skin laxity with disappearance of the platysmal bands, and adequate correction of jowling with better definition of the mandibular border. There is an improvement of the marionette grooves and nasolabial folds, and an obvious volumetric replenishment of the midface with better transition of the eyelid skin into cheek skin and shortening of the vertical height of the lower eyelid

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