Introduction

Facial rejuvenation surgery has had an interesting evolution over the last 75 years. It is an interesting exercise to examine the chronicle of progress of facial rejuvenation surgery and at the same time, critically ask ourselves: “What were they thinking when they came up with that particular procedure for facial rejuvenation?” Our concept regarding facial rejuvenation has evolved beyond surgical technique to now encompass facial aesthetics, ancillary treatments, biomechanics of facial rejuvenation, and consumer preferences for lesser-invasive procedures with rapid recovery.

In retrospect, we have moved back and forth between a variety of technical solutions versus a more holistic process of how to optimally deliver operational excellence in facial rejuvenation for a diverse patient population. As a surgeon, it is sometimes easier to fall in love with a single technique of facial rejuvenation and not engage in critical thinking about the shortcomings and tradeoffs of that particular technique. At the same time, when confronted with newer techniques and concepts for facial rejuvenation, many surgeons adopt a defensive reasoning mindset that prevents adoption of these approaches.

MACS-lift is an acronym for “minimal access cranial suspension”.¹ The first time that I (the author) read the MACS short-scar rhytidectomy paper by Tonnard et al.,²^–⁵ it seemed a puzzling principle which relied on suture loop suspension to a cranial anchoring point, far different that the sheet tightening approach of the classic SMAS-lift that I was performing at the time. It took a trip to the anatomy lab and a visit with Tonnard and Verpaele in Belgium to convince me that there was something different (and possibly better) about the MACS-lift. Once this approach for facial rejuvenation was examined in light of other publications by Labbé,⁶ Mendelson,⁷ Besins,⁸ Pessa/Rohrich,⁹ and Gardetto,¹⁰ there actually appears to be a unifying concept that has scientific and biomechanical validity as a mainstay technique for facial rejuvenation.

First, we should ask ourselves, “Why do we think that it is necessary to delaminate the face in order to rejuvenate? Can we accomplish volume redistribution/repositioning without having to engage in complex, deep anatomic dissections? What is the validity of using a cranial suspension platform to re-suspend facial structures over traditional ways?” And finally: “Can we innovate a less-invasive procedure for facial rejuvenation that gives a durable outcome and allows for future revisions?”

Surgical foundation for the MACS-lift

The surgical foundation for facial rejuvenation should address the biomechanical effects of facial aging and volume loss for each patient, depending on their particular needs. Surgeons must be faulted in the past for not having a fundamental understanding of facial aging, volume loss, laminar anatomy, and biomechanical engineering. Our current understanding of the anatomy of facial aging is thoroughly reviewed in Chapter 10, giving insight into the complex biomechanics of facial aging. Aging involves the gravimetric effects on skin and SMAS, loss of elastic property of tissue, volume loss and descent within in fat compartments, and extrinsic effect of sun, genetics, weight loss/gain, and smoking.¹¹^–¹³ Fat within the face does not exist as a confluent mass, but in discreet compartments separated by septae, formerly known as ligaments. Facial anatomy involves a laminar concept in which, movement between layers is possible without surgical delamination. Proponents of ligament release feel that such movement is inadequate for facial rejuvenation, but experience with the MACS-lift provides evidence that sufficient interlayer movement is, indeed possible and surgically effective.

From the perspective of biomechanics, surgical approaches that rely on sheet tightening of attenuated facial structures (SMAS) may not produce a long-term effect due to the loosening of this layer over time (shear-yield). Suture line repairs such as linear plication or excision techniques (plication or SMASectomy) remain vulnerable to disruption (shear failure and “cheese wiring”) by down-pulling the platysma whose fascia is contiguous with the SMAS facial rejuvenation, is therefore an exercise in biomechanical engineering in terms of how much force is required to vertically lift facial and neck structures and suspend them in place with approaches that are less prone to failure. Surgery is part of the solution for facial rejuvenation, but ancillary procedures found in cosmetic medicine such as medical skin care, fillers, neurotoxins, and light-based treatments work synergistically to produce a “wow effect” when used masterfully.

The MACS-lift concept involves the use of suture loops placed in a purse-string fashion in order to elevate deep facial tissue by anchoring to a fixed point. In the basic MACS-lift, there is one anchoring point on the deep temporal fascia, just above the lateral zygoma, and posterior to the passage of the temporal branch of the facial nerve. This is a very robust anchor point that will hold a 0-0 or 2-0 suture without a pull-out failure The “CS” part of the MACS-lift is “cranial suspension”, which refers to the deep temporal fascia’s attachment to the cranium along the temporal crest line. The MACS-lift does not utilize sheet tightening of the SMAS, SMAS plication, or SMASectomy, but relies purely on specialized suture suspension. The basic MACS-lift involves two suture loops, one vertical and one oblique, while the “extended MACS-lift” involves an additional suture to elevate the malar fat to a more anterior anchoring point (Figs 11.4.1, 11.4.2). Suture loops placed within facial tissues results in a gathering and suspension of tissue. Tonnard and Verpaele describe this as “microimbrication” (Fig. 11.4.3).