Facelift by minimal access cranial suspension (MACS)







Table 24.1

Indications for surgery











Lower face and neck laxity
Jowling and marionette lines
Heavy nasolabial folds
Blunting of the cervicomental angle


Table 24.2

Preoperative evaluation















History of prior facial surgery/trauma
History of smoking/anticoagulant use
Extent of midface, lower face and neck laxity
Platysmal banding
Facial nerve function
Extent of submental fat in the neck


Introduction


There are various methods for performing face and neck lifting, including plication of the superficial musculoaponeurotic system (SMAS), SMAS-ectomy, and deep plane facelifts. Each has its benefits and drawbacks and can work very well in the appropriate patient. The short incision facelift, also known as the minimal access cranial suspension (MACS) lift, which was described by Tonnard and Verpaele, has the benefit of being safe, fast, and having a rapid recovery period. Rather than extending the flap incision posterior to the ear, the MACS lift incision extends only to the base of the earlobe. Elevation of the SMAS is achieved with placement of a vertical and oblique purse-string suture that is secured to the deep temporalis fascia ( Figure 24.1 ). However, in patients with a dramatic amount of excess skin or heavy necks, various additions to the MACS lift or alternative facelift methods are recommended to achieve an optimal result.




Figure 24.1


Facelift by Minimal Access Cranial Suspension

The MACS lift is achieved by using a vertical and oblique purse-string suture to plicate the SMAS and lift it towards its suspension point on the deep temporalis fascia just above the posterior zygomatic arch. Figure 24.1 shows the safe and danger zones of the facial nerve. The temporal branch of the facial nerve leaves the parotid gland anteriorly, crosses over the zygomatic arch, approximately 1.8 cm anterior to the tragus (shaded in red), and runs superiorly to innervate the frontalis muscle in the forehead. Keeping the plication sutures within the substance of the SMAS and anchoring the sutures posterior and superior to the arch minimizes risk of injury to the facial nerve.


The preoperative evaluation should focus on the presence of lower face and neck laxity, jowls, marionette lines, nasolabial folds, and blunting of the cervicomental angle. The MACS lift can be combined with an anterior or posterior cervicoplasty and is often combined with neck liposuction to help sculpt the neck. However, thick necks with substantial laxity may be better candidates for a SMASectomy, SMAS flap facelift or a deep-plane facelift.


Other considerations should include whether concurrent procedures would be beneficial, such as a brow lift, upper and lower blepharoplasty, fat grafting or fillers, botulinum toxins, or laser skin resurfacing.


Careful photographs of the face and neck taken from the primary position, profile, and oblique angle should be taken at all visits. A full and informed consent should be performed to ensure appropriate expectations and that postoperative instructions are followed. Patients should stop all anticoagulants at least 7 days prior to surgery with approval from their primary care physician and/or cardiologist. Smokers must strictly cease all tobacco use, which can affect viability of the facelift flap. Immediately after surgery, a facial pressure wrap is placed and at the 24 hour postoperative visit, any drains placed are removed. Throughout the first 2 weeks, the patients should be encouraged to call the office or return sooner if there is a non-resolving fluid collection under the flap. Skin sutures are removed 5–7 days after surgery.




Surgical Technique







Figure 24.2A and 24.2B


Skin marking

The skin marking should run from the base of the earlobe within the earlobe crease, make a perpendicular cut across the intertragal sulcus, follow the rim of the tragus, continue up the anterior border of the helix, and then continue along the sideburn and temporal hairline. The incision along the sideburn and temporal hairline can be either curvilinear or saw-toothed in design, which can help disguise incision lines ( Figure 24.2A ). The incision can also be placed just within the fine hairs at the front-most extent of the hairline to further camouflage the incisions. The anterior extent of the dissection plane should be marked and extends from approximately 1 cm above the zygomatic arch down to the angle of the mandible. At its most anterior extent, the dissection extends about 5–6 cm anterior to the tragus ( Figure 24.2B ).



Figure 24.3


Injection of tumescent anesthetic

Tumescent anesthetic is injected on a 22-gauge spinal needle using a dilute solution as outlined in Table 24.3 . Careful attention is paid to injecting the incisions and then continuing in a subcutaneous plane. Approximately 20–30 mL of anesthetic are injected on each side of the face in this fashion, and additional tumescent anesthetic can be injected into the neck if neck liposuction will be performed ( Figure 24.3 ). Before performing skin closure as the final step on the first side, tumescent anesthetic is injected on the contralateral side to allow for maximal hemostasis prior to making the incisions.


Table 24.3

Tumescent anesthetic solution




























Component Concentration Amount
Normal saline 0.9% 450 ml
Lidocaine (plain) 1% 50 ml
Epinephrine 1 : 1000 (1 mg/ml) 0.5 ml
Sodium bicarbonate 8.4% 0.5 ml
Triamcinolone (optional) 10 mg/ml 0.5 ml

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Facelift by minimal access cranial suspension (MACS)

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