The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part VIII  Face Lift and Neck Lift
Intermediate Plane
The platysma and the small amount of fat between the medial border of each
platysma muscle make up this plane. Plication of the platysma in the midline is the
most common procedure at this level. In a patient with a heavy submental area, the
intervening fat between these medial borders is resected as necessary. If fat is resected
from between the platysma muscles and deep to the platysma, it is important that
sufficient fat be left deep to the skin. Removing fat aggressively below the skin, be-
tween the platysma muscles and deep to it, leads to an unnatural hollowing of the
submental area. Very rarely do I remove fat from all three layers. The more deep fat
I remove, the more superficial fat I leave behind.

To distinguish between excessive preplatysmal (subcutaneous) fat and subplatysmal
fat, a useful maneuver is to grasp the submental fold between the thumb and index
finger and then ask the patient to grimace, thus contracting the platysma muscles. If
the fold between the examiner’s thumb and index finger is unchanged, the bulk of
the fat is subcutaneous; if it diminishes, then the bulk of the fat is deep to the pla -
tys ma and must be removed in that plane to recontour the submental area.
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Deep Plane
The subplatysmal fat, digastric muscles, and the submandibular gland make up the
structures of the deep plane. Resection of the subplatysmal fat, the anterior belly of
the digastric muscle, and the superficial lobe of the submandibular gland are the pro-
cedures performed in this plane. If needed, a suprahyoid fascial release is also per-
formed in the deep plane.
Hyoid bone
Skin
Subcutaneous fat
Platysma
muscle
Digastric muscle
Interplatysmal fat
Subplatysmal fat
Submandibular
gland

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Part VIII  Face Lift and Neck Lift
A large submandibular gland is often visible preoperatively. Once the digastric mus-
cle has been identified, the superficial lobe of an enlarged submandibular gland is
readily visible. If it bulges further on neck flexion, the superficial lobe can be resected
to further enhance neck contour and improve on the visible bulge.
Extent of Skin Undermining
With the exception of liposuction only, extensive neck undermining is the rule to fa-
cilitate the redraping of the apparent excess skin of the neck, especially in the sub-
mental area. The undermining usually extends from the sternomastoid muscle on
each side, across the midline, and down to the level of the thyroid cartilage. More
extensive lateral and inferior dissection and undermining may be necessary in some
individuals who have an excessive amount of neck skin or inelastic skin.
Posterior belly
of digastric muscle
Submandibular
gland
Anterior belly
of digastric muscle
Platysma
muscle
Digastric
muscle
Once the subplatysmal fat has been dissected, the anterior belly of the digastric mus-
cle is easily viewed. If it appears as a bulge when the patient’s neck is flexed, a tan-
gential excision of the anterior belly would further improve the submental contour.

Vectors
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Chapter 41  Clinical Decision-Making in Face Lift and Neck Lift
Incisions
Fat Distribution
Neck Lift: Incisions and Anatomic Features
Planes or
Sub-
Layers of
Liposuction
Deep or
Digastric mandibular Hyoid
the Neck
Access
Submental Subcutaneous Interplatysmal Subplatysmal Platysma
Muscles
Gland
Fascia
Superficial


Intermediate




Deep








Choosing the Best Option
Structures
The vectors that influence the appearance of the neck and jawline include the verti-
cal vector applied to the jawline through the platysma plication of a face lift. A more
diagonal and posterior vector involving the lateral border of the platysma combined
with a medial plication of the two platysma muscles defines the submental area and
the neck-jaw angle.

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Part VIII  Face Lift and Neck Lift
Sutures
Suspension Sutures
Suspension sutures running over the platysma and below the mandibular border, de-
signed to define the neck-jaw angle, were described by Guerrerosantos and later
popularized by Giampapa. In carefully selected patients, suspension sutures can be
effective, but I have found them to be of limited value in individuals with large sub-
mandibular glands. In my experience, a more direct approach in the deep plane pro-
duces longer-lasting results.
Plication Sutures
Plication of the platysma in the midline, as advocated by Feldman (the corset platys -
ma plasty), is highly effective in recontouring the submental area. When combined
with a lateral plication, platysmal plication defines the jawline and neck-jaw angle.
This step is an integral part of almost all the neck lifts I perform.
Ancillary Procedures
Although volume management in the neck almost always means removal of fat or
partial resection of the digastric or submandibular gland, volume addition in the
form of autologous fat or acellular dermal matrix has been advocated for correction
of the contour irregularities associated with aggressive oversuction superficial to the
platysma. Resurfacing either with laser or my preference, TCA peels, is an accept-
able adjunct to neck lift. The energy levels on the laser are set below that for a face
lift. I apply 20%, 30%, or even 50% TCA to the face, but I limit neck peeling to
20% TCA, and even then the endpoint is a mottled frosting rather than the uniform
frosting that I look for on the face.

The MACS-Lift Short-Scar
Rhytidectomy With Fat Grafting

PATRICK L. TONNARD, ALEXIS M. VERPAELE
CHAPTER 42

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Part VIII  Face Lift and Neck Lift
W
hen different surgical techniques in facial rejuvenation are compared, one is
tempted to focus on the result without considering the global risk-benefit
ratio associated with any surgical intervention. Some techniques can produce superb
results, but the trade-off may be a high complication rate or a prolonged postoper-
ative recovery. Today, many patients prefer a simpler route to rejuvenation. Bearing
in mind that the ultimate goal of aesthetic surgery is a happy patient, it is not always
the most aggressive and extensive surgery that delivers the greatest patient satisfac-
tion. Ultimately, it is the delicate subjective balance between the final result and the
morbidity of the procedure that will determine the level of patient happiness. The
appeal of the minimal access cranial suspension lift (MACS-lift) lies primarily in the
fact that it strikes the right balance, offering a stable, natural facial rejuvenation
through a simple and safe procedure. The operation takes only 2 to 21⁄2 hours to per-
form and can be done with a local anesthetic in an outpatient setting. In compari-
son with a classic face lift, the MACS-lift has a quicker recovery time and a lower
morbidity rate, with a final scar that 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 jawline by cor-
rection of the jowls, restoration of the midfacial volume, and correction of the na-
solabial folds. Patients who are seeking improvement of one or more of these fea-
tures are good candidates for a simple or extended MACS-lift procedure. Adjunctive
procedures to enhance the results may include upper and lower blepharoplasty, micro -
fat grafting, short-scar temporal lifting, and anterior and posterior cervicoplasty.
Basic Concepts
Traditional face-lift designs all have an oblique vector of traction on the superficial
musculoaponeurotic system (SMAS), which can be divided into a horizontal and a
vertical component. In recent years, more emphasis has been put on reorienting this
vector in a more vertical direction.

In classic face-lifting, the direction of skin redraping still follows an oblique vector.
The horizontal component of the vector of traction on the SMAS and on the skin does
not rejuvenate the face; rather, it tends to flatten the face and put it under tension.
With the MACS-lift, the vertical rejuvenating vector is the only vector applied on the
deep tissues as well as on the overlying skin. The MACS-lift eliminates the horizon-
tal vector of traction; it can therefore be considered a pure vertical vector face-lift
technique.
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When lateral skin redraping is performed, as in classic face lifts, a dog-ear is created
at the earlobe, necessitating redraping with a retroauricular flap dissection. No dog-
ear is produced under the earlobe with vertical skin redraping, thus obviating the
need for retroauricular dissection. Therefore the MACS-lift can also be considered a
purely antigravitational procedure.
The MACS-lift 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 su-
perficial subcutaneous plane without any deeper undermining. The skin excess is re-
draped in a vertical direction and resected in the temporal region and lower eyelid.
In recent years the concept of volumetric rejuvenation has gained worldwide ac-
ceptance. We now know that the restoration of facial volumes is more important
than the amount of skin resected and the tension on the skin and SMAS. There are
many methods to obtain this volumetric restoration; the question remains: In what
plane should the surgery be done to obtain a good result while minimizing morbid-
ity? The MACS-lift technique provides a safe and effective method for accomplish-
ing these goals. This technique acts directly on the sagging soft tissues, with suspen-
sion sutures in the superficial subcutaneous level and limited skin undermining, to
provide an efficient, safe, and durable correction with significantly lower morbidity
and faster recovery.

Overview of Technique:
Simple and Extended MACS-Lift
The key concept underlying the MACS-lift procedure is the vertical suspension of
sagging facial soft tissues with slowly resorbable monofilament purse-string sutures.
These are strongly anchored to deep temporal fascia through a preauricular and tem-
poral prehairline incision. Excess skin is excised in the temporal region after pure
vertical redraping of the skin flap. Submental suction lipectomy always precedes the
lifting procedure. The extent of the skin undermining is just sufficient for placing the
purse-string sutures. There are two variations of the procedure:
 The simple MACS-lift (S-MACS), in which two purse-string sutures are placed
for correction of the neck and the lower third of the face (cervicomental an-
gle, jowls, and marionette grooves)
 The extended MACS-lift (X-MACS), in which a supplementary third purse-
string suture is placed to suspend the malar fat pad; this suture will have an
added impact on the nasolabial groove, midface, and lower eyelid
Simple MACS-Lift
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With the simple MACS-lift approach, the incision begins at the lower limit of the
earlobe, extends preauricularly to the temporal hairline, and traces the temporal
hairline along the sideburn up to the level of the lateral canthus. The skin is under-
mined at a subcutaneous level over 5 to 6 cm in an anterior direction. The inferior
limit of undermining goes as caudal as necessary to visualize the lateral border of
the platysma muscle. Usually the undermining is marked 2 to 3 cm below the
mandibular angle.

The first purse-string suture is anchored to the deep temporal fascia 1 cm in front of
the helical rim and 1 cm above the zygomatic arch. It runs downward toward the
mandibular angle as care is taken to incorporate a firm bite in the craniolateral bor-
der of the platysma muscle, and then it turns upward as a narrow U-shaped loop to-
ward the original anchor point. The suture is firmly woven into the SMAS tissue,
which is not undermined. When this purse-string suture is tightened, the lateral por-
tion of the platysma is pulled upward. This suture, when combined with a closed-
suction lipectomy, produces a dramatic correction of the cervicomental angle and
contour of the upper neck.
The second purse-string suture starts at the same anchor point on the deep temporal
fascia, extends more obliquely toward the jowls ( 30 degrees from the first suture),
and follows the borders of the undermining as a more open, O-shaped, purse-string
loop. It ends at the original anchor point. When this suture is tightened, the SMAS
is placed under concentric tension, producing a lift to the jowl, the marionette groove,
and the corner of the mouth.
Extended MACS-Lift
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Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
The incision for the extended MACS-lift follows the same course as in the simple
MACS-lift but is extended in a cranial direction for 1 to 2 cm along the anterior tem-
poral hairline, up to the level of the tail of the eyebrow. The skin is undermined as
in the simple MACS-lift, but a supplementary area over the malar fat pad is included.
The third purse-string suture has a narrow U-shape, like the first one. Its anchor point
is located in the most anterior part of the deep temporal fascia, just lateral to the lat-
eral orbital rim. This suture runs first downward toward the malar fat pad, then turns
back toward the anchor point. Tightening this suture serves to suspend the malar fat
pad, thereby correcting the nasolabial groove and midface ptosis and shortening the
height of the lower eyelid.

In both the S-MACS and X-MACS procedures, after placement of the sutures, the
skin is redraped in a purely vertical direction and the excess skin above the tempo-
ral hairline incision is resected without any traction. Because there is no lateral trac-
tion on the skin, there will be no dog-ear at the level of the earlobe, eliminating the
need for retroauricular dissection. This is contrary to the classic face-lifting concept
in which skin is redraped in a more oblique direction, generating a skin excess be-
low the earlobe that needs to be redraped further backward through a retroauricu-
lar flap dissection.
As a consequence of lifting the malar fat pad toward the lateral orbital rim, the skin
“bunches up” in the region of the lateral part of the lower eyelid and the paracan-
thal zone. This necessitates a skin excision in the subciliary and paracanthal region.
Because of the good structural support of the lower eyelid provided by the third
purse-string suspension suture, this pure skin resection is easy and safe. The excess
skin is evaluated by pinching the skin between the teeth of a forceps and is excised
through a lower eyelid bleph a roplasty incision with paracanthal extension (the pinch
blepharoplasty). The surgeon can easily resect 4 to 8 mm of skin, especially in the
paracanthal region, without risk of causing ectropion or scleral show.
The MACS-lift will adequately treat 90% of our patient population. When the lim-
its of the MACS-lift procedure are reached, ancillary procedures will supplement this
procedure. Care is taken not to overtreat any patient.
Ancillary Procedures
Anterior Neck
Preoperatively, the patient’s facial and cervical flaccidity is assessed by the surgeon
by digitally lifting the facial skin upward at the mandibular angle region. If this ma-
neuver produces correction of visible platysma bands, one can be confident that the
MACS-lift will adequately tackle this problem. If the platysmal bands are not cor-
rected with this preoperative maneuver, an anterior cervicoplasty is added at the end
of the MACS-lift procedure. Because suturing together platysmal bands on the mid-
line counteracts the lifting effect on the cheeks, the neck work is delayed until the face-
lift procedure is completed. At the end of a MACS-lift procedure, the lateral parts of
the platysma are so tightly pulled upward by the vertical purse-string sutures that it
is virtually impossible to bring the medial borders of the platysma together to the
midline. Therefore we prefer an open resection of the medial bands of the platysma
at the end of the procedure. A resection of about 1 cm of medial muscle border is
carried out, with or without a horizontal relaxation incision at the level of the hy-
oid. Conservative open resection of subplatysmal fat is done when indicated.
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Part VIII  Face Lift and Neck Lift

Posterior Neck
The limits of MACS-lifting depend on the amount of skin excess in the neck as well
as the quality of the skin. Problems can arise when dealing with thin, sun-damaged
neck skin with a significant amount of wrinkles down to the clavicular region. In
these cases, after vertical skin redraping, vertical skin folds will begin to appear in
the infralobular neck region. These folds are aesthetically unacceptable and need to
be corrected at the end of the procedure with a posterior cervicoplasty (see p. 1407).
This maneuver consists of tension-free redraping of the skin in an occipital direction
from a prehairline posterior neck incision.
Forehead
Indications for brow lifting are very surgeon dependent. Some surgeons believe that
everyone needs one; others—and we fall into this category—are more conservative
in their approach and do not routinely elevate every patient’s eyebrows.
Many procedures are available for forehead correction, ranging from open fore-
headplasty to endoscopic brow lift or limited incision temporal lifting techniques.
With the introduction of botulinum A toxin into our practice, our indications for
surgical brow-lifting have diminished impressively. Almost every patient is offered
botulinum toxin treatment after surgery. It completes the treatment, optimizes the
result, and leads to improved patient satisfaction.
Indications and Contraindications
The MACS-lift short-scar technique is particularly appropriate for younger patients
who usually are not willing to undergo aggressive and potentially risky procedures
to achieve their goals. It is also suitable for older patients who do not want to change
too much, but only want to obtain correction of their obvious signs of aging. For
these patient populations, less aggressive but still effective surgical rejuvenation tech-
niques are welcome.
The ideal patient for a surgeon’s initial MACS-lift case is a 45- to 50-year-old woman
whose main complaint is a moderate submental laxity with a blunted cervicomen-
tal angle, but without visible platysmal bands. Jowls, marionette grooves, and na-
solabial folds are developing but are mainly disturbing to the patient when she bends
forward. This is a frequent complaint in middle-aged women who discover these
signs of aging in the lower third of the face. This type of patient is ideally suited for
treatment with the two-suture simple MACS-lift technique.
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Part VIII  Face Lift and Neck Lift
This patient’s mild jowling and central anterior neck laxity make her an ideal can-
didate for correction by a simple MACS-lift.
The extended MACS-lift, with the addition of a third suture, is particularly appro-
priate for a patient who needs correction of the upper half of the nasolabial folds
and the midface. The third suture suspending the malar fat pad gives a powerful cor-
rection of these features and also enhances the volumetric restoration of the mid-
face, providing very strong support to the lower eyelid skin. Therefore the indication
for the third suture can be extended to patients of all ages who have a flattened malar
mound and laxity of the lower eyelids. The need for the third suture is not only de-
termined by age, but also by the bony anatomy of the face. A person with a poorly de-
veloped malar eminence will be subject to earlier midfacial aging than one with a
strong malar relief. This is also often related to poor lower lid support.
Both of these women would benefit from an extended MACS-lift. For a younger pa-
tient, it will correct the malar insufficiency and flattening of the lateral cheek. In an
older patient, it will also correct the nasolabial folds and midfacial hollowing.

In classic teaching, smoking is considered an absolute contraindication for face-lift
surgery. Because of the limited subcutaneous dissection and the absence of multi-
planar dissection, we consider smoking to be a relative contraindication. For the
same reason, combining the MACS-lift with skin resurfacing techniques is safe and
well tolerated.
As a general rule, only patients with no major medical history of disease or cardio-
vascular risk factors are selected for outpatient, office-based surgery. The decision
whether to perform the MACS-lift with a local or general anesthetic depends on the
surgeon’s and patient’s preferences.
Pertinent Anatomy
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Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Three permanent purse-string sutures are woven into the deep subcutaneous tissues,
which consist of parotid fascia and SMAS in the preauricular area, and the malar
fat. The sutures are anchored into the deep temporalis muscle fascia to ensure a strong
hold.

The main danger zone in the placement of sutures is located on the zygomatic arch,
halfway between the ear and the lateral orbital rim. This zone is completely avoided,
because no suture crosses the zygomatic arch. The anchor point of the first two su-
tures is located posterior to the frontal branch of the facial nerve. The first loop is
directed vertically downward and reaches the lateral edge of the platysma muscle in
the region of the mandibular angle. The marginal mandibular branch of the facial
nerve is out of danger for entrapment by the purse-string suture, since it runs more
anteriorly.
The second purse-string suture loop runs at an angle of 25 to 30 degrees and reaches
to 1 to 2 cm above the mandibular border. The third loop takes its origin in the tem-
poralis muscle fascia just lateral to the lateral orbital rim and is also directed down-
ward. It lies well anterior to the course of the frontalis branch of the facial nerve.
Preoperative Assessment
Generally, it is very important to listen carefully to the patient’s wishes in the first
clinical consultation. We start by inquiring what bothers the patient and has
prompted this visit.
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Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
When asked what they are seeking, most patients consulting for facial rejuvenation
demonstrate a maneuver that they have repeatedly executed before their mirrors: they
push the skin of the mandibular angle upward. This maneuver has a beneficial effect
on the neck and on the jowling. Some patients also include the zygomatic region into
this maneuver and push it upward. This will have an additional effect on the na-
solabial fold, the midface, and the lower eyelid.
The main consideration when assessing a potential candidate for MACS-lift surgery
is determining whether a simple or an extended MACS-lift is indicated. A simple
MACS-lift acts primarily on the lower half of the face—the upper neck and sub-
mental area, jowls, marionette grooves, and lower cheeks.
This 52-year-old woman exhibits moderate fatty deposits in the submental area with
jowling and marionette grooves. There is a slight downward slant of the corners of
the mouth. She has a somewhat heavy neck, which will require maximal power-
assisted liposculpture (PAL) for contouring. Her malar area has well-preserved defi-

nition, and there is no obvious skeletonizing of the lower eyelid. Treatment will con-
sist of submental liposculpture combined with a simple MACS-lift to correct the neck
laxity, jowl deformity, and marionette grooves. (Her results can be seen on p. 1418.)
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Part VIII  Face Lift and Neck Lift
This 56-year-old woman had general sagging of the lower part of the face with a
lax, fatty, infiltrated neck with obvious platysmal bands, marked jowling, deep na-
solabial folds and marionette grooves, and pronounced nasojugal grooves with de-
marcation of the inferior orbital rim. A simple MACS-lift would improve her neck,
jowls, and marionette grooves, but to adequately address her midface, an extended
MACS-lift with a third purse-string suture to the malar area is needed. This would
restore a youthful ogee curve to the cheek, correct the upper nasolabial folds, refill
the lower orbital rim, and correct the nasojugal grooves. Her planned treatment con-
sists of a submental liposculpture, an extended MACS-lift, and a lower pinch bleph -
aroplasty. (Her postoperative result is shown on pp. 1426-1427.)
It is important to explain the concept of the MACS-lift intervention to the patient.
To do this, it is helpful to simulate the feasible correction on the facial features with
the patient looking in the mirror and the physician standing behind. This will give
the patient an idea of the possibilities and limitations of the technique. The patient
will learn that the MACS-lift is a lifting procedure that addresses the neck and lower
two thirds of the face, without having an influence on the forehead. The patient will
also understand that the main goal is to restore the facial volume and to get rid of
most of the facial laxity.

It is rare for a patient to demand an extreme correction at the risk of a completely
flattened, expressionless face. Patients want to look younger, not different. Many
patients are afraid of changing too much and losing facial expression. In the major-
ity of patients, it is perfectly feasible to reproduce the desired result with the MACS-
lift procedure. In some cases, ancillary procedures can be proposed, but the patients
must be informed of the cumulative morbidity to be expected. Once the surgeon un-
derstands the patient’s expectations, a treatment plan can be designed to meet pa-
tient goals. The patient’s input is essential to this process.
All patients are fully informed of the details of the proposed procedure, including
the benefits, limitations, risks, time of surgery, expected morbidity and recovery, and
the potential for problems and complications. This informed consent is provided
both verbally and in written documents given to the patient.
Preoperative Planning
Photography
A standardized series of nine pictures is taken of the patient.
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The frontal view shows the face from the top of the head down to the sternal notch.

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Part VIII  Face Lift and Neck Lift
A perfect perpendicular side view should show only one eyebrow, with the patient
gazing straight forward.
The oblique view has the tip of the nose just within the contour of the opposite cheek
to demonstrate the distribution of the facial volumes.

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Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
An extra side view picture is taken with the patient looking down at the knees, pro-
ducing a double chin. We refer to this as the “Bruce Connell view,” because he has
pointed out its importance.
A close-up view of the lower face is taken to focus on the contour of the jaw line,
marionette grooves, and nasolabial folds and to demonstrate any perioral rhytids
(the “bar code”). A close-up view of the upper half of the face reveals detailed in-
formation about the upper and lower eyelids, tear troughs and periorbital fold,
grooves and wrinkles.

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Part VIII  Face Lift and Neck Lift
Patient Instructions
The patient is instructed to take the following medications:
 Oral ampicillin 500 mg every 6 hours, beginning the morning of surgery and continu-
ing for 4 days
 Acyclovir 800 mg once daily for 10 days, beginning 2 days preoperatively, if erbium-
YAG laser resurfacing is performed
 Arnica montana 30K for prevention of ecchymoses and edema, of which five doses are
taken:
– 1 week preoperatively
– 1 day preoperatively
– Immediately before surgery
– Immediately after surgery
– 1 day postoperatively
 Continue any home medication
The patient is instructed to respect the following guidelines:
 Stay in the company of a friend or relative for the first 24 hours.
 Relax in a quiet environment.
 Avoid stressful activities.
 Avoid bending forward and Valsalva maneuvers.
 Sleep with the head slightly elevated.
 A soft diet is recommended, since mouth-opening is painful the first 5 days because of
traction on the temporalis muscles.
Dressing instructions after resurfacing include the following:
 Avoid allowing the resurfaced area to dry out by regularly applying copious amounts
of Vaseline/paraffin ointment at least every 2 hours.
 Gently remove the ointment every 4 hours, then apply a gauze soaked in a solution of
tepid tap water and vinegar (1 coffee spoon of vinegar to 1 coffee cup of tepid water).
 Do not remove the yellowish, fibrous exudate that covers the wound for 4 to 5 days.
It will disappear spontaneously as the skin heals.
The patient is also informed about normal postoperative discomfort, swelling, and ecchy-
mosis, especially in the eyelids. He or she is instructed to contact the surgeon if any of the
following conditions develop:
 Rapidly increasing swelling and/or pain in the cheek area, which could indicate a post-
operative hematoma
 Pain or increasing discomfort in the resurfaced area
 A temperature greater than 38° C (100.4° F)
 Any visual impairment

Operative Technique
Preoperative Markings
Any makeup is removed by the nurse and a new set of nine pictures is taken. The pa-
tient sits upright in front of the surgeon for the initial markings. Submental lipo-
suction is planned for almost every patient. Fat tends to accumulate in this area, so
even in slim patients, liposuction in this region helps to enhance the cervicomental
angle.
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Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
The patient is asked to make a double chin, and the area where excess fat is palpated
is marked with a pencil (left). Care is taken to include the lateral “wings” of the sub-
mental fat, which go as far as the infralobular area, and the lower pole of the jowls.
When the nasolabial folds, midface, and/or lower eyelids require correction, an ex-
tended MACS-lift is planned. This necessitates extra preoperative marking to guide
the placement of the third suture.
A point is marked 2 cm caudal to the lateral canthus (right). In most people this
point coincides with the bulk of the malar fat pad. During surgery this point will be
suspended by the third suture to the most anterior part of the deep temporal fascia,
just lateral to the lateral orbital rim. An arrow is marked between the two points
and is repeated on the contralateral side.

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Part VIII  Face Lift and Neck Lift
Anesthesia and Surgical Setting
We prefer to perform the MACS-lift using a local anesthetic with sedation. If the sur-
geon prefers, heavier sedation can be used, but patient cooperation will diminish and
oxygen must be administered. This procedure can also be performed with the pa-
tient under general anesthesia, depending on the surgeon’s preference.
The MACS-lift is designed to be performed, ideally, in a private surgical office by
one surgeon and one nurse. If the instrument table is well prepared in advance, no
circulating nurse is necessary. A headlight or a lighted retractor is required for place-
ment of the purse-string suture beneath the cheek flap. The height of the operating
table must be controllable by foot switch, and the surgeon’s seat must also be ad-
justable in height by nonsterile foot manipulation.
Submental Infiltration
The sequence of infiltration follows the sequence of the procedure:
1. Upper eyelids
2. Submental area
3. Cheek infiltration
For a submental suction lipectomy, an average of 30 to 40 ml is infiltrated in the pre-
platysmal fat until a moderate degree of tumescence is achieved.

Markings and Incisions
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Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
With the patient supine on the operating table, marking resumes at the lower limit of
the lobule, extending up in the preauricular crease. The incision is usually carried
out on top of the tragus. At the level of the incisura intertragica, the marking makes
a 90-degree turn backward to preserve the integrity of this anatomic landmark. Mark-
ings then follow the posterior edge of the tragus, ascending toward the helical root.
Because there is a distinct color difference between the cheek skin and the auricular
skin, it is essential that the markings precisely follow this line of demarcation. At the
superior limit of the ear, the marking traces the small hairless recess between the
sideburn and the auricle and then turns downward to follow the inferior implanta-
tion of the sideburn.
In men, the marking descends approximately 1.5 cm before turning anteriorly to
cross the sideburn.

1396
Part VIII  Face Lift and Neck Lift
The horizontal marking then continues forward in a zigzag pattern 2 mm within the
lower and anterior implantation of the sideburn. This zigzag pattern increases the
length of the temporal incision for better congruence with the length of the cheek
flap. In a 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
(note dotted line). The total length of the incision will not exceed 7 to 9 cm, de-
pending on the dimensions of the auricle (vertical branch of the incision) and the
width of the sideburn (horizontal branch of the incision).
The surgeon palpates the mandibular angle with an index finger and marks it 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 toward the marking of
the mandibular angle, then curving anteriorly to 5 to 6 cm in front of the ear. Next,
the marking is directed toward the upper end of the incision. For an extended MACS-
lift, the preoperative marking of the malar eminence should be incorporated. If a
simple MACS-lift is planned, the malar eminence is not included in the demarcation.
When adjunctive procedures are planned (such as an upper/lower blepharoplasty,
fat grafting, short-scar temporal lifting, anterior/posterior cervicoplasty), they are
marked together with the MACS-lift markings. (For detailed descriptions, see the in-
dividual adjunctive procedures later in this chapter.)

The subcutaneous plane is infiltrated with the preferred solution of local anesthetic.
Normally 30 to 40 ml of solution is injected in the cheek, which gives a moderate
degree of tumescence. At the end of the cheek infiltration, a distinct blanching is vis-
ible in the previously infiltrated eyelid and submental areas.
Suction Lipectomy
1397
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
We prefer to use a 3 mm spatula cannula with one opening. The opening is always
directed downward, not toward the skin, to avoid dermal damage. Two or three in-
cisions are used to crisscross the marked area optimally. The lipectomy is performed
in a preplatysmal plane under tactile guidance of the nondominant hand. A maxi-
mal lipectomy is performed so that in the end the cannula is visible just beneath the
skin. For patients with heavy necks, power-assisted liposuction (PAL) is used. It en-
hances patient comfort, since the cannula movements are less vigorous, especially
when the patient is under local anesthesia. It also diminishes the physical effort for
the surgeon.

1398
Part VIII  Face Lift and Neck Lift
Incision
The incision starts at the lobule and continues along the previously described mark-
ings. The surgeon carefully respects the incisura intertragica by making a distinct 90-
degree step at the beginning of the tragus.
The tragal incision is made exactly on the edge of the tragus. An incision placed too
anterior to the tragus will leave a visible color difference between the pale tragus
skin and the slightly darker cheek skin.
The blade is then inclined to an angle of 30 degrees to the skin so the incision goes
obliquely through the dermis, perpendicular to the hair shafts. The incision follows
the marked zigzag pattern 2 mm within the hairline.
An oblique incision within the hairline will allow hair to grow through the scar. Af-
ter hair regrowth, the final scar will be hidden a few millimeters within the hairline
and become virtually invisible.

Flap Creation
1399
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Blind undermining of the skin is performed with Rees face-lift scissors, and the dis-
section proceeds in a subcutaneous plane. The scissors points are directed toward
the skin to ensure that the surgeon has visual and palpable control over the thick-
ness of the cheek flap. Most of the dissection is accomplished by spreading maneu-
vers with the scissors. Care is taken to create a flap sufficiently thick to mask small
irregularities of the underlying layer.
After the flap is created, hemostasis is achieved by direct coagulation with microneedle
cautery under direct illumination by a lighted retractor or a headlight.
First Purse-String Suture: The Vertical Loop
The initial purse-string 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. (The zygomatic
arch is marked for demonstration purposes.) An extra dose of local anesthetic is in-
jected at the anchor point (note dot) down to the temporal bone, then the needle is
withdrawn and all layers of tissues are infiltrated.

1400
Part VIII  Face Lift and Neck Lift
With the iris scissors in the spreading mode, a 0.5 cm diameter window is made in the
subcutaneous tissue to visualize 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 sagging facial and neck soft tissues. A Prolene, Gore-
Tex PTFE, or Mersilene suture can be used.
The first bite starts in the window where we visualize the deep temporal fascia and
goes down to the temporal bone. The needle is oriented toward the tragus, so there
is no danger of damaging any facial nerve branch. The frontal branch of the facial
nerve runs deep in this region and becomes superficial several centimeters more an-
teriorly. Firm bites approximately 1 to 1.5 cm long and 0.5 cm deep are taken in the
SMAS tissue—parotid fascia in the upper two thirds and platysma in the lower third.
With every bite it is essential to confirm that the needle enters a substantial part of the
SMAS tissue so the suture will not pull through.

The suturing goes down toward the region of the mandibular angle to the lower limit
of the undermining. In this region direct visualization by means of a headlight or a
lighted retractor is helpful.
1401
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
This creates a narrow U-shaped purse-string loop about 1 cm wide. (The course of
this loop is marked on the patient for demonstration purposes.) After the first purse-
string suture is tied, some obvious skin dimples might occur at the mandibular angle.
Most of these will disappear with the vertical redraping of the skin, but some will
have to be freed with scissors.
When the region of the mandibular angle is reached, the suturing is turned upward
and continued toward the starting point.

1402
Part VIII  Face Lift and Neck Lift
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 toward the jowls, at an angle
of  30 degrees with the vertical. This loop is more O-shaped than 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 1 cm maximum are taken in the parotid fascia and the SMAS
tissue.
Third Purse-String Suture: The Malar Loop
The first and second sutures start from a common anchor point 1 cm above the zy-
gomatic arch and 1 cm anterior to the helical rim. (The projection of the three purse-
string sutures has been marked on the patient’s skin for orientation and demon-
stration purposes.) The third suture has a separate anchor point on the deep temporal
fascia, just lateral to the lateral orbital rim. Here a window is made in the orbicu-

laris muscle by spreading the iris scissors. This suture forms a narrow U-shaped loop
to prevent bulging of subcutaneous tissue in the highlighted zygomatic area. It runs
to the malar fat pad, which has been preoperatively located by a point marked 2 cm
below the lateral canthus.
1403
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
With the same suture (2-0 Prolene, Gore-Tex, or Mersilene), a deep bite is taken to an-
chor the suture to the deep temporal fascia. The purse-string suture is oriented
obliquely downward and medially. The malar fat pad is recognizable by a more fi-
brous consistency than the surrounding subcutaneous fat. At the preoperatively
marked point—the malar fat pad—the direction of the suturing is reversed, now in
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 win-
dow 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 the short-scar face lift is the vertical redraping
of the skin. This provides a “lock” to the subcutaneous sculpturing work in the cheek.
Because the vector of the subcutaneous lifting is almost purely vertical, the redraping
and resection of the skin in the same direction will seal the underlying suspension
effect. Vertical redraping also prevents formation of dog-ears at the lobule. The ear-
lobe is pulled upward by the suspension sutures and will have to be set back in the
cheek flap, taking the place of any dog-ears.

1404
Part VIII  Face Lift and Neck Lift
When vertical redraping of the skin is performed, the need for retroauricular skin
redraping will be avoided or limited to the few cases with extreme neck skin laxity.
The skin flap is put under moderate vertical tension, and the skin excess is deter-
mined with the help of the Pitanguy-d’Asumpçao forceps. The skin marking is in-
cised with the knife, and the excess is excised with the scissors. The skin resection on
the cheek flap is carried out in linear fashion and will be sutured to the zigzag bor-
der of the temporal hairline incision. The zigzag incision will now open up when
coapting with the linear cheek flap, thereby compensating for the incongruence in
length of both borders and reducing possible dog-ears. Closure with interrupted
4-0 Vicryl buried sutures is started from the superior end of the incision backward to
avoid dog-ears in this section.
The lateral part of the cheek flap is trimmed only minimally just to coapt with the
preauricular incision. Absolutely no traction is exerted on this part of the incision.
The skin is incised with the knife, and the flap is resected with the scissors. The ear-
lobe is pulled upward by the action of the suspension sutures and the redraping of

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 incongruence in length between both sides.
1405
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
A small, hollow, silicone tube is inserted for drainage at the lowest point of the in-
cision. This tube will drain into the loose retroauricular dressing during the first 24
hours postoperatively, after which it is removed, together with all dressings. The rest
of the suturing is done with running and separated 6-0 nylon sutures.
the skin in the vertical direction. To put the earlobe back into its natural position, a
small segment of skin has to be excised anterior to the earlobe. It is preferable to un-
derresect rather than to overresect in this area to avoid postoperative position changes
of the earlobe.

Adjunctive Procedures
Pinch Lower Blepharoplasty
A pinch lower blepharoplasty is routinely added after performing an extended MACS-
lift, because the lifting of the malar mound creates skin excess in the lower eyelid re-
gion. The concept of the pinch blepharoplasty of the lower eyelid is to safely remove
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 MACS-lift procedure.
1406
Part VIII  Face Lift and Neck Lift
The skin excess is estimated by a pinching maneuver with a nontoothed forceps and
marked with methylene blue. The pinch blepharoplasty is performed through a clas-
sic lower blepharoplasty incision.
The skin is freed from the orbicularis, vertically redraped without any tension, and
resected.

One or two inverted 5-0 Vicryl buried subcutaneous sutures are placed in the can-
thal and paracanthal part of the incision. The skin is closed with a running 5-0 ny-
lon intradermal suture.
Posterior Cervicoplasty
One of the consequences of vertical redraping of the skin is that in some patients,
aesthetically unacceptable vertical folds appear in the infralobular region. This oc-
curs primarily in patients with extreme neck laxity and thin, elastotic, wrinkled neck
skin, which is typically associated with severe sun damage. In our series this repre-
sented 2% of cases. (This procedure was not performed on the patient whose case
presentation began on p. 1389 and whose postoperative care is detailed on pp. 1426-
1427, but was performed on the patient described on pp. 1430-1431.)
1407
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
A 5 cm incision is designed in a zigzag pattern at the occipital hairline. The area of
skin undermining is designed to reach 1 cm beyond the anteriormost infralobular
skin fold. The skin flap is created by blind scissors dissection in a superficial subcu-
taneous level.

The skin is redraped in an occipital direction, and the skin excess is resected. The
skin is approximated with buried 4-0 Vicryl sutures and finished with a running
4-0 nylon horizontal mattress suture over a hollow silicone drainage tube (arrow).
Short-Scar Temporal Lift
The goal of face-lift surgery is to turn back the hands of time, rejuvenating the pa-
tient’s appearance, delaying the process of aging, and restoring a look more like the
individual appeared at a younger age.
1408
Part VIII  Face Lift and Neck Lift
When analyzing a patient’s photographs in her twenties and thirties, the vast ma-
jority of photos show full upper eyelids, with only a minimal show of the eyelid
above the cilia. The medial part of the eyebrow usually is relatively low, and the lat-
eral third is at the same level or even higher than the medial third.
With aging, the tail of the eyebrow descends to a variable degree, depending on the
underlying anatomy of the frontalis muscle. The part of the population that has a
frontalis muscle insertion extending to the tail of the eyebrow will have less descent
of this part of the eyebrow and often will respond very well to a chemodenervation
with botulinum toxin of the temporal portion of the orbicularis oculi muscle.

However, most people do not have good support of the lateral third of the eyebrow
and develop a degree of temporal hooding with time. It is this deformity that we aim
to correct with the short-scar temporal lift. Additionally, when a vertical face lift of
any kind is performed, the problem of temporal hooding is aggravated by a gather-
ing of skin in the paracanthal region. This can be anticipated in the preoperative con-
sultation with the patient in front of the mirror. If too much skin redundancy ap-
pears in the paracanthal area when simulating the vertical lift, the patient is counseled
about the necessity of a temporal lift.
To address these problems, a modified Fogli’s temporal lift by fasciapexy is performed.
The principle of this operation is basically the same as for a subcutaneous forehead
lift, limited to the lateral third of the forehead, in which the galea is used as a vehi-
cle to suspend the ptotic temporal tissue and provide a tension-free skin closure in
the temporal hair-bearing skin.
Technique
The subcutaneous part of the temporal undermining is performed from the MACS-
lift incision in continuity with the subcutaneous cheek skin undermining. It stops at
a level at least 2 cm above the tail of the eyebrow.
The temporal lift is done after the loop sutures are placed, but before the final re-
draping and resection of the cheek and lower eyelid skin to reduce the dog-ear for-
mation in the temporal and paracanthal region.
Markings
1409
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
When a temporal lift is planned in combination with a MACS-lift, the markings are
adapted, so that the subcutaneous dissection of the cheek is extended over the tem-
poral region to a level at least 2 cm above the tail of the eyebrow. The skin incision
is marked horizontally in the temporal hair-bearing skin.
Transection of galea
Skin incision
Subgaleal undermining
Subcutaneous undermining

1410
Part VIII  Face Lift and Neck Lift
From here a subgaleal undermining is performed downward to a level about 2 cm
above the tail of the eyebrow.
Here the galea is transected with the tip of the scissors from deep to superficial, to
fall into the subcutaneous undermining already performed earlier. This maneuver
protects against possible damage to the frontal branch of the facial nerve, which runs
at the undersurface of the temporoparietal fascia, about 2 cm cranial to the tail of
the eyebrow.

1411
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Tying these knots will produce a bulging of skin that will disappear after 6 to 8 weeks
when the Vicryl sutures lose their strength. After the knots are firmly tied, a few mil-
limeters of skin are resected to minimize skin bulges and the incision is closed with
3-0 running nylon suture.
For the medial part of the forehead, botulinum toxin therapy is recommended, be-
cause it is an effective way of treating glabellar and frontal grooves without the need
for further surgical procedures.
Two U-shaped Vicryl 2-0 sutures are placed be-
tween the cranial edge of the transected galea and
the galea at the site of the skin incision.

1412
Part VIII  Face Lift and Neck Lift
Microfat Grafting
Deflation through loss of subcutaneous fat is a recognized causative factor in facial
aging. Guided by early patient photographs (age 20 to 30), we decide which areas
need volumetric restoration by additional fat grafting. Experience has taught us that
almost every patient loses volume in the nasojugal and nasolabial folds and mari-
onette grooves. About 50% of these individuals will benefit from adding volume to
the malar area and the medial upper eyelid.
Technique
Fat grafting is performed before the MACS-lift. This minimizes the cold ischemia
time of the prepared fat grafts. At this stage there is also no distortion of the face by
edema resulting from the surgery.
The fat is usually harvested by the assistant at the time of infiltration of local anes-
thetic to the face. The abdomen is the preferred donor site because of its ease of ac-
cess. A multiholed grater cannula (Tulip; Wells Johnson, Tucson, AZ) with 1 mm
sharp holes is used for fat harvesting. The fat parcels harvested this way are small
enough to be placed with a 0.9 mm or 0.7 mm grafting cannula.
The fat is then strained through a sterile nylon cloth and rinsed with normal saline
solution. Then the fat is collected in 10 cc syringes for final transfer to 1 cc Luer-Lok
syringes.
The fat is injected using 0.9 to 0.7 mm diameter blunt cannulas with one small hole
on the side. No incision is needed to insert the cannula. A puncture with an 18-gauge
needle works well. The puncture hole need not be closed.
Harvesting cannula
Grafting cannula

1413
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
The medial part of the upper eyelid is grafted deep to the orbicularis oculi muscle in
contact with the interior aspect of the superior orbital rim.
Medial hollow of upper eyelid
(A-frame deformity)
Malar and tear
trough grooves
Marionette groove and
prejowl sulcus
Intradermal lip rhytids
Nasolabial fold
The malar area is grafted very deep, in contact with the malar bone, so that no grafted
fat is encountered when the skin is being undermined over the lateral part of the
malar area in an extended MACS-lift.
The nasolabial fold is filled in a deep plane, after which a subcision is performed
with an 18-gauge needle. Additionally, a small quantity of fat (approximately 0.5 cc)
is injected in the cavity created by the subcision to prevent reattachment of the skin
to the deeper plane. Intradermal injections are made into vertical perioral, nasolabial
and glabellar rhytids and sometimes in the corners of the mouth. This is only possi-
ble with the use of the ultrafine microfat parcels harvested with the method described.
Areas for Fat Grafting

1414
Part VIII  Face Lift and Neck Lift
In many persons the vertical height of the upper lip increases with age, hiding the
upper incisors and sometimes even covering a part of the lower teeth. Lifting the up-
per lip has a very rejuvenative effect, especially when combined with microfat grafting.
The excision is planned as a subnasal gull-wing or bullhorn pattern down to the level
of the orbicularis oris muscle. No skin undermining is performed. Meticulous clo-
sure with 5-0 subcutaneous polylactic or polydioxanone sutures and 6-0 horizontal
mattress nylon sutures is performed.
Injection Guidelines
Grafted Area
Level of Injection
Volume (cc)
Upper eyelid
Deep
0.8-2.0
Malar
Deep
3.0-25.0
Nasolabial fold
Deep and superficial and intradermal
1.0-3.0
Perioral
Superficial and intradermal
1.0-4.0
Marionette grooves
Deep and superficial
1.5-3.0
Lip Lift Combined With Laser Resurfacing
of the Perioral Region

1415
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
In combination with perioral micrografting, the results of skin resurfacing with an
erbium-YAG laser can be significantly enhanced. For the patient on p. 1414, we com-
bined subcutaneous and intradermal microfat grafting with laser resurfacing and lip
lift. The depth of the ablation can be reduced when appropriate filling of the rhytids
is done by intradermal microfat injection.
Postoperative Care
The area of the neck where liposuction was performed is supported with an adhe-
sive elastic tape. The preauricular incision is covered with a transparent adhesive foil
dressing (OpSite, Tegaderm).
Cooling of the skin with ice has been abandoned because of the rebound postoper-
ative vasodilation that occurred. Instead we now use a temperature-controlled cool-
ing device (Hilotherm) that has closed-circuit cooled water circulation through a
snug facial mask. The water temperature is set on 15° to 17° C (59° to 63° F). This is
sufficient to diminish the facial edema without causing discomfort, while avoiding
postcooling rebound swelling. Our clinical experience has shown significantly re-
duced postoperative swelling and bruising. There is usually some swelling in the su-
perior sternocleidomastoid region; the patient is reassured that this temporary de-
formity will resolve over the next 2 weeks.
Suction drains and submental adhesive tape are removed on the first postoperative
day; the patient is allowed to shower and shampoo. Sutures are removed on post-
operative day 6, and any remaining ecchymoses can be concealed with camouflage
makeup.

1416
Part VIII  Face Lift and Neck Lift
This patient, who is the subject of the operative series on pp. 1393 through 1405, is
seen here 24 hours after surgery. At that time the submental adhesive tape, all dress-
ings, and the silicone drainage tube were removed. The undermined area was gently
milked out in the direction of the lobule to remove any residual serosanguineous
fluid. Usually some swelling in the superior sternocleidomastoid region is apparent;
this is often described by the patient as a “bull neck.” The patient is reassured that
this temporary deformity will resolve over the next 2 weeks. From this point on the
patient is allowed to shower and shampoo daily.
The patient returned 1 week postoperatively for suture removal. Postoperative edema
has resolved significantly. Some ecchymoses are still visible, which can be concealed
with camouflage makeup.

Two weeks postoperatively, edema and ecchymoses have almost completely subsided,
which allows the patient to return to normal professional and social activities. The
sternocleidomastoid swelling has also disappeared, but the patient will still note some
mild tension in the temporal region. The patient is informed that this may take
2 months to disappear completely.
Six weeks postoperatively, correction of jowling, marionette grooves, and nasolabial
folds is obvious. On frontal view, note the general volume shift in a cranial direction,
resulting in a triangularization of her face. On lateral view, note the volume reduction
in the submental area, with correction of the cervicomental angle. No folds or dog-
ears are visible near the lobulus, confirming the futility of a retroauricular incision
in this case. The axis and position of the auricle are unchanged in the vertical as well
as in the horizontal direction.
1417
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Preoperative
2 weeks postoperatively
6 weeks postoperatively

Results
Simple MACS-Lift
1418
Part VIII  Face Lift and Neck Lift
Surgical Plan
This 52-year-old woman was discussed earlier in Preoperative assessment (p. 1387).
Her correction was performed under local anesthesia with intramuscular sedation.
The results are seen 1 year after surgery. Note the correction of the cervicomental
angle and jowling, as well as the triangularization of her face and better definition
of the jawline, which is best seen on the oblique view.
 A simple MACS-lift
 Submental liposculpture

This 50-year-old woman presented with mild corrugator frown lines, correctly po-
sitioned eyebrows, and a discrete upper blepharochalasis. She complained of deep
nasolabial folds, the downward slant of the corners of her mouth, and beginning
laxity of the upper neck.
1419
Chapter 42  The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting
Surgical Plan
 A simple MACS-lift
 Botulinum toxin injections to the corrugator, procerus frontalis, and orbicularis oculi
muscles
 Upper blepharoplasty with resection of skin and muscle and removal of fat from the
medial compartment
 Submental liposculpture
Seen 1 year postoperatively, the patient shows a softening of the nasolabial folds,
correction of the marionette grooves and the downward slant of the corners of the
mouth, better definition of her jawline, and a tighter upper neck.

1420
Part VIII  Face Lift and Neck Lift
Extended MACS-Lift
This 63-year-old woman presented with facial aging, including facial deflation, sag-
ging, and perioral rhytids. The general shape of her face was rectangular; her eye-
brows were in the correct position. She had an apparent skin excess in the upper eye-
lids, caused by a combination of deflation of the medial part of the eyelid and descent
of the tail of the eyebrow. She had baggy lower eyelids, with a moderate skin excess
and a marked nasojugal groove. The midface was mildly deflated, especially in the
suborbital area. There was a degree of midface ptosis marking the upper third of the
nasolabial fold. In the lower third of the face, there were fine rhytids on the upper
and lower lip, a downward slanting of the oral commissures, and marked marionette
groove and jowling. The laxity in the neck was discrete.
Analysis of the photograph in her early twenties reveals a youthful oval shape to her
face. The eyebrows are in a low horizontal position. The upper eyelids are full, with
little marginal show. The lower eyelid is taut, with a smooth transition between eye-
lid and cheek skin and therefore there is no nasojugal groove. She has no nasolabial
folds and smooth perioral skin. The jawline is clear, with no jowls or marionette
grooves.
Her results 1 year postoperatively show a restoration of the youthful oval shape of
her face. The tail of the eyebrow is slightly elevated, and the upper and lower eyelids
have regained their youthful fullness. The sharp shadows of the nasojugal and na-
solabial folds and marionette grooves are effaced. The perioral rhytids have disap-
peared without the use of any resurfacing technique. The jawline is again straight
and well defined, and the neck contour is improved.
Surgical Plan
 Extended MACS-lift
 Short-scar temporal lift
 Discrete upper skin blepharoplasty
 Lower blepharoplasty with arcus marginalis release and fat redraping, with discrete
skin excision at the end of the procedure
 Microfat grafting in the medial part of the upper eyelid (2 cc), malar area (7 cc), na-
solabial fold with subcision, including intradermal injection (2 cc), upper lip, including
intradermal injection (2.6 cc), and lower lip, including intradermal injection (2.6 cc)