Minimal Access Cranial Suspension Research Articles

Lipofilling With Minimal Access Cranial Suspension Lifting for Enhanced Rejuvenation

Loss of volume is an important aspect in facial aging, but its relevance is frequently neglected during treatment. The authors discuss lipofilling as an ancillary procedure to improve the impact of facelifting procedures. Fifty patients who underwent minimal access cranial suspension (MACS) lifting alone were retrospectively analyzed, and their results were compared to 42 retrospective cases of MACS lifting with adjuvant lipofilling. The results were evaluated with a photographic ranking system by two panels (five plastic surgeons and five medical students). Combined MACS lifting and lipofilling yielded overall cosmetic results that were significantly better than the results achieved with MACS lifting alone. Photographic evaluations showed that improvements were more pronounced in the tear trough (P < .05) and malar eminence (P < .01) than in the nasolabial groove (P > .05). Volume restoration with lipofilling following MACS lifting procedures produces significantly better postoperative results than MACS lifting alone. This combined procedure produces the most dramatic improvements in the tear trough and malar eminence regions.

Minimal Access Cranial Suspension (MACS) lift

Minimal Access Cranial Suspension (MACS) lift

Use of the Zygomatic Arch for Stable Anchorage in Minimal Access Cranial Suspension Lifting

Use of the Zygomatic Arch for Stable Anchorage in Minimal Access Cranial Suspension Lifting

Aesthetic Plastic Surgery Symposium, Toronto, Ontario, April 17–18, 2009

Dr Walter Peters, Course Director, and the University of Toronto hosted the annual symposium and Dr WRN Lindsay, our founding plastic surgeon, attended. Dr Grady Core, Dr Mark Jewell and Dr Renate Saltz were our visiting professors in addition to local speakers. This reporter noted many things of interest although it is not possible to mention them all or to attribute each to individuals. There is a trend to analyse augmentation mammaplasty to attempt to better predict outcomes and the incidence of reoperations; for example, choosing textured implants for shaped devices and smooth implants for augmentation mastopexy. Dr Saltz said shape was more important than the scar in mastopexy. Patients will accept the scar if the shape is good and long lasting and the superior pedicle or medial pedicle is useful. If the inferior pedicle is used it can be used to augment the upper pole. Dr Lista said surgery can be done faster with an improvement in quality noting that lessons can be learned from successful car manufacturers such as Toyota, the key being organization, repetition, staff training and planning. Surgical quality is now better in private clinics than in general hospitals. Sadly, general hospitals have no way to catch up because they are working on an old-fashioned model and show few signs of moving toward the future. Larger volumes mean better quality as surgery changes from the craft model, where every operation is different, to the assembly line idea, where similarities are stressed. This can be done while retaining patient personal contact and ultimately, results will speak for themselves. Ontario now spends 46% of tax revenue on health care. As revenues decrease there will be a squeeze, necessitating the adoption of new delivery models. Surgical dissection and cautery using ultrasound is on the horizon but expensive. This allows dissection without heat or smoke. Dr Core presented abdominal wall reconstructions advising the use of very wide mesh. It was noted that the complications of TRAM flaps seem to be under-reported by some. Dr Peters presented a fascinating history of injectibles. These have been widely used around the world and despite cautions and in some jurisdictions illegal (eg, silicone injections), are still being done. ‘Permanent fillers’ need to approached with caution because some develop inflammatory reactions many years later and are difficult to treat. In the past 20 years, a new class of injectible fillers has been widely used in Ukraine, Russia and China – polyacrylamide hydrogel. History has a repeated itself. As of May 2006, the Chinese Food and Drug Administration has banned its use. Drs Ford and Core presented midface rejuvenation using the lower eyelid approach by relocating lower lid fat and elevating the malar fat fad. This produces a good result without a preauricular incision, and has an acceptable recovery period. Dr Core is pleased with the transaxillary augmentation under visualization and can insert up to a 300 mL low-profile gel implant this way. The simplest incision is likely the best. Cosmetic medicine is a growth field, fuelled by lowering of insurance payments and family doctors diversifying. There was much discussion on the advantages and disadvantages of broadening one’s practise to increase traffic flow through one’s clinic. During the recession surgery seems down or postponed, but injectibles and medical aesthetics seem strong. Income sharing seems an important motivator and practice stabilizer and can lead to inequities, with nurses earning less than estheticians. A new initiative will remind the public that plastic surgeons are best qualified to do all cosmetic procedures for the safety and benefit of patients. Dr Jewell thinks the minimal access cranial suspension face-lift is a good procedure, but takes practice. The neck can be improved in some patients without much neck dissection and the three sutures are safe. The skin is released after the suture if irregularities are seen. The level of lift is vertical in front of the ear, which means a shorter scar behind the ear. It moves volume back up into the cheek. He likes size 0 PDS absorbable sutures. Dr Saltz told us abdominoplasty can be improved by suction of the sides and back before abdominoplasty then limiting the dissection lateral to the rectus abdominus. Dissection of the flap superficially, preserving perforators, is of help. Obesity and combining operations increase the complication rate. Dr Core said the key to endoscopic brow lift is fixation. The use of endoscopy seems to be waning likely due to the expense of equipment. He does midface lifts through the lower eyelid using a skin-muscle flap and elevates the malar fat pad, inserting the orbital fat pad into the naso-jugal groove. He also elevates the orbicularis oculi. The meeting was well attended and a large turnout of nurses was noted.

Platysma-SMAS plication facelift

Whilst numerous facelifting techniques have been described there remains a continual drive towards minimal access and limited 'downtime' in order to maintain the effects of more aggressive procedures. The MACS (minimal access cranial suspension) lift is well-established, but has limitations, particularly with respect to its vectors and effect on the neck. Platysma-SMAS plication (PSP) represents an evolution that seeks to balance procedural invasiveness with recovery time and aesthetic outcome. The study reports the initial 117 consecutive patients who were followed prospectively. Using a 5-point assessment scale, the cosmetic outcome was graded 4.45 and 4.49 by patients and surgeon respectively at initial follow up. At final follow up 82.2% of scores had either improved or remained the same and overall grading was 4.43 and 4.45 respectively. Complications were seen in 15.4%:3.4% haematoma and 3.4% transient facial nerve motor dysfunction. There were no long-lasting or permanent motor palsies and all occurred in the initial 30th centile. We have found platysma-SMAS plication to give high satisfaction and reproducible results. With the SMAS being plicated rather than being raised as a flap, it is a quick procedure and is safe with regard to the facial nerve. The technique has furthermore been shown to be easily acquired by less experienced aesthetic surgeons.

Face Lift with Suspension Sutures

Sir We appreciate Dr. Stocchero’s concern about the completeness of a reference list when publishing in scientific journals. The letter presents two major issues that can teach us more about what motivates someone to take up his or her pen (or computer) and write a letter to the editor. First, Dr. Stocchero is happy that Dr. van der Lei et al. found an article in Aesthetic Plastic Surgery from Duminy and Hudson describing a technique similar to the one we finally described. Apparently, this article has never been cited by any other author, and Dr. Saylan is immediately accused of being the first to omit this reference. Moreover, we are also accused of “forgetting” to cite Saylan’s name in further publications on minimal access cranial suspension lifting. Second, Dr. Stocchero is unhappy that we did not cite his article published in 2001 in Plastic and Reconstructive Surgery, entitled “The Roundblock SMAS Treatment: A Face Lift with Suspension Sutures,” and admits that his sutures are applied, “fortunately,” in a different way. We still believe that it is impossible, useless, and time consuming to try to obtain a comprehensive reference list. The articles cited in a reference list are the works that have influenced your way of thinking before your personal technique has developed. Unfortunately, we were not aware, like many others, of the work of Duminy and Hudson or the work of Stocchero. It was in 2005 at a meeting in São Paulo that we first met Dr. Stocchero, and we were impressed with his beautiful results. We do not think it is either fair or friendly to suggest that we intentionally did not mention his or others’ publications. It adds nothing constructive to the whole discussion, and moreover, it is bad karma. To illustrate the relativity of Dr. Stocchero’s reaction, we would like to mention another reference that we came across while visiting Professor Ricardo Mazolla for a meeting he organized in Milan in April of 2007. As many of us know, Professor Mazolla has one of the most important historical libraries on plastic surgery in the entire world, and his Fondazione Sanvenero-Rosselli is taking care to maintain and protect this treasure. On a Sunday morning we had the opportunity to dive into the history of facial rejuvenation techniques, and among other articles, we came across a very remarkable article by a French plastic surgeon named Virenque entitled “Traitement Chirurgical des Rides de la Face et du Cou” (“Surgical Treatment of Facial and Neck Rhytides”). The article was published in a book edited by Victor Pauchet, entitled La Pratique Chirurgicale Illustréé, in Paris in 1927! As you can see in Figures 1 and 2, the technique of incision, undermining (although very limited), and placement of three sutures is very similar to what we are doing today in our modern minimal access cranial suspension lift. Why was this technique not popularized before? Similarly, we know that open rhinoplasty incisions existed before but were only popularized in the 1980s. As said before, we do not pretend that we have invented anything. The only credit we could take is to have popularized a technique and a vision toward less invasive facial rejuvenation techniques, for which nowadays there is great public demand. Let us not forget, after all, and we are the first to admit this, as illustrated by this 1927 publication, that plastic surgery is and will ever stay a lesson in humility.Fig. 1.: Incision line and limited undermining. Placement of the three sutures, attached to the parotid fascia. From Virenque. Traitement chirurgical des rides de la face et du cou. In La Pratique Chirurgicale Illustrée. Paris, 1927.Fig. 2.: Redraping of the skin flap before resection and placement of the final scar. From Virenque. Traitement chirurgical des rides de la face et du cou. In La Pratique Chirurgicale Illustrée. Paris, 1927.Patrick Tonnard, M.D. Alexis Verpaele, M.D. Coupure Centrum voor Plastische Chirurgie, Gent, Belgium

Experience in the treatment of HIV-associated lipodystrophy

To evaluate the outcome of patients with HIV-associated lipodystrophy treated within the Edinburgh unit to date. Information was collected from the medical case notes on the clinical features, method of treatment, postoperative complications, and length of follow up for each patient. A questionnaire was devised to assess patient satisfaction and facial volume was evaluated using three-dimensional imaging. Forty-six patients with HIV-associated lipodystrophy were treated over a 3-year period. Twenty-six patients received Coleman fat injections, 10 patients were treated with Newfill, eight patients were treated with Bio-alcamid, 21 patients received liposuction, and three patients had a minimal access cranial suspension facelift. Follow up ranged from 1 to 14 months. Patient and surgeon satisfaction was high with autologous fat injections although fat resorption occurred in nine patients. Aesthetic improvement with Newfill was moderate and required up to seven treatment sessions. The results of treatment with Bio-alcamid were good immediately postoperatively, although two patients required further corrective procedures. Two patients who had liposuction to the dorso-cervical fat pad reported recurrence at 5 and 9 months, respectively. Based on our experience, a treatment algorithm has been devised to aid management decisions. We favour the use of autologous fat injections for facial lipoatrophy but have found fillers to be useful in patients with inadequate fat reserves.

The Sling Lift: An Ancillary Procedure for Malar Rejuvenation

The malar region has been a crucial target in many facial rejuvenation techniques because the beauty and youthful contour of a convex midface and a smooth eyelid-cheek sulcus are key features of a pleasing face-lift result. The full midface subperiosteal lift has helped to address these issues. However, the desire of patients currently for a rapid recovery and return to work with a natural-looking result has influenced procedural selection. Another concern is for safer procedures with reduced potential risk. Progressively fewer invasive techniques, such as the minimal access cranial suspension (MACS) lift, have been a response to these core concerns. After 3 years of performing the conventional three purse-string suture MACS lift, the author developed a practical procedural modification. For a total of 17 patients, the author combined limited regional subperiosteal lift and periosteal fixation with a simple sling approach to the more fully released malar tissue mass to make a single-point suspension just above the lateral orbital rim. The percutaneous sling lift appears to offer a degree and naturalness of rejuvenation of the malar region similar to those of the MACS lift and the full subperiosteal midface lift, but with fewer suspension points and less undermining. Also, the author observed less ecchymosis and edema than with the full midface subperiosteal lift, as would be expected. In all 17 cases, the need for the second and third purse-string sutures was eliminated. The early results for the percutaneous sling lift indicate that it offers promising results, rapid recovery, and reduced risk of serious complications.

The third suture in MACS-lifting: making midface-lifting simple and safe

The minimal access cranial suspension (MACS)-lift is a short scar rhytidectomy with vertical purse string suture suspension of the facial tissues. It exists in a simple and extended version. The simple MACS-lift achieves a vertical lifting of neck and lower half of the face with two purse string sutures. The action of a third, malar suture gives additional correction of the middle third of the face, and results in the extended MACS-lift. To draw attention to the power and advantages of the 'third' malar suture in the extended MACS-lift in achieving volumetric restoration of the midface, softening of the nasolabial fold and enhancing support of the lower eyelid. The core principle of this technique is the use of strong purse string sutures in a pure antigravitational direction for correction of the ageing neck and lower two-thirds of the face. In a simple MACS-lift the neck is corrected by a first narrow vertical purse-string suture. The volume of jowls and cheeks is repositioned in a cranial direction with a second, slightly oblique purse string suture. To achieve better control over the midface an extended MACS-lift is performed by adding a third malar vertical purse string suture between the paracanthal area and the malar fat pad. 557 MACS-lift procedures have been performed by the two senior authors, of which 183 were simple and 374 extended. A retrospective review of this technique revealed high patient satisfaction, only one major complication and a minor complication rate of 6%. Both versions of the technique deliver a vertical vector correction of sagged facial features. The third suture restores the volume of the midface and malar mound and provides strong support of the lower eyelid. The third suture in the MACS-lift short scar rhytidectomy produces a natural midface lifting through a short scar, with adequate softening of the nasolabial fold and good support of the lower eyelid.

The MACS-lift short scar rhytidectomy

The minimal access cranial suspension (MACS) lift, a short scar face lift for the lower and middle third of the face, uses a pure vertical vector, involves no lateral tension, and may be performed with the patient under local anesthesia in 2 to 2.5 hours. According to the authors, the procedure reduces recovery time and morbidity, and results are as stable as more classic, extended face lift techniques.

Bilateral pyoderma gangrenosum complicating minimal access cranial suspension face lift

We present the case of a previously healthy 53-year-old woman upon whom a minimal access cranial suspension (MACS) face lift and bilateral upper and lower blepharoplasty were performed. Her preauricular wounds recurrently broke down postoperatively, and after surgically excluding stitch granuloma, a diagnosis of pyoderma gangrenosum was made. The wound breakdown resolved with topical steroid treatment. Our case highlights the need to be aware of pyoderma gangrenosum to avoid unnecessary surgery.

A Clinical Retrospective Study Comparing Two Short-Scar Face Lifts: Minimal Access Cranial Suspension versus Lateral SMASectomy

The purpose of this study was to retrospectively compare the short- and long-term cosmetic outcomes of two minimal incision rhytidectomies and analyze their advantages and disadvantages. The results of minimal access cranial suspension face lift versus minimal incision rhytidectomy with lateral SMASectomy were evaluated after 1 and 24 months. Statistical analysis considered surgeon/patient satisfaction, time used in the procedures, pain, and learning curves. Photographs were sent to the patients and two plastic surgeons, unfamiliar with the cases, for evaluation of results that were assessed by an objective grading system described by Strasser. Eighty-two patients completed 1 and 24 months' follow-up. Complications were two hematomas, two retroauricular-lobule dog-ears, and one hypertrophic preauricular scar. Surgical time was longer for the SMASectomy. Postoperative pain was worse for minimal access cranial suspension face lift. There were no differences in cosmetic results between the two techniques at 1-month and 2-year follow-up. Incorporating age, sex, postoperative pain, and duration of surgery as confounding factors did not modify the model. Surgeon/patient satisfaction showed no difference with either technique, but the photographic evaluation of all cases at 24 months revealed that more than 50 percent of the sample needed a tuck procedure to correct jowling and redundant skin. Advantages of short-scar face lifts are the avoidance of the postauricular and occipital incisions, and the disadvantages are the moderate results in the neck and nasolabial folds and their potential short duration. For 24 months in this study, the duration of results was similar for both minimal access cranial suspension and lateral SMASectomy.

The MACS-Lift Short-Scar Rhytidectomy

The minimal access cranial suspension (MACS) lift, a short scar face lift for the lower and middle third of the face, uses a pure vertical vector, involves no lateral tension, and may be performed with the patient under local anesthesia in 2 to 2.5 hours. According to the authors, the procedure reduces recovery time and morbidity, and results are as stable as more classic, extended face lift techniques.

Optimising Results from Minimal Access Cranial Suspension Lifting (MACS-Lift)

Between November 1999 and February 2005, 450 minimal access cranial suspension (MACS) lifts were performed. Starting with the idea of suspension for sagging soft tissues using permanent purse-string sutures, a new comprehensive approach to facial rejuvenation was developed in which the vertical vector appeared to be essential. The neck is corrected by extended submental liposuction and strong vertical traction on the lateral part of the platysma by means of a first vertical purse-string suture. The volume of the jowls and the cheeks is repositioned in a cranial direction with a second, slightly oblique purse-string suture. The descent of the midface is corrected by suspending the malar fat pad in a nearly vertical direction. In 23 cases (5.1%), the result in the neck was unsatisfactory, and additional work had to be done secondarily, or in later cases, primarily. The problem that appeared was unsatisfactory correction of platysmal bands (resolved with an additional anterior cervicoplasty) or vertical skin folds that appeared in the infralobular region (corrected with an additional posterior cervicoplasty). This article describes two ancillary procedures that, although not frequently necessary, can optimise the result of MACS lifting.

Optimising Results from Minimal Access Cranial Suspension Lifting

Over the past 40 years, about 1,000 rejuvenating surgical techniques to correct the aging face have been described. The methods that have survived the test of time to be used in everyday practice are efficient, logical, and reliable, with few complications. In fact, many techniques are good, but a technique is nothing if it is not adapted to a particular case. We must adapt good methods to good patients. In other words, we must identify the indications, so we must be aware of all the procedures. As I said in a recent ISAPS meeting, my technique for the middle face is the result of many procedures taken from almost 10 different surgeons. The precapillary incision I sometimes use was described by B. Connell, and the preauricular incision is from I. Pitanguy. Another technique I use inside the sideburn was performed by B. Guyuron. My retroauricular incision was described by S. Hoefflin, and my primary liposuction of the neck was used by Y. Illouz. The skin undermining I have adopted was reported by Skoog, Aufricht, and Mac Indoe, and my deep muscular plane treatment is the one used by G. Jost and me. Often I use a deep undermining of the fat to suspend the malar pad, as described by S. Hamra, and I often add a transconjunctival approach associated with light erbium laser abrasion of the inferior eyelid skin, as advocated by T. Roberts. I could add that I suspend the platysma angle without undermining the neck skin, as done by D. Labbe, and I could also use a vertical purse suture, as shown by P. Tonnard. Why not? It is also an effective technique when appropriate. In fact, these are the logical findings by the authors of this article. Platysma suspension by a purse suture to the deep plane or to the Lore s fascia is not sufficient in the presence of significant anterior platysma bands. Therefore, it is logical in these cases to include an anterior cervicoplasty. The vertical suspension of a minimal access cranial suspension (MACS) lift cannot deal with excess posterior skin on the neck. Therefore, in these cases, a posterior cervicoplasty is also mandatory. Consequently, we must adapt our techniques to the patient, to her or his skin conditions, hair situation, former operations, shape of the platysma on the neck, particular excess of skin, and the like. One single procedure is not sufficient to please the patient, and one technique is never completely adapted to one case. We always need additional procedures for the finesse of a result. The authors of the article have shown this perfectly.

300 MACS-lift short scar rhytidectomies: analysis of results and complications

Between November 1999 and April 2004, 300 MACS-lifts (Minimal Access Cranial Suspension–lifts) were performed. Starting from the idea of suspension of sagged soft tissues with permanent purse-string sutures, a new comprehensive approach to facial rejuvenation was developed, in which the vertical vector appeared to be essential.The neck is corrected by extended submental liposuction and strong vertical traction on the lateral part of the platysma by means of a first vertical purse-string suture. The volume of the jowls and the cheeks is repositioned in a cranial direction with a second, slightly-oblique purse-string suture. The descent of the midface is corrected by suspending the malar fat pad in a nearly vertical direction.The skin excess generated by these actions is redraped in a pure vertical direction and excised at the temporal hairline and the paracanthal region. As no horizontal pull on the skin is exerted, a retro-auricular incision becomes obsolete. The result is a pure antigravitational lifting procedure, which produces a natural facial rejuvenation through a short scar.

Minimal access cranial suspension lift: a modified S-lift.

There is a strong trend at hand toward less dramatic facial rejuvenation surgery. Most of the authors' patients want a cosmetic improvement but not at the cost of prolonged disfigurement or a high risk of complications. In 1999, a very simple but effective rhytidectomy technique, termed an S-lift, was described in the literature and was adopted by the authors. Its basic principle is the suspension of sagging facial features by a strong, permanent purse-string suture. The procedure is performed with the patient under local anesthesia. Significant modifications were applied to the incision, to the purse-string suture anchoring site, and to the direction and shape of the skin excision. The authors named the modified procedure the minimal access cranial suspension lift to specifically describe the concept of the technique. Through an inverted L-shaped preauricular incision with extension below the sideburn, a limited skin undermining is performed. Two strong, permanent purse-string sutures are woven into the superficial musculoaponeurotic system tissues in a vertical U and an oblique O shape, initiating from a strong anchorage in the deep temporal fascia at the level of the helical crus. Tying these sutures produces a very powerful vertical correction of descended facial features that acts mainly on the jowls and the upper neck. The procedure can be extended by continuing the dissection over the malar fat pad, placing a third vertical purse-string suture with strong action on the nasolabial groove, and vertically repositioning the midfacial volumes. During 20 months, pleasing results and a very low complication rate were obtained in 88 consecutive patients with a mean age of 551/2 years. In this article, the authors provide a detailed description of the anesthetic and surgical technique, a demonstration of the results in different patient age categories, and a discussion comparing the minimal access cranial suspension lift with other types of facial rejuvenation procedures.