this Article PDF

OPEN ACCESS
Research Article
The fourth suture in MACS facelifting – adressing the neck
Die vierte Naht zur Halsstraffung im MACS-Lift
Abstract
Objective: The MACS facelift alone shows poor results on the medial
neck in cases of pronounced, rigid platysmabands (McKinney III–IV°).
The original MACS (“Minimal Access Cranial Suspension”) facelift delivers excellent results on the midface and leads to sustainably improved
outcome on the neck by adding a fourth suture on the platysma.
McKinney type I–II platysmabands can be treated only by lateral approach of the ‘fourth suture’, type III–IV should be treated with closed
platysma myotomy before.
Methods: Between October 2007 and November 2013 a number of
219 patients were treated with the MACS facelift technique accomplished by a fourth suture on the platysma and liposuction or optional
lipectomy on the neck. On 47 patients closed transcutaneous platysma
myotomy was performed.
Results: Surgery time lasted on average 2.5 hours and was performed
under sedation with local anesthesia in 85%. Recovery time ranged
between 14 to 16 days until the patients were back to work. Due to
their health status 54% of our patients had an inpatient arrangement
for one night and 46% an outpatient arrangement.
Conclusion: The modification of the MACS lift with the ‘fourth suture’
on the platysma keeps the benefits of the original technique but improves the aesthetic outcome on the neck.
Kai O. Kaye1
Daniel R. Sattler2
1 Oceanclinic, Plastic and
Aesthetic Surgery, Marbella,
Spain
2 University Hospital
Magdeburg, Department of
Plastic, Aesthetic and
Handsurgery, Magdeburg,
Germany
Keywords: MACS lift, face lift, neck lift, fourth suture, platysma myotomy
Zusammenfassung
Einleitung: Das MACS-Facelift alleine liefert unbefriedigende Ergebnisse
im Bereich des medialen Halses, besonders wenn ausgeprägte Platysmabänder bestehen (McKinney II–IV°). Die Erstbeschreibung des MACSFacelift („Minimal Access Cranial Suspension“) nach Tonnard et al. erzielt exzellente Ergebnisse im mittleren und unteren Gesichtsdrittel bis
zur Mandibula. Durch eine vierte laterale Platysmanaht gelingt es auch
die mediale Halsregion nachhaltig zu straffen. Weniger ausgeprägte
Platysmabänder (McKinney I–II°) können allein durch den lateralen
Zug der vierten Naht korrigiert werden, während akzentuierte Platysmabänder (McKinney III–IV°) primär mit einer geschlossenen Platysmaband-Myotomie angegangen werden sollten.
Material und Methoden: Zwischen Oktober 2007 und November 2013
wurden 213 Patienten mit einem MACS-Facelift und eine zusätzliche
vierte laterale Platysmanaht operiert. Die Halsregion wurde immer mit
einer Liposuktion und optional mit einer offenen Lipektomie behandelt.
Bei 47 Patienten wurde eine geschlossene transkutane PlatysmabandMyotomie durchgeführt.
Ergebnisse: Die durchschnittliche Operationszeit betrug 2,5 h und 85%
der Fälle wurden unter Sedation/Lokalanästhesie operiert. Die mittlere
Regenerationszeit bis zur Rückkehr in den Beruf betrug 14–16 Tage.
In Abhängigkeit der Grunderkrankungen wurden 54% der Patienten
stationär, 46% ambulant geführt.
Schlussfolgerung: Die Modifizierung des MACS-Facelifts durch die
vierte Naht erhält die Vorteile eines „short scar“-Faceliftes, verbessert
aber nachhaltig die ästhetische Kontur des Halses.
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
1/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
Figure 1: Young patient requesting a facelift, pre- (a, c, e) and postoperative view (b, d, f)
Introduction
Facelifting is a crucial tool in the daily practice of a plastic
surgeon. Ten to 15 years ago the facelifting procedures
were requested by a small patient population in Europe
[1]. Today it is widely requested and standard repertoire
of every aesthetic surgeon. The request for a face lift
procedure is claimed by much younger and better informed patients (Figure 1, Figure 2, Figure 3) [2]. This
change of attitude among patients implies a challenge
for the treating surgeon as these patients usually expect
minimal scarring, short down time and natural results.
We introduce modifications on the MACS (“Minimal Access Cranial Suspension”) lift that accomplish these expectations and provide an excellent treatment option for
a large patient group.
Material and methods
Between October 2007 and January 2013 a number of
219 patients were treated with the MACS lift technique
accomplished by a fourth suture on the platysma and
liposuction or optional lipectomy on the neck. We found
a mean age 58 years and operated on 168 female,
51 male patients. Follow-up was scheduled 1, 3, 6, 12,
24 months after surgery (Table 1). On 89 patients closed
transcutaneous platysma myotomy was performed. On
six patients the platysma myotomie was performed secondary under local anesthesia, because they complained
remaining platysmaband appearance after the primary
classic MACS lift.
Surgery time lasted on average 2.5 hours and was performed under sedation with local anesthesia in 85%. We
prefer the optional intraoperative patient mobility of the
head and neck and appreciate the higher muscle tone
under sedation compared to general anesthesia. Recovery
time ranged between 14 to 16 days until the patients
were back to work. Due to their health status 54% of our
patients had an inpatient arrangement for one night and
46% an the outpatient arrangement.
In 91% the modified MACS lift was combined with other
rejuvenation procedures of the face: fat grafting 1%,
canthopexy 10%, perioral peeling 18%, injectables 21%,
eyebrow lift 24%, platysma myotomy 35%, malar sling lift
37%, blepharoplasty superior/inferior 51%/56%, liposuction neck 97%.
Modification
For cases of severe cervical excess skin and destinct
platysmabands we describe a modification of the original
MACS lift which maximizes the rejuvenation effect on the
neck but keeps the proven benefits of short and barely
visible scars. The modification consists of a fourth SMAS
(“Subcutaneous Musculo Aponeurotic System”) plication
suture on the lateral aspect of the platysma and a 3–4 cm
advanced dissection below the mandible to accentuate
the submandibular angle.
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
2/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
Figure 2: Young patient requesting a facelift, pre- (a, c, e) and 24 months postoperative view (b, d, f)
Figure 3: Young patient requesting a facelift, pre- (a, c, e) and 6 months postoperative view (b, d, f)
Table 1: Follow up compliance of male and female patients
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
3/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
‘Fourth suture’
A fourth plication suture on the lateral platysma was
called ‘fourth suture’ in addition to the publication on the
‘third sutrure’ by Verpaele et al. [3]. The medial anchorage
point is located on the platysma in an imaginary vertical
line below the first premolar (Figure 4). The lateral anchorage point is located on the fascia of the sternocleidomastoid muscle. Dissection is done under cold light control and extented beyond the mandibular angle. No further
incisions are needed. The fourth suture is done with nonresorbable 3-0 monofilament and it is crucial to position
the knot inverted deep to the fascia so that it does not
become palpable time after the surgery. The vector pulls
bilateral and adresses the medial platysma with an adequate lifting effect (Figure 5). Several authors support
that aging leads to a certain medialisation of facial skin
which is counteracted by the fourth suture on the
platysma (Figure 6) [4]. The bilateral approach to correct
the platysma appears more physiologically compared to
a medial corsettplasty which is prone to subcutaneous
visible scar formation. Hughe amounts of cervical skin
can be redistributed without any tenting phenomenon on
the neck (Figure 7).
Figure 5: Standard MACS lift dissection boarders (yellow),
boarders of dissection neccessary for the ‘fourth suture’
(orange), lipodissection boarders (green) and traction vector
(white)
Platsyma myotomy
Figure 4: Traction vector of the ‘fourth suture’ (yellow) with its
anchorage point on the sternocleidomastoid fascia (K. O. Kaye)
Platysmabands can be either soft as result of a relaxed
muscle filament due to aging or hard when it forms
palpable fibrotic muscle cords. Careful preoperative examination disginguishes both types and indicates the
adequate surgical technique.
Soft platysmabands (McKinney I–II°) can be treated with
good results by the fourth suture (Figure 7). Hard platysmabands (McKinney III–IV°) need to be treated by
myotomy before applying the fourth suture [5]. We use a
closed myotomy by placing serveral stab incisions
(2–3 mm) along the palpable platysmaband (distance
2–3 cm). Hollow canulas are pierced through the incisions
dorsal and ventral to the platysmaband. A polyfilament
thread (2-0) or wire is flossed in a U-shape around the
platysmaband and the canulas are removed. By moving
it laterally back and forth with decent pressure, it is used
like a saw to dissect the platysmaband on 4 to 5 locations
(Figure 8). The technique was described by different authors such as Daher et al. [6], [7]. Only after platysmaband myotomy the fourth suture can evolve its full
impact on medial platysma lifting.
Complications
The modification of the MACS lift through the fourth suture on the platysma and liposuction or optional lipectomy
on the neck did not alter the complication rate compared
to Verpaele et al. [3]. We analysed a complication rate of
6% which is analog to the classic MACS lift. One patient
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
4/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
Figure 6: Relaxed (a) and tentioned (b) ‘fourth suture’ and its impact on the medial neck
Figure 7: Illustration of the amount of cervical skin that can be redistributed during the modified MACS lift with its ‘fourth suture’
needed revision of a postoperative bleeding due to a
poorly controlled hypertension. Two patients suffered
from a self-limiting preauricular bleeding (<2 cm), which
did not need to be revised. One patient suffered from a
superficial preauricular skin necrosis (<1,5 cm) that
healed by secondary intention without sequelae. One
patient showed postoperative neurapraxy of the marginial
mandibular branch of the facial nerve that recovered
without sequelae within 2 months. There were no injuries
of the zygomatic or buccal branches of the facial nerve.
Discussion
The MACS facelift technique was described by Tonnard
and Verpaele and evolved to an established and popular
technique for facial rejuvenation [3], [8], [9], [10]. The
main advantages of the method are highlighted: Short,
barely visible scars, which make the procedure attractive
for many patients especially for male patients or female
patients with short hair. Limited undermining decreases
the risk of blood circulation disorders and skin necrosis
particularly in patients at risk, such as smokers. The
technique is less invasive than most SMAS (“Subcutaneous Musculo Aponeurotic System”) elevation or SMAS
dissection techniques. It is a save procedure in relation
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
5/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
Figure 8: Outcome of a modified MACS lift and the ‘fourth suture’, pre- (a, c, e) and 6 months postoperative view (b, d, f)
to potential nerve injuries and has a shorter postoperative
down time [11].
Due to the short scar and the purely vertical lifting vector
the option to redistribute larger amounts of excess skin
of the medial neck and submandibular area is limited
[10]. Redistribution of skin is prone to leave pleats the
preauricular area resulting in uneven perilobular scars.
The MACS lift alone shows poor results on the medial
neck in cases of pronounced, rigid platysmabands
(McKinney III–IV°) [10], [12].
The strictly vertical lifting vector as described in the original publication does not sufficiently adress the platysma
and fails to correct medial platysmabands. Since the
vertical traction on the platysma originates cephalad of
the ramus mandibulae a tenting phenomenon results
(Figure 9). The platysma spans and raises the underlying
submandibular fat in a convex instead concave way. As
a result the cervicomandibular angle is blurred instead
of defined.
Verpaeles et al. original publication recognizes the first
two disadvantages and recommends a combination of
their technique with an anterior cervicoplasty to correct
medial platysmabands and a posterior cervicoplasty to
prevent lateral skin pleats in the preauricular area [9].
The presumption of Verpaele et al. that extended dissection along the platysma would lead to a higher rate of
postoperative bleedings could not be seen in our patients.
All surgeries were done under perioperative epinephrine
application. Since the duration of action is shorter than
surgery time we found no altered risk of delayed reactive
hyperemia and consecutive postoperative bleeding. The
use of perioperative epinephrine administration facilitates
the identification of functional structures, allows safer
dissection and shortens surgery time [13]. Analgosedation
provides physiologic blood pressure throughout the surgery without reactive alterations especially during extubation [14]. After facial liposuction the dissection of the very
delicate facial flaps should be performed carefully, any
pressure or stretching of the flap should be avoided. On
smokers limited undermining can be indicated to prevent
necrosis [15], [16]. Plication techniques of the SMAS are
less prone to nerve injuries compared to smasectomy
methods [17].
Conclusion
The modification of the MACS lift with the ‘fourth suture’
on the platysma keeps the benefits of the original technique but improves the aesthetic outcome on the neck
(Figure 10). Short scars, short surgery time and a high
safty of the procedure make it convenient to both patient
and surgeon. Platysmabands should be examined and
classified prior to surgery. McKinney type I–II can be
treated only by lateral approach of the ‘fourth suture’,
type III-IV should be treated with closed platysma myotomy
before. Liposuction of the cheeks and neck is an important tool to prepare and ease dissection. Optional retroplatysma lipectomy can be indicated to reconstruct the
cervico-mandibular angle if retroplatysma fat deposits
are responsible for a hanging neck. The original technique
of the MACS lift delivers excellent results on the midface
and leads to sustainably improved outcome by adding
the fourth suture as key procedure to accentuate the
mandibular angle of the neck.
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
6/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
Figure 9: Closed myotomy of hard platysma bands (McKinney III–IV°)
Figure 10: Disappearance of hard platysma bands (McKinney III–IV°) after closed myotomy, modified MACS lift and the ‘fourth
suture’
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
7/8
Kaye et al.: The fourth suture in MACS facelifting – adressing ...
Notes
11.
Kestemont P. Description et analyse critique de la technique de
X-MACS-lift dans la suspension malaire, selon Tonnard et
Verpaele [Description and critical analysis of the Tonnard and
Verpaeles technique for malar suspension]. Ann Chir Plast Esthet.
2009 Oct;54(5):421-4. DOI: 10.1016/j.anplas.2009.03.009
The authors declare that they have no competing interests.
12.
McKinney P, Tresley GE. The maxi-SMAS: management of the
platysma bands in rhytidectomy. Ann Plast Surg. 1984
Mar;12(3):260-7. DOI: 10.1097/00000637-198403000-00008
Level of evidence
13.
Koeppe T, Constantinescu MA, Schneider J, Gubisch W. Current
trends in local anesthesia in cosmetic plastic surgery of the head
and neck: results of a German national survey and observations
on the use of ropivacaine. Plast Reconstr Surg. 2005
May;115(6):1723-30. DOI:
10.1097/01.PRS.0000161671.34502.40
14.
Friel MT, Shaw RE, Trovato MJ, Owsley JQ. The measure of facelift patient satisfaction: the Owsley Facelift Satisfaction Survey
with a long-term follow-up study. Plast Reconstr Surg. 2010
Jul;126(1):245-57. DOI: 10.1097/PRS.0b013e3181dbc2f0
Prendiville S, Weiser S. Management of anesthesia and facility
in facelift surgery. Facial Plast Surg Clin North Am. 2009
Nov;17(4):531-8, v. DOI: 10.1016/j.fsc.2009.06.010
15.
Pusic AL, Klassen AF, Scott AM, Cano SJ. Discussion. The
measure of face-lift patient satisfaction: the Owsley Facelift
Satisfaction Survey with a long-term follow-up study. Plast
Reconstr Surg. 2010 Jul;126(1):258-60. DOI:
10.1097/PRS.0b013e3181dbba19
Abboushi N, Yezhelyev M, Symbas J, Nahai F. Facelift
complications and the risk of venous thromboembolism: a single
center’s experience. Aesthet Surg J. 2012 May;32(4):413-20.
DOI: 10.1177/1090820X12442213
16.
Knobloch K, Gohritz A, Reuss E, Vogt PM. Nikotinkonsum und
plastische Chirurgie: Eine aktuelle Ubersicht [Nicotine in plastic
surgery: a review]. Chirurg. 2008 Oct;79(10):956-62. DOI:
10.1007/s00104-008-1561-3
17.
Prado A, Andrades P, Danilla S, Castillo P, Leniz P. A clinical
retrospective study comparing two short-scar face lifts: minimal
access cranial suspension versus lateral SMASectomy. Plast
Reconstr Surg. 2006 Apr;117(5):1413-25; discussion 1426-7.
DOI: 10.1097/01.prs.0000207402.53411.1e
Competing interests
Level IV, therapeutic study
References
1.
2.
3.
Verpaele A, Tonnard P, Gaia S, Guerao FP, Pirayesh A. The third
suture in MACS-lifting: making midface-lifting simple and safe.
J Plast Reconstr Aesthet Surg. 2007;60(12):1287-95. DOI:
10.1016/j.bjps.2006.12.012
4.
Truswell WH 4th. Aging changes of the periorbita, cheeks, and
midface. Facial Plast Surg. 2013 Feb;29(1):3-12. DOI:
10.1055/s-0033-1333840
5.
McKinney P. The management of platysma bands. Plast Reconstr
Surg. 1996 Nov;98(6):999-1006. DOI: 10.1097/00006534199611000-00011
6.
Daher JC. Closed platysmotomy: a new procedure for the
treatment of platysma bands without skin dissection. Aesthetic
Plast Surg. 2011 Oct;35(5):866-77. DOI: 10.1007/s00266-0119782-0
7.
Gonzalez R. Composite platysmaplasty and closed percutaneous
platysma myotomy: a simple way to treat deformities of the neck
caused by aging. Aesthet Surg J. 2009 Sep-Oct;29(5):344-54.
DOI: 10.1016/j.asj.2009.04.007
8.
Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy.
Aesthet Surg J. 2007 Mar-Apr;27(2):188-98. DOI:
10.1016/j.asj.2007.01.008
9.
Tonnard PL, Verpaele A, Gaia S. Optimising results from minimal
access cranial suspension lifting (MACS-lift). Aesthetic Plast Surg.
2005 Jul-Aug;29(4):213-20; discussion 221. DOI:
10.1007/s00266-005-0047-7
10.
Verpaele A, Tonnard P. Lower third of the face: indications and
limitations of the minimal access cranial suspension lift. Clin
Plast Surg. 2008 Oct;35(4):645-59, vii. DOI:
10.1016/j.cps.2008.04.001
Corresponding author:
Dr. med. Daniel R. Sattler
University Hospital Magdeburg, Department of Plastic
Aesthetic and Handsurgery, Leipziger Str. 44, 39120
Magdeburg, Germany
daniel@sattler.com
Please cite as
Kaye KO, Sattler DR. The fourth suture in MACS facelifting – adressing
the neck. GMS Ger Plast Reconstr Aesthet Surg. 2014;4:Doc09.
DOI: 10.3205/gpras000028, URN: urn:nbn:de:0183-gpras0000286
This article is freely available from
http://www.egms.de/en/journals/gpras/2014-4/gpras000028.shtml
Published: 2014-12-22
Copyright
©2014 Kaye et al. This is an Open Access article distributed under the
terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You
are free: to Share — to copy, distribute and transmit the work, provided
the original author and source are credited.
GMS German Plastic, Reconstructive and Aesthetic Surgery 2014, Vol. 4, ISSN 2193-7052
8/8