51. Elastic MACS lift and elastic Canthopexy
KEYWORDS: Elastic MACS lift and elastic canthopexy, elongation of the eyes, round eyes, Elasticum suture, Jano needle, close-up eyes
Correction of drooping cheeks and round eyes. An elastic MACS lift and elastic canthopexy are carried out. The point of anchorage of the elastic thread is marked very close to the external canthus or immediately below it. The apex of the malar suspension triangle and the two apexes of the triangles that will lift the cheeks are marked out. The bisectors of the Isosceles triangles are also drawn.
The preoperative design is only indicative. Especially in the cheeks, the operator may vary the position of the lowest point of traction and the inclination of the Isosceles triangle, to obtain a uniform suspensive effect. Before implanting the first elastic thread in the cheek, the operator uses a finger to raise the skin to be placed under traction. This maneuver avoids the formation of skin folds.
Local anesthesia is carried out with lidocaine or mepivacaine; ½ mg of epinephrine is also added to the 10 mL vial.
The skin incision crosses the sideburn and follows the hairline and then the ear, stopping at the tragus. Dissection of the skin flap is carried out above the fascia and extends slightly beyond the zygomatic arch. The operator remains within the rectangle marked in blue, so as not to come close to the temporal branch of the facial nerve, which is sensitive even to the simple compression of a spreader.
The elastic threads (Elasticum EP3,5 – EP4, KORPO) are implanted from the inside to the outside. The first Isosceles suspension triangle is the one used for canthopexy. The Jano needle enters directly into the fascia and emerges from the skin, fixing the elastic thread. In this way, the base of the Isosceles triangle is created. The two-tipped needle is extracted until 5 mm of the posterior tip remains in the tissues. It is then rotated and emerges very close to the external canthus or, preferably, below the external canthus at a distance of about 8 mm from the apex of the canthus, where it is easier to fix the elastic thread to the retinaculum. The tip of the needle must meet with a certain resistance; this indicates that it is correctly passing through the fibrous tissue of the retinaculum. The Jano needle passes through the subcutaneous tissue and reaches the entry point on the temporal fascia. The two ends of the elastic thread are placed under tension and knotted. The operator now creates the second suspension triangle, which lifts the malar region. The pathway of the needle is superficial and does not extend beyond the apex of the cheekbone. When the Isosceles suspension triangle is complete, the two ends of the elastic thread are placed under tension and knotted. If the malar skin does not rise, the elastic thread must be re-implanted more superficially.
The first elastic thread is implanted in the cheek. The thread runs through the subcutaneous tissue at a uniform depth. To check that the pathway is regular, the operator moves the needle slightly up and down. If any introflexion of the skin is observed, it means that the pathway is too superficial at that point. Once the triangle has been completed and the two ends of the thread have been placed under tension, no skin folds must form. If they do form, the thread is extracted and re-implanted along a modified pathway. The same procedure is followed in order to implant the second and last thread in the cheeks. The Jano needle now remains within the dissected area. To enable the volumes to be raised, the tip of the Jano needle must always enter and exit the subcutaneous tissue in the superficial part of the angle of dissection. In this way, the operator avoids the risk of fixing the flap to the underlying facial tissues. When the elastic threads have been implanted, the excess skin becomes evident. With the Pitanguy pincers, the operator marks the portion of the flap that will be removed. The skin excision must be complete. Unlike what happens in traditional lifting procedures, in the elastic MACS lift the skin that is drawn upwards helps to keep the volumes up. The incision used to excise the flap is inclined in order to enable the deep portion of the flap to be fixed to the temporal fascia. The flap is fixed to the fascia with 3-0 sutures that are absorbed in 120 days; further skin stitches with a 4-0 thread of medium-term absorption are inserted. Subsequently, an intradermal suture is carried out with Quick absorbable threads. The suture is completed by means of separate Quick stitches.
Capurro S. (2021): Elastic MACS lift and elastic Canthopexy. CRPUB Medical Video Journal. Elastic Plastic Surgery section. www.crpub.org.
Can you lift the canthus through the incision used for MACS lifting?
The eyes can be elongated. If a more marked lifting effect is desired, it is preferable to create an Isosceles suspension triangle higher up. An incision of a few millimeters is made at the hairline, in a higher position than the incision used in MACS lifting. If elastic canthopexy is performed through the MACS lift incision, the eyes will be elongated, an effect which constitutes natural rejuvenation of the original shape of the eyelids. If the patient has down-sloping eyes, the canthus can be visibly raised through this incision, too. As elastic canthopexy elongates the eyes, it visibly improves the appearance of those whose eyes are very close together.
Do you only use absorbable suture threads?
Yes, I use sutures that are absorbed over different times: 120 days in depth, 30 days in the dermis, and about 10 days at the surface.
Is the skin that is marked out by means of the Pitanguy pincers completely removed?
Yes, because the traction of the skin helps to raise the volumes.
Isn't there a risk that you may not be able to close the substance loss?
This has never happened. However, if it did happen, we would dissect ½ cm or 1 cm of the upper part of the sideburn and then suture. In any case, the flap is fixed to the temporal fascia.
Some women have low sideburns. What should be done in such cases?
In women, the incision enables us to reduce sideburns that are too long, which reduce the brilliance of the face.
Can Elastic MACS lifting improve the results of traditional face-lifting techniques?
Yes, it can improve the results of traditional facelifts without damaging the trophism of the cheeks and neck, which, as we have seen, are not dissected. Moreover, broadening the base of the Isosceles triangles enables us to lift even heavy faces. Implantation of the elastic threads replaces the manipulations of SMAS. The advantages are many: Elastic MACS lifting requires only minimal entry incisions, even of a few millimeters; it avoids the damage to blood vessels and nerves that is caused by dissection, which is a characteristic of traditional procedures; and it is a simple procedure that is carried out under local anesthesia. Moreover, the results can always be subsequently perfected by means of minor ambulatory procedures. For example, further elastic threads can be implanted in order to correct marionette wrinkles; Adipofilling can be performed in order to correct volume deficits or rejuvenate the skin in depth, and mixed peeling can be carried out to rejuvenate the surface of the skin. In addition, the tissues can be kept youthful and firm by applying the Korpocare bionic serums, which are INCI green-coded and created by means of a nuclear technology.
After elastic MACS lifting, no bandaging is required; only an ointment is applied to the incisions. The small alterations of the skin can initially be masked by the hair, but will disappear within a short time. As the threads do not cut into the tissues, and are transformed into ligaments, the result is permanent.
If necessary, elastic MACS lifting can also be performed in the third decade of life, as it is minimally invasive and prevents gravitational ptosis.
Some surgeons think that suspension by means of threads is not efficacious…
Evidently, these surgeons are not well informed, are unwilling to explore the subject, or do not want to learn new techniques. I have never implanted absorbable suspension threads nor the common non-absorbable suspension threads. In 1983, I designed the two-tipped needle and tried it out with all the existing threads, but without success. I therefore designed the elastic thread together with a new two-tipped needle. This combination works well not only in the face and neck, but also in the breast, buttocks and arms, and in large skin excisions. Nowadays, patients no longer want to undergo traditional lifting. Rather, they are looking for procedures that do not destroy the trophism of the region – procedures that do not require dissection of the cheeks and neck, which enable them to resume their normal activities, even the very next day, and which yield natural results that are superior to those of traditional techniques, especially if performed in the third, fourth, fifth and sixth decades of life.
The frontal branch of the facial nerve must never be compressed. Is that right?
If dissection remains within the preoperatively drawn rectangle, there is no risk of torpor of the nerve. If the nerve is compressed, however, the eyebrow may descend, and this effect may last from a few days to a few weeks. In this case, botulin toxin injections are carried out in order to reduce the height of the contralateral eyebrow until the situation normalizes.
No comments yet