06. Elastic MACS lift and Adipofilling
KEYWORDS: Elastic MACS lift, elastic suture, two-tipped atraumatic needle, Adipofilling.
Elastic MACS lift is one of the face-lifting procedures of Elastic Plastic Surgery. This ambulatory procedure yields excellent aesthetic results and involves minimal blunt dissection of the tissues. The operation can be performed in an ordinary surgical ambulatory. An incision is made which loops around the sideburn and continues to the tragus. Depending on the amount of excess skin, the incision may end at the tragus or, as in the case described, extend to the earlobe. In the temporal region, subcutaneous dissection is carried out immediately below the hair bulbs, above the superficial temporal fascia. The elastic thread (Elasticum, Korpo SRL), equipped with a two-tipped atraumatic needle (Jano Needle®), enables skin dissection and its associated complications to be kept to a minimum. If neck lifting is to be carried out at the same time, the peri-auricular incision is extended to the lobe and, in patients with severe drooping of the skin, to the posterior portion of the ear. Dissection of the skin around the inferior portion of the ear is directly proportional to the amount of skin that needs to be removed (see Elastic Neck Lift).
Elastic MACS lift
When dissection of the region and haemostasis have been carried out, the Jano Needle® passes through the deep temporal fascia in order to anchor the elastic thread. The two-tipped needle is now inserted into the subcutaneous tissue in the direction indicated by the vertical lines drawn preoperatively on the skin in accordance with the face-lifting needs of the patient. The anterior tip of the needle emerges 1 cm beyond the point predetermined for suspension. The two-tipped needle must not be completely extracted. When the point where the thread is attached to the needle is visible, the operator pulls the elastic thread through and withdraws the needle until the posterior tip reaches the predetermined point. The posterior tip now becomes anterior and travels back towards the temporal region through the subcutaneous tissue until it reaches the point where the thread enters the deep temporal fascia. The elastic thread is then knotted. The vertical traction on the cheek and lateral region on the neck is clearly visible. The second elastic thread is now implanted.
The Elasticum® thread has the advantage that it does not cut into the tissues. Moreover, as it has the same consistency as the subcutaneous tissue, it is impalpable to the touch. Within a few weeks, the thread is colonised by fibrohistiocytic cells, and becomes a natural suspensive ligament which exerts a long-lasting lifting action.
A third thread is implanted in the orbicular muscle. The Jano Needle® passes through the deep temporal fascia. The elastic thread is placed under traction, the excess skin is removed and the wound is sutured.
Minor ambulatory procedures are able to rejuvenate the face by correcting gravitational ptosis and reducing subcutaneous tissue.
Ambulatory elastic MACS lift and simultaneous Adipofilling®. Result after one week. Before this procedure, the patient had already undergone shortening of the upper lip.
Capurro .S, Capurro M.E. (2008): Elastic MACS lift. CRPUB Medical Video Journal. Elastic Plastic Surgery section. http://www.crpub.org
Is the blunt dissection subcutaneous?
In this procedure, it is. Blunt dissection is subcutaneous and proportional to the amount of excess skin.
Can it be deep?
If it is deep, i.e. at the level of the deep temporal fascia, dissection is even more limited and does not extend below the zygomatic arch.
What are the advantages of the elastic MACS lift?
The advantages of the procedure are: great efficacy achieved through minimum invasiveness, lower risk of haematoma, maintenance of normal vascularisation and innervation, and the fact that this is an ambulatory procedure. As is well known, dissection damages the trophism of the tissues and increases both the risks involved and the duration of postoperative recovery.
What precautions should be taken when the elastic thread is being implanted?
The operator has to study the face and mark out the pathway of the elastic thread. Once slight dissection has been carried out, the Jano Needle® is inserted into the subcutaneous tissue at the same depth. Moving the tip of the needle up and down slightly will indicate whether the pathway of the needle is becoming too superficial; if it is, the needle is withdrawn slightly and the trajectory is corrected. Once the two-tipped needle has reached the point of (partial) extraction, the posterior tip must not be brought too close to the surface, as the traction of the elastic thread would cause introflexion of the skin.
What must be done if this happens?
The thread must be removed and implanted again.To avoid introflexion of the skin, the tip of the needle should be made to penetrate slightly more deeply before it emerges from the skin. The depth marks on the shaft of the needle help the operator to implant the thread at the correct depth.
What must be done if the two-tipped needle is completely extracted by mistake?
In this case, too, the elastic thread must be removed and replaced.
How long does it take for the elastic thread to be colonised by fibrohistiocytic cells?
This will depend on the vascularisation of the region where the thread is implanted. We can, however, suppose that colonisation occurs in three weeks and is completed within a few months. Moreover, we have the impression that applying physiological solution to the thread before implantation can accelerate its integration into the tissues.
What about lifting the medial third of the face?
This procedure can be used to lift the medial third. If greater lifting is required, subperiosteal dissection of the malar region is performed through an incision.
On the basis of your experience over the years, what suggestions would you make for operators who would like to start performing Elastic MACS lift?
The first thing is to insert the Jano Needle® accurately; the slight up-and-down movement of the tip helps to ensure that the needle is not too superficial, thus avoiding the creation of evident introflexion of the skin. Another suggestion is to wet the Elasticum thread with physiological solution. Finally, the right amount of skin must be removed, as this will affect the result. Naturally, suturing must be carried out in two layers and with care.
Video publication (6) shows an incision extending to the lobe of the ear and dissection extending well beyond the zygomatic arch. In more recent MACS lifts, the incision stops at the tragus and dissection extends only slightly beyond the zygomatic arch. In Elastic Plastic Surgery, dissection is limited as it produces trophic and nerve damage, which is unnecessary and certainly does not help to make the patient’s appearance more youthful.
In the most recent MACS lifting procedures performed by means of the elastic thread, an elastic Neck lift that exploits the same access is almost always carried out at the same time. A subcutaneous tunnel beneath the fascia of Loré enables the elastic threads to be anchored for the Neck lift. The elastic thread fixed between the two fasciae of Loré restores the cervico-mandibular angle and markedly reduces the lateral excess skin, which is not removed.
Combining elastic MACS lifting with Adipofilling is a highly effective way of enhancing facial volumes and symmetry and improving the trophism of the tissues. Adipofilling can be injected both in depth and superficially, immediately beneath the dermis, without the complications of lipofilling. (30/07/15)