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38. Basic Elastic MACS and Neck Lift without dissection of the cheeks and neck, step-by-step

KEYWORDS: Elastic MACS Lift, Elastic Neck lift, Elastic Plastic Surgery, Elasticum suture, Jano needle

The video illustrates all the phases of this ambulatory procedure, which is carried out under local anaesthesia through a very short incision that surrounds the lower part of the sideburn and stops at the tragus.
In MACS and Neck Lifting by means of the elastic thread and two-tipped needle, the cheeks and neck are not dissected.
The absence of dissection avoids trophic damage to the tissues of the face and neck.
The procedure is performed when the skin at the sideburns can be pitched between two fingers.
The aim of this procedure is not to make the patient more beautiful, but to rejuvenate the face and neck in a natural way.

This patient is about to undergo an elastic lifting procedure. We have chosen to perform MACS lifting because the excess skin at the sideburn can be pinched between two fingers. Elastic lifting of the neck will also be carried out through the same short incision at the sideburn.
A line is drawn between the lower margin of the wing of the nose and the lowest part of the earlobe.
The skin at the two corners of the mandibula is pressed upwards, the patient's head is bent slightly forward and the cervicomandibular angle is marked out.
The excess volumes are identified.
The first of the two vectors that will suspend the cheek is drawn at a distance of 2 cm from the ear. The second vector is drawn at a distance of 3 cm from the first one.
The vector that will suspend the malar region is now drawn.
Next, we draw the incision, which surrounds the lower part of the sideburn and stops at the tragus. The return pathway of the elastic thread is drawn 1 cm above the cervicomandibular angle; this thread will support the submental tissues. If the return thread is positioned below, it will lift the antero-inferior skin of the neck.
The scheme of the Basic Elastic MACS and Neck Lift utilises two triangles to lift the cheeks, one triangle to lift the malar region, and one elastic thread running between the two fasciae of Loré.
Local anaesthesia is carried out by means of 10 mL of 2% mepivacaine and 10 mL of 2% lidocaine. From 2/3 mg to 1 mg of epinephrine is added to the mepivacaine vial. A 10 mL syringe is filled with 5 mL of 2% mepivacaine and 5 mL of 2% lidocaine; the anaesthetic is administered along the lines of the incisions, in the areas of dissection in the temporal region and in the preauricular tunnel.
Two 10 mL syringes are filled with 2.5 mL of 2% mepivacaine and 2.5 mL of 2% lidocaine. The syringes are then topped up with Ringer lactate solution or physiological solution to a level of 12 mL. This anaesthetic solution is injected along the pathway of the threads.
This is the amount of anaesthetic solution needed if liposuction or Adipolysis are not performed.
Once the excess subcutaneous tissue has been evaluated, it is reduced by means of liposuction or, as in this case, Adipolysis. Liposuction is used when large amounts of fat are to be removed.
When only a modest amount of adipose tissue is to be removed, we prefer to perform Adipolysis, as this does not leave scars or produce fibrosis, and can be repeated after two months.
When Adipolysis is performed, the anaesthetic is injected at the entry point of the partially insulated electrode and, if necessary, around the area to be reduced, but never at the point where the procedure is to be performed.
Adipolysis reduces the adipocytes without damaging the connective stroma. Moreover, it does not require any elastic containment.
The incision used in elastic MACS lifting surrounds the lower portion of the sideburn, which can be raised if it is too low or lowered if the patient has already undergone a traditional lifting procedure that has raised it. If the sideburn is too high, the face will have an unnatural appearance; if, by contrast, it is too low, the face will not look bright.
Next, the incision travels upwards in the hairless area in front of the ear and then descends, stopping at the tragus. The operator now inclines the scalpel in order to avoid damaging the hair follicles and to maintain good vascularisation of the margins.
The sideburn should be raised if the distance between the incision and the zygomatic arch is too great. It must also be borne in mind that part of the dissected skin flap will be removed, as it constitutes the excess vertical skin that was assessed by pinching the skin of the sideburn before the elastic MACS lift procedure.
Dissection is started by means of scissors. The dissection is carried out on the superficial fascia. The operator carries out hemostasis as dissection proceeds.
Particular attention must be paid to dissection in the vicinity of the frontal branch of the facial nerve, in order to avoid paralysis; in our experience, however, this is always temporary.
The area of interest in this region is a small circular area which is slightly depressed on palpation; it is located immediately laterally to the orbital margin, at the point where this latter meets the zygomatic arch. In this area, the nerve branch is more superficial, running immediately beneath the superficial fascia.
Dissection extends slightly beyond the zygomatic arch. In order to perform elastic lifting of the neck, the operator uses scissors to create a subcutaneous tunnel anterior to the ear; about 1 cm wide, this tunnel first reaches and then goes beyond the fascia of Loré.
Dissection is easy if the operator skims the parotid fascia and the fascia of Loré. The elastic thread will be anchored to the fascia of Loré in order to lift the neck.
The operator uses a finger to check that dissection extends beyond the zygomatic arch.
Dissection is now over and thorough haemostasis is carried out.
A spreader is used to check the subcutaneous tunnel above the fascia of Loré.
The three suspension triangles are now created; these lift the tissues situated inside the triangles and the adjacent tissues.
The two-tipped Jano needle anchors the elastic thread to the temporal fascia.The needle enters the upper portion of the corner of the skin flap and is directed towards the pre-established point.
The operator moves the needle slightly up and down and laterally to check that the pathway of the needle is superficial and regular and is not causing any indentation of the skin.
In the malar region, the pathway of the two-tipped needle must be above the superficial fascia, below which the frontal branch of the facial nerve runs.
The two-tipped needle is now directed towards the entry point in the temporal fascia. The operator uses a finger to check that the needle emerges from the skin flap in the upper portion of the corner.
The two ends of the elastic thread are placed under tension and knotted.
The second elastic thread is now implanted.
As always, the Jano needle passes through the temporal fascia and an enters the upper portion of the corner of the skin flap.
The operator checks that there are no introflections and that the skin is mobile. The elastic thread is pulled through. When 5 mm of the tip of the needle remains in the tissues, the posterior tip becomes anterior and the needle is rotated slightly and directed towards the point of entry in the fascia, where the thread is placed under traction and knotted.
Now we implant the elastic thread that creates the second triangle to suspend the cheek – the triangle closer to the ear.
The Jano needle anchors the elastic thread to the temporal fascia. Bleeding is rare during this manoeuvre; if it does occur, the thread is extracted and the bleeding is stopped by means of trans-facial stitches. The Jano needle is partially extracted and the thread is pulled through.
The depth marks on the shaft of the needle are counted. When 5 mm of the tip remains in the tissues, the two-tipped needle is slightly rotated and directed towards the entry point in the temporal fascia. The operator uses a finger to check that the needle emerges in the upper part of the corner of the dissected skin flap.
The ends of the elastic thread are placed under tension and pinched together by means of a Klemmer.
Now the Elastic Neck Lift is carried out.
The suspension thread is implanted between the two fasciae of Loré.
Having inserted the spreader, the operator pierces the fascia of Loré tangentially and superficially with a 16.5 cm two-tipped needle. The fascia of Loré has a fibrous consistency. To fix the elastic thread, a short passage is sufficient: 5-8 mm in length and about 2 mm in depth. Particular care needs to be taken in this region if the patient has already undergone a traditional lifting procedure, owing to the loss of subcutaneous tissue.
The Jano needle partially emerges along the lower line of the design, which represents the position of the cervicomandibular angle.
The elastic thread is pulled through. When 5 mm of the tip remains in the tissues, the two-tipped needle is rotated and continues on its pathway along the preoperative design. The operator moves the needle slightly up and down to ensure that it is not too superficial. The Jano needle partially emerges along the line drawn preoperatively.
The needle is partially extracted and the elastic thread is pulled through and placed under tension. When 5 mm of the tip remains in the tissues, the two-tipped needle is rotated and continues along its pathway. When the needle is rotated, particular care must be taken to ensure that it does not come out of the tissues.
The two-tipped needle is partially extracted and the elastic thread is pulled through.
The Jano needle is now rotated and directed towards the contralateral fascia of Loré.
The needle enters the tunnel under the guidance of the spreader. The elastic thread is pulled through. The two-tipped needle pierces the fascia of Loré tangentially in order to anchor the elastic thread.
In this procedure, the elastic thread can be anchored by sight, through the tunnel. If no other elastic threads are to be implanted, for example in order to place traction on the submental platysma or to flatten marionette wrinkles, it is not necessary to create this tunnel; the thread is anchored to the fascia of Loré blindly.
The two-tipped needle partially emerges along the anterior line of the design. The elastic thread is placed under tension. The Jano needle continues to travel along the upper line of the design in the direction of the entry tunnel. The spreader is inserted and the two-tipped needle emerges from the tunnel. The two ends of the elastic thread in the neck are placed under tension and knotted.
The operator knots the ends of the threads that form the second triangle that suspends the cheek.
All the excess vertical skin is now removed. The excess skin is marked with the aid of the pincers. The scalpel is inclined in order to leave enough subcutaneous and dermal tissue to attach the flap to the temporal fascia.
The stitches that attach the flap are made of long-dwelling absorbable material. The dermal and intradermal stitches are made of a material that is absorbed in a shorter time.
The procedure is over.
The patient will need to wear an elastic bandage for at least two months, though not continuously, in order to enable the elastic threads to be transformed more rapidly into ligaments.
Skin folds and pits can easily be covered by the patient's long hair, and will disappear within a few weeks. The patient has a natural, rejuvenated look. The skin has been raised and its vascularisation improved. Now that it is no longer stretched by gravitational ptosis, the skin looks younger.

Capurro S. (2017): Basic Elastic MACS and Neck Lift without dissection of the cheeks and neck, step-by-step. CRPUB Medical Video Journal. – Elastic Plastic Surgery section. http://www.crpub.org

FAQ

This video publication shows that dissection of the cheeks and neck is not necessary. What are the advantages of not performing dissection in these two regions?

Elastic MACS and Neck Lifting does not carry the risks of traditional lifting procedures, and can be performed even on heavy smokers. The concept underlying the elastic lifting procedures differs from that of traditional lifting procedures, in which ample dissection of the tissues of the cheeks and neck is carried out; instead of dissecting the tissues, new ligaments are implanted.
As the cheeks and neck are not dissected, the trophic damage caused by dissection is avoided. When the elastic thread and the two -tipped needle (Elasticum, Korpo) are used, the cheeks and neck no longer need to be dissected. Today, it is irrational to think that the face or neck can be rejuvenated by damaging their vascularization. The results of dissection are well known: loss of the subcutaneous tissue and of the natural coloring of the face. In elastic MACS and Neck lifting, the cheeks and neck are placed under traction and suspended by means of elastic threads, which are transformed into ligaments within a short time. Only in the temporal region, below the sideburn, do we carry out a few cm² of dissection, which enables the excess vertical skin to be removed. In comparison with traditional lifting procedures, the scars left by elastic MACS lifting are short, stopping at the tragus.
In the neck, there is no need to remove any skin; the excess skin and subcutaneous tissues cover the new cervicomandibular angle or are repositioned laterally, where they are used to correct hypotrophy of the neck region.
After Elastic MACS lifting, the skin has a more pleasing and more vascularized look; the vessels are no longer stretched by gravitational ptosis and the blood supply to the tissues is improved. The results of Elastic MACS and Neck lifting are extremely natural. With these lifting procedures, the patient does not become more beautiful, but has a more youthful look.
The absence of dissection of the cheeks and neck enables maintenance over time to be carried out easily. Any defects that arise are corrected by means of incisions of a few millimeters. Moreover, the two-tipped needle enables traction to be applied to the tissues exactly where it is needed.

When is basic MACS and Neck Lifting indicated?

MACS lifting is carried out if the skin at the sideburn can be folded. For what concerns the neck, simply running the elastic thread between the two fasciae of Loré is indicated in patients who do not have drooping neck skin. The patients seen in this video was a borderline case. If there is drooping skin, Elastic Neck Lifting is performed by means of safety pins. This recent procedure prevents the skin in the anterior neck region from sliding downwards and creating a skin fold. As it is minimally invasive, the basic MACS lift is also indicated in young patients who wish to counteract gravitational ptosis and retard aging.

What are the complications?

Immediately after the procedure, the patient may feel some pain, which can be alleviated by specific analgesics. For a few weeks, some skin alterations may remain; these can normally be masked if the hair is long. Particular attention should be paid to the temporal branch of the facial nerve. This nerve is very sensitive and simple traction of the malar region can cause monolateral drooping of the eyebrow. If this happens, we immediately restore symmetry by means of botulin and wait until the nerve resumes its function, as has always been the case. In some cases, we carry out elastic lifting of the eyebrows and neck regions, if this has been planned. This elastic lifting procedure requires no dissection either.

What is Adipolysis used for?

Just as Adipofilling enables us to increase tissue volumes where necessary, Adipolysis enables us to reduce tissue volumes (if they are not so large as to require liposuction). We apply this technique of Timedsurgery to reduce a slight double chin, excess volume of the cheeks, and malar pouches. Adipolysis, when performed at the same time as lifting, visibly improves our results. The advantages that Adipolysis has over liposuction are that it does not leave any marks, it causes little trauma, small areas can be treated, it does not cause fibrosis, and it can be repeated after two months, if necessary.  Adipolysis reduces the number of adipocytes without damaging the connective stroma. There is no need to apply an elastic bandage to the areas treated. Just one word of warning: the anesthetic solution must not be infiltrated into the areas where Adipolysis is to be performed; rather, barrier anesthesia is carried out.

How have these new techniques of elastic lifting without dissection been received by other aesthetic surgeons?

Those who have got to know them, both in Italy and abroad, have adopted them. In Korea, for example, all the most important clinics in Gangnam use the elastic thread. The surgeons who have adopted these procedures operate more and are able to meet the needs of their patients more effectively and more economically; it should be remembered that all the Elastic Plastic Surgery operations are ambulatory procedures. In Italy, a small percentage of surgeons have shown no interest in these techniques, perhaps because it is difficult to imagine lifting the face and neck without ample dissection.
The elastic thread has been designed by a surgeon with great experience of lifting procedures. It does not cut into the tissues and is transformed into a suspension thread. The same surgeon invented the two-tipped needle in 1983. However, after testing the needle with all the threads available at that time, he abandoned its use for several years; all the threads cut into the subcutaneous tissues! Hence, the invention of the elastic thread. This author has never been known to implant an absorbable thread. Moreover, the only non-absorbable thread he has implanted is the Elasticum thread. Indeed, as the son of a professor of Anatomy and Histology, he has profound knowledge of the subcutaneous tissue. He therefore realized that only a new suturing thread could be efficacious, and that a surgical technique that did not damage the trophism of the tissues would revolutionize the surgical lifting of the face, neck, breast and buttocks.

POST-PUBLICATION REVIEW

Elastic MACS lifting replaces the traditional lifting procedures, which require tissue dissection and manipulation of the SMAS. Its advantages are numerous: it does not cause trophic damage to the tissues, markedly rejuvenates the face, requires only a minimal skin incision (from the sideburn to the tragus), enables elastic neck lifting to be performed through the same incision (again without dissection), and is vertical and minimally invasive.
The isosceles triangles created by the elastic thread lift the facial volumes and straighten the vasculature, giving the skin a more pleasing appearance The results can easily be maintained over time by means of tiny incisions.
This ambulatory procedure is carried out under local anesthesia. Only two 10 ml vials of 2% Mepivacaine are enough for elastic MACS and Neck lifting. The content of one vial is applied pure to the access points, above the zygomatic arch and in the tunnels above the fascia of Loré. The content of the other vial is diluted to 40% and used to anesthetize the pathways of the threads in the cheeks and neck.
After MACS lifting, no bandages are needed; only an antibiotic ointment is applied to the skin incisions, and will be reapplied over the following days until the stitches are removed. If the patient has long hair, this will cover all the areas that have undergone lifting. During the same session, and through the same access, the recently designed Elastic Canthopexy procedure can be performed; this elongates the eyes and completes the rejuvenation of the face.
The elastic threads can also be used to correct the results of traditional lifting operations.
As elastic MACS lifting conserves the integrity of the circulation in the cheeks, it can also be performed in patients in the fourth decade of life (30-42 years), thereby preventing aging of the face.
Elastic MACS lifting constitutes the future of face-lifting in both young and elderly patients. (31/10/19)