SECTION I • Aesthetic Surgery of the Face

Facelift: Facial rejuvenation with loop

6.4 
sutures – the MACS lift and its derivatives
Mark Laurence Jewell

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sometimes easier to fall in love with a single technique of facial

SYNOPSIS
■ Limit undermining of skin to planned areas for suture loops or for
redraping of skin. The indiscriminate delamination of skin of neck
structures or in the postauricular region can unduly influence outcomes.
Undermine only as necessary to accomplish the lift, not more.
■ Ensure that the neck loop suture has a good bite of platysma fascia.
This is important to prevent failure of the necklifting component.
■ Do not make the cheek loop too small. This can result in a wad of
tissue that cannot be made smooth.
■ Understand the ability that you have to innovate with the MACS lift,
based on your patient’s individual needs. Too often, we become
wedded to a sequence of techniques and ancillary procedures that
limits our ability to individualize and adapt for each of your patients.
■ The MACS suture loop suspension approach works nicely in
secondary or revisionary situations, where there has been earlier deep
layer work and repeat deep layer dissections could be both challenging
and risky. MACS loop sutures hold well in scar from previous surgery.
■ Critical evaluation of outcomes is part of the learning process in terms
of determining what went right and areas that require improvement.
Refinement of technique comes with an honest analysis of the outcome.
Introduction
Facial rejuvenation surgery has had an interesting evolution
over the last 75 years. It is an interesting exercise to examine
the chronicle of progress of facial rejuvenation surgery and at
the same time, critically ask ourselves, “What were they
thinking when they came up with that particular procedure
for facial rejuvenation?” Our concept regarding facial rejuve-
nation has evolved beyond surgical technique to now encom-
pass facial aesthetics, ancillary treatments, biomechanics of
facial rejuvenation, and consumer preferences for less invasive
procedures with rapid recovery.
In retrospect, we have moved back and forth between a
variety of technical solutions versus a more holistic process of
how to optimally deliver operational excellence in facial reju-
venation for a diverse patient population. As a surgeon, it is
rejuvenation and not engage in critical thinking about the
shortcomings and trade-offs of that particular technique. At the
same time, when confronted with newer techniques and con-
cepts for facial rejuvenation, many surgeons adopt a defensive
reasoning mindset that prevents adoption of these approaches.
MACS lift is an acronym for “minimal access cranial sus-
pension”.1 The first time that I (the author) read the MACS
short scar rhytidectomy paper by Tonnard et al.,2–5 it seemed
a puzzling principle that relied on suture loop suspension to
a cranial anchoring point, far different from the sheet tighten-
ing approach of the classic SMAS-lift that I was performing
at the time. It took a trip to the anatomy lab and a visit with
Tonnard and Verpaele in Belgium to convince me that there
was something different (and possibly better) about the MACS
lift. Once this approach for facial rejuvenation was examined
in light of other publications by Labbé,6 Mendelson,7 Besins,8
Pessa/Rohrich,9 and Gardetto,10 there actually appeared to be
a unifying concept that has scientific and biomechanical valid-
ity as a mainstay technique for facial rejuvenation.
First, we should ask ourselves, “Why do we think that it is
necessary to delaminate the face in order to rejuvenate? Can
we accomplish volume redistribution/repositioning without
having to engage in complex, deep anatomic dissections? What
is the validity of using a cranial suspension platform to resus-
pend facial structures over traditional ways?” And finally, “Can
we innovate a less invasive procedure for facial rejuvenation
that gives a durable outcome and allows for future revisions?”
Surgical foundation for the MACS lift
The surgical foundation for facial rejuvenation should address
the biomechanical effects of facial aging and volume loss for
each patient, depending on their particular needs. Surgeons
must be faulted in the past for not having a fundamental
understanding of facial aging, volume loss, laminar anatomy,
and biomechanical engineering. Our current understanding
of the anatomy of facial aging is thoroughly reviewed in

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154 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Chapter 6.1, giving insight into the complex biomechanics of
facial aging. Aging involves the gravimetric effects on skin
and musculo-aponeurotic system (SMAS), loss of elastic
property of tissue, volume loss and descent within in fat
compartments, and extrinsic effect of sun, genetics, weight
loss/gain, and smoking.11–13 Fat within the face does not exist
as a confluent mass, but in discreet compartments separated
by septae, formerly known as ligaments. Facial anatomy
involves a laminar concept in which movement between
layers is possible without surgical delamination. Proponents
of ligament release feel that such movement is inadequate for
facial rejuvenation, but experience with the MACS lift pro-
vides evidence that sufficient interlayer movement is, indeed,
possible and surgically effective.
From the perspective of biomechanics, surgical approaches
that rely on sheet tightening of attenuated facial structures
(SMAS) may not produce a long-term effect due to the loosen-
ing of this layer over time (shear yield). Suture line repairs
such as linear plication or excision techniques (plication or
SMASectomy) remain vulnerable to disruption (shear failure
and “cheese wiring”) by down-pulling the platysma whose
fascia is contiguous with the SMAS. Facial rejuvenation is
therefore an exercise in biomechanical engineering in terms of
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how much force is required to vertically lift facial and neck
structures and suspend them in place with approaches that
are less prone to failure. Surgery is part of the solution for
facial rejuvenation, but ancillary procedures found in cosmetic
medicine such as medical skin care, fillers, neurotoxins, and
light-based treatments work synergistically to produce a
“wow effect” when used masterfully.
The MACS lift concept involves the use of suture loops
placed in a purse-string fashion in order to elevate deep facial
tissue by anchoring to a fixed point. In the basic MACS lift,
there is one anchoring point on the deep temporal fascia, just
above the lateral zygoma, and posterior to the passage of the
temporal branch of the facial nerve. This is a very robust
anchor point that will hold a 0-0 or 2-0 suture without a
pull-out failure. The “CS” part of the MACS lift is “cranial
suspension”, which refers to the deep temporal fascia’s
attachment to the cranium along the temporal crest line. The
MACS lift does not utilize sheet tightening of the SMAS,
SMAS plication, or SMASectomy, but relies purely on special-
ized suture suspension. The basic MACS lift involves two
suture loops, one vertical and one oblique, while the “extended
MACS lift” involves an additional suture to elevate the malar
fat to a more anterior anchoring point (Figs. 6.4.1 & 6.4.2).
Fig. 6.4.1  The basic MACS lift involves two suture loops
placed into the SMAS in a purse-string fashion. The vertical
loop captures the platysma muscle below the angle of the
mandible, elevating soft tissues of the neck. The cheek loop
captures and elevates soft tissue of the midcheek and jowl.

Suture loops placed within facial tissues results in a gathering
and suspension of tissue. Tonnard and Verpaele describe this
as “microimbrication” (Fig. 6.4.3).
How the loops are designed and sequenced is crucial, as
once the platysma is pulled upward, it is possible to rotate the
layers of the face without a downward traction component of
Fig. 6.4.3  MACS sutures result in a bunching up of soft tissue. This has been
termed “microimbrication”.
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Surgical foundation for the MACS lift 155
Fig. 6.4.2  The extended MACS lift adds a third suture to
elevate the malar fat pad. The “hockey stick” dissection
pattern.
the platysma. By not dissecting skin off the platysma, there is
tightening of the neck skin when the platysma is tightened.7
The zone of adherence just anterior to the earlobe, called
Lore’s fascia, can be used as a fixed structure to pull against
in order to achieve vertical tightening of the platysma as
described by Labbé.5
The traditional skin incision for the MACS lift utilizes a
“short scar” anterior hairline approach with no retroauricular
dissection. After deep tissue reposition, skin redraping is
designed in a purely vertical direction (Fig. 6.4.4).
The amount of skin excision with the vertical approach of
the MACS lift is much less than seen with the classic SMAS-
lift. Attention must be paid to a tension-free skin closure in
order to promote excellent healing and avoid earlobe distor-
tion. In a divergence of philosophy and practice from Tonnard
and Verpaele, patients with greater facial and neck laxity will
require extending the incision into the retroauricular area in
order to manage lax skin (Fig. 6.4.5).
Therefore, the “MA” (minimal access) portion of the MACS
terminology must be expanded to address situations where
there is more tissue laxness necessitating a retroauricular
incision. In optimal situations, with younger patients, the
156 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives

2.0

1.8 2.0

Fig. 6.4.4  The short scar incision used in the standard MACS lift.

short scar approach is preferable yet can be modified when

the amount of loose tissues cannot be managed with a short
scar approach. Extending the incisions into the postauricular
region resolves bunching of loose skin at the level of the
earlobe.
There are numerous advantages of the MACS lift. Deep
tissues are readily repositioned without the deep plane dis-
section that risks injury to the facial nerve. Less dissection is
also likely to result in faster recovery. The short scar approach
avoids dissection over the sternocleidomastoid muscle and
therefore removes the potential for injury to the great auricular
nerve. MACS sutures are anchored at fixed points that avoid
the temporal branches of the facial nerve (Fig. 6.4.6). Fig. 6.4.6  The temporal branches of the facial nerve course over the middle third
It has outcomes that are acceptable over time and favorable of the zygomatic arch. The MACS suture anchor points are designed to avoid
biomechanics that address volume redistribution and facial damage to these nerve branches.
tightening without deep layer work. This technique appears
very adaptable to most patients seeking primary and second-
ary facial rejuvenation. It also has the advantage of being
reversible during surgery, as suture loops can be changed or
the entire technique abandoned for a more traditional
Patient evaluation
approach. The learning curve for successful adoption of the Each patient is unique with respect to their particular needs
MACS lift is something that can be mastered by most surgeons for facial rejuvenation. It then is incumbent on the surgeon to
who are willing to invest the time required to learn a new formulate a strategy that will provide solutions for each
approach to surgical facial rejuvenation. patient. In the author’s experience, a more holistic approach
works best in his own patient population. This involves both
cosmetic medicine and aesthetic plastic surgery, allowing for
care to be ongoing and to advantage each patient with adjunc-
tive services of medical skin care, fillers, neurotoxins, and
light-based treatments.
The following components of a patient’s face require evalu-
ation and strategy.

Facial skeletal structure and asymmetry

Structural needs such as cheek or chin deficiency must be
addressed. Evaluate for facial nerve function, muscular func-
tion, any asymmetry.

Skin quality, character, and looseness

Photodamage and photoaging must be addressed and consid-
eration given for medical skin care or light-based treatments.
Fig. 6.4.5  Vertical skin advancement in the standard short scar approach for a Rhytides and looseness in the perioral area cannot be resolved
MACS lift. with rhytidectomy.

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Forehead and glabellar rhytides
Forehead rejuvenation may involve the use of neurotoxins or
rejuvenation surgery through the endoscopic or transpalpe-
bral approach.
Facial volume
Assessment of the loss of facial volume is made. Volume
enhancement in the submalar sulcus may be done with
surgery, autologous fat grafts, or synthetic fillers. The recogni-
tion of volume loss that occurs due to attritional lipoatrophy
is underestimated.
Ocular region
Dermatochalasis, brow position, brow ptosis, fat bags, lower
eyelid looseness requiring lateral canthal work, lower eyelid
skin, and malar bags should all be assessed. Given the sub-
stantive lift of the MACS lift, a lower eyelid blepharoplasty is
often an integral part of this approach.
Neck
Neck laxness and platysmal banding will influence the need
to consider extended incisions and possibly a submental
approach for direct work on platysma banding. The presence
of submental fat may be addressed either through lipoplasty
if superficial, or direct excision if submuscular. Direct man-
agement of platysmal bands and fat layers is commonplace
and adds to the quality of outcomes.
Jowls
The squareness of the jawline is largely influenced by the
downward descent of facial structures. Depending on the
severity, dissection into the premasseteric space may be
required.
Previous surgery
Patients seeking additional refinements or “maintenance” of
facial rejuvenation from previous surgical procedure may
present with distorted changes due to conflicting traction
vectors or ineffectual outcomes. This type of patient requires
thoughtful consideration of what can be safely addressed
with reoperative surgery.
Medical history
Patients seeking facial rejuvenation may have medical
conditions that can influence their safety during facial
rejuvenation. Not everyone seeking facial rejuvenation
surgery is a candidate for surgery, based on chronic medical
disorders. Attention should be paid to a thorough review
of systems with emphasis on cardiac and circulatory issues.
Unique subsets of patients with surgical weight loss pro-
cedures may present with additional factors such as facial
lipoatrophy, tissue wasting, and obstructive sleep apnea.
Deep venous thrombosis (DVT) risk must be assessed and
managed.
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Surgical strategy 157
Patient expectations
The management of patient expectations becomes a major part
of facial rejuvenation, whether surgical or medical. It is essen-
tial that patients see themselves for who they are before treat-
ment and that realistic portrayal of outcomes be communicated.
Occasionally, there is the need for revisionary surgery/
procedures that must be addressed prior to treatment rather
than afterwards. Revision surgery may not be successful.
The better informed that patients are regarding their par-
ticular needs and your recommendations, both surgical and
non-surgical, the more likely they will be able to obtain the
best outcome. If a patient does not appear to be capable of
obtaining an outcome from treatments/procedures, it is better
to communicate this upfront and avoid the vexing problem of
a dissatisfied patient who had unrealistic expectations.
Surgical strategy
The use of worksheets and templates has proven useful in
many areas of aesthetic surgery and cosmetic medicine. A
simple form based on your practice helps you develop your
surgical strategy for each patient’s care. It allows you to make
notes, show specific details, and more importantly determine
the trade-offs involved. Such a form is a nice fit with your
informed consent(s) for the surgical procedure or cosmetic
treatments (fillers, neurotoxins, etc.).
How you choose to communicate your strategy with the
patient is also important. Simple aids such as a 10 × 15 cm
print from a digital camera on which you can draw, can be
useful. Other approaches involve drawing on the patient with
an eyeliner marker (easily removed) and taking a photograph.
Both of these are good communication tools to make certain
that your plans are in alignment with the patient’s expecta-
tions and needs. Even something as simple as displaying a
digital photograph on a large-screen LCD television works far
better than using a hand mirror.
Anesthesia for the MACS lift can be (1) minimalistic – local
anesthetic with conscious sedation; or (2) more complex with
monitored anesthesia care (MAC) deep sedation or general
anesthesia (GA). If general anesthesia is contemplated, the
author prefers an endotracheal tube (ET) over the laryngeal
mask device because the ET causes less neck distortion. Other
important considerations would be DVT prophylaxis and a
warming blanket for prevention of hypothermia. Although
some surgeons consider chemoprophylaxis with fractionated
heparin on long cases, there are reasonable concerns of
increased risk of hematoma incidence. Some anesthesiologists
prefer GA over MAC because of better airway management
and the ability of a gas analyzer to measure end tidal CO2 as
an index of ventilation.
Care should be given during the procedure to installing
protective eye ointment in order to prevent corneal exposure
problems. Sterile tape strips may also be used to prevent
eyelid opening. Individuals with a history of laser-assisted in
situ keratomileusis (LASIK) procedures are especially at risk
for corneal problems due to diminished corneal sensory
innervations that trigger tearing. When operating on a post-
LASIK patient, consider an evaluation by an ophthalmologist
for adequacy of tear production and tear film quality.
158 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives

Surgical sequence (Video 6.4.1 )

The patient is marked before the start of the procedure; key
points are the planned incision, the degree of undermin-
ing, and the location of suture loops. The degree of skin
flap undermining typically extends inferiorly just past the
mandibular angle and anteriorly 5–6 cm in front of the
ear. If an extended MACS lift is planned, undermining is
marked over the malar prominence. The sequence of per-
forming a MACS lift is straightforward. If autologous fat
grafting is considered, the author harvests and processes
fat at the beginning, followed by injection prior to the inci-
sions for the MACS lift. It is preferred not to store fat graft
tissue at ambient temperature for long periods during the
procedure. Any anterior neck surgery, such as lipoplasty,
is performed first. The cheek flap is then dissected and the
loop sutures are placed. If a temporal lift or endobrowlift is
contemplated, it is done next. A blepharoplasty, if planned, is
done last.

Skin incision and undermining
Local anesthetic containing epinephrine is injected along
the incision line. In the area of flap undermining, the author
prefers lipoplasty wetting solution that contains epinephrine
1 : 500 000. The short scar incision extends from the earlobe
below to the anterior hairline above. It follows the attach-
ment of the earlobe from the retroauricular crease, around to
the anterior attachment of the earlobe, following the tragal
edge, the anterior helical attachment to the root of the helix,
then across the lower portion of the sideburn and up the
anterior hairline. Anteriorly, the incision is made in a zigzag
pattern 1–2 mm within the hairline. The zigzag incision effec-
tively increases the length of the temporal incision to better
receive the elevated cheek flap. In the standard MACS lift,
the incision is carried up to the level of the lateral canthus,
while in the extended MACS lift, the incision extends up
to a point opposite the tail of the eyebrow. Flap elevation
is accomplished with scissor dissection. If an extended
incision in the retroauricular zone is required, this is done
early in the procedure as it generally facilitates suture loop
placement and skin redraping when the neck is tightened
vertically.
Anchor point
The deep temporal fascia anchor point is chosen to avoid the
superficial temporal vessels and the temporal branch of the
facial nerve. Small scissors are used to create a window in
the subcutaneous tissue approximately 1 cm above the zygo-
matic arch and 1 cm in front of the helical rim in order to
expose the deep temporal fascia (Fig. 6.4.7).
When placing the suture into the temporalis fascia, the
author sews away from the temporal vessel location. A single
anchor point is used for both the neck loop and the cheek loop
in order to diminish the amount of suture used and the pal-
pability of knots. Absorbable monofilament sutures such as
barbed 0-polydioxanone are preferred over non-absorbable
polypropylene or braided polyester suture. Bunching in the
cheek region can be nicely managed by serpentine imbrication
with the barbed suture and minor amounts of scissor
snipping.
Fig. 6.4.7  The short scar incision has been made, and the skin flap raised. The
zygomatic arch is marked in purple. Note the marks on the skin designating the
location of the suture loops. The scissors are dissecting a window down to the deep
temporal fascia that will be used as the anchor point for the vertical and cheek
suture loops.
The neck suture
The suture loop for the neck is placed first. Going inferiorly
in the natural sulcus that is anterior to the tragus, firm bites
between 1 and 1.5 cm long are taken into the SMAS. Progress-
ing inferiorly past the angle of the mandible, two or three
suture bites are taken into the platysma before the suturing is
directed upward and back to the anchor point. A U-shape
loop about 1 cm wide is created, and the knot is then tied at
the anchor point under tension. The suture loop is tied without
any instrument that might be used to hold the first knot. This
diminishes the possibility of suture damage and breakage. In
my (the author’s) first few cases, I found that I did not have
an adequate grip on the platysma fascia and that neck tighten-
ing was not optimal; for neck tightening to occur, adequate
suture purchase of the platysma below the angle of the man-
dible is imperative. When performing the short scar variation,
a fiber-optic retractor is helpful to visualize correct suture
placement in the depth of the dissection. Additional reinforce-
ment of the neck is accomplished by engaging the platysma
fascia and pulling both superiorly and slightly retrograde by
using the mastoid fascia as a secondary anchor point. Remain-
ing barbed suture is then run through the region of Lore’s
fascia and then back up along the pretragal area (Fig. 6.4.8).
The cheek suture
The cheek loop is placed next. It originates at the same anchor
point from the deep temporal fascia. Taking bites of the SMAS,
suturing progresses inferiorly just anterior to the first loop and
then curves more anteriorly, creating a wider loop above the
jowl extending anteriorly as far as the skin flap has been
raised. The author has found that the loop works best when it
is in the configuration of a logarithmic spiral, like a nautilus
shell. This allows for upward rotation of facial structures and
volume repositioning. The overall angle of the cheek loop is

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A to preserve this normal sulcus.
B formation and eliminates the requirement for drains. Care
Fig. 6.4.8  (A,B) Cadaveric example demonstrating placement and the effect of the
vertical neck suture. The orientation is vertical, and neck traction depends on
achieving excellent suture purchase of the platysma muscle below the angle of the
mandible.
approximately 30° across the cheek, as compared to the verti-
cal neck loop. The suture is then tied under tension. Novice
MACS lift surgeons tend to make too small a cheek loop and
are then faced with a situation of a peculiar wad of tissue when
the loop is tied. Experience teaches that if a suture loop appears
unsatisfactory, the best strategy is to take it out and replace it.
The malar suture
Once the cheek loop is tied, it is possible to add a third loop
for elevation of the malar fat; this constitutes the “extended
MACS lift” variant. A different anchor point is used anterior
to the temporal branch of the facial nerve. This point can
either be the deep temporal fascia just lateral to the lateral
orbital rim, or the periosteum of the zygoma, approximately
1.5 cm lateral to the lateral canthal area. Access to either of
these anchor points requires a small window in the orbicularis
muscle where the fibers run vertically. This purse-string
suture travels obliquely toward the malar fat pad where at a
point 2 cm below the lateral canthus, the direction is reversed,
creating a narrow U-shaped loop that is tight under tension.
In my experience, the direction of pull will be oblique, but
ideally should be as vertical as possible. If the surgeon is
dissatisfied with the placement of the loops, it is easy to cut
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A personal evolution of the MACS lift 159
and replace the loops until satisfied with their placement and
tissue gathering.
Tissue bunching is an integral problem with the MACS
suture loops. It is resolved with serpentine imbrications with
the 0-polydioxanone barbed suture or 4-0 polyglactin imbrica-
tions with 4-0 polyglactin braided suture. The author prefers
the version of this suture that contains triclosan, an antibacte-
rial agent, in order to diminish risk of stitch abscess. Before
leaving the deep tissue, it is necessary to place the skin flap
over the tissue and observe for unresolved bunching and
tissue tethering at the margins of the undermined area. Scissor
removal of protruding fat may be needed in order to produce
a smooth tissue surface inside the loops. Imbrication of tissue
in the region just anterior to the tragus is important in order
Skin advancement and resection
The skin flap is then redraped along a vertical axis, and the
excess skin is resected. If there is excess skin at the level of the
earlobe, it must be resolved by incisions in the posterior ear
region. My philosophy is to resolve this skin by extending my
incisions in the posterior sulcus of the ear, instead of dealing
with skin bunching post-surgery. If necessary, the author uses
a classic rhytidectomy incision in the postauricular region,
depending on the patient’s neck laxity. The goal for skin exci-
sion is to have a tension-free closure with wound margins
coapted against each other.
The author’s personal technique uses approximately 1 cc
of fibrin glue (5 units/mL dilution) that is sprayed on the flaps
and held for 3 min. I find that this diminishes ecchymosis
must be given to not apply excessive fibrin glue as it can
interfere with revascularization of the flaps.
Wound closure is also straightforward with absorbable 5-0
monofilament in the deeper layers and 5-0 and 6-0 polypro-
pylene skin sutures placed as interrupted and continuous
(horizontal mattress).
Dressings involve customary facelift dressings. The author
personally prefers some silicone-backed foam for the anterior
neck if lipoplasty has been performed. Otherwise, aftercare is
similar to standard facelift procedures.
Three representative cases utilizing the MACS lift concept
are shown in Figs. 6.4.9 and 6.4.10.
A personal evolution of the MACS lift
Overview
The original procedure as described by Tonnard, Verpaele,
et al. has evolved into a more holistic approach for compre-
hensive facial rejuvenation. While originally described as a
“minimal access cranial suspension” approach, the procedure
has evolved into “cranial suspension rhytidectomy” (CSR),
where facial structures are resuspended from a cranial anchor
point. This approach uses a strong anchor point versus relying
on sewing age-attenuated SMAS layers back together with
a linear suture repair. Additionally, experience with the origi-
nal MACS and its failures dictates a better approach for
management of the lax neck and platysmal bands than
described by the originators of the MACS lift.
160 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives

A B C

D E F

Fig. 6.4.9  Preoperative (A–C) and 12-month postoperative (D–F) photographs of a 61-year-old woman who underwent a three-loop extended MACS lift, submental
liposuction, autologous fat graft to submalar region, and hyaluronic acid fillers to the perioral area.

The technical evolution of the CSR includes the use of
barbed sutures (polydioxanone; PDO), volume restoration
with autologous fat grafting, selection of postauricular inci-
sions as needed to address lax neck skin, use of fibrin glue to
mitigate ecchymosis, and open anterior neck platysmaplasty.
The concept of cranial suspension remains valid, but evolu-
tion of technique and strategy encompasses a more compre-
hensive approach of surgery to reposition lax tissues of face
and neck, volume restoration of orbit and midface, medical
skin care, correction of brow ptosis, tissue fillers, neurotoxins,
and energy-based treatments to improve skin quality/texture
and tighten subsurface layers.
Surgical facial rejuvenation as part of
the continuum of beauty
While we as surgeons are fascinated with the technical
approaches for facial rejuvenation surgery, the aesthetic mar-
ketplace around us is changing with regard to what patients
are seeking in facial rejuvenation and the utility of non-invasive
procedures. Formerly, we would abandon one surgical
approach for another in order to stay ahead of what competi-
tors were offering in facial rejuvenation. There was little
appreciation of the biomechanics of aging or facial fat compart-
ments, but rather a fixation on technical factors because all that

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 A personal evolution of the MACS lift 161

we knew was surgical facial rejuvenation. Most plastic sur-
geons were dismissive of non-surgical treatments because it
was not surgery that they knew and loved. “After all, all of this
non-surgery nonsense was being championed by those who
could not operate”, said one plastic surgeon.
In the current era, much has changed regarding what patients
are seeking from facial rejuvenation and their willingness to
only utilize surgery as their treatment of choice. Sure, there is
no substitute for a well-performed, comprehensive rhytidec-
tomy, but patients are looking for more than just surgery, both
before needing it and afterwards to help maintain its results.
Patients find tremendous value in the results that cosmetic
injectables deliver when administered by a skilled injector.
There has been an evolution from filling wrinkles to facial
volumization with long-lasting hyaluronic acid (HA) fillers. The
effects of cosmetic neurotoxins when correctly placed produce
natural outcomes without the stigma of a frozen face. Injections
of lipolytic drugs can reduce fat deposits in the jawline without
liposuction. Micro-focused high-intensity ultrasound or radio-
frequency energy can be an adjunct for skin tightening.
Surgical facial rejuvenation appears to be part of a contin-
uum rather than the entire focus for patients. A holistic concept

A B C

D E F

Fig. 6.4.10  This 56-year-old woman developed a relapse of neck soft-tissue laxity after a MACS lift. She underwent a secondary procedure with the placement of both neck
and cheek sutures. The result shown preoperatively (A–C), after the MACS lift (D–F), and 12 months after revision surgery (G–I). Continued

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162 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
G H
Fig. 6.4.10, cont’d
of facial rejuvenation and maintenance of beauty has now
evolved. The combination of non-surgical treatments and
facial rejuvenation surgery provides better, more natural, and
satisfying outcomes for patients.
In the first part of the chapter, I focused on the MACS lift
as envisioned by Tonnard and Verpaele. Since applying the
MACS lift principles, I have evolved my technique and believe
that I have been able to achieve improvements over what was
originally described. I also decided to add additional sub-
components as needed for each patient, depending on the
concept of “What does it take to achieve a satisfactory facial
rejuvenation outcome for this particular patient?” Moreover,
my appreciation of the value of a comprehensive program of
medical skin care, cosmetic injectables, and energy-based treat-
ments has increased, given the benefits that they provide
patients.
Within the naming conventions of surgical procedures, I
renamed the MACS lift, the “cranial suspension rhytidectomy”
(CSR). I believe that this should no longer be called a minimal
access procedure and that the surgeon should have the ability
to manage what incisions are needed to accomplish the intended
outcome. For example, I believe that it is permissible to utilize
the classic rhytidectomy incision in the retroauricular area if
you are planning on extensive neck tightening. I still believe
that the sideburn incision offers the greatest utility versus inci-
sions in the temporal scalp or a 90° “London Chop” incision.
The concept of cranial suspension or, actually, cranial
“resuspension” remains valid as a way to reposition the
mobile SMAS layer upward and to passively move other
facial structures along. Personally, I like a non-delamination
procedure like the CSR over a subSMAS dissection. I believe
that I can accomplish almost as much from the CSR approach
as a procedure that delaminates the face to rejuvenate. Skin
resection in the pre-/postauricular area remains as described
by Tonnard and Verpaele. Skin closure should be without
tension and signs of skin tethering to deeper layers.
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I
Cranial suspension techniques are useful as a primary form
of facial rejuvenation, in secondary and even tertiary situa-
tions over the traditional subSMAS approaches. Other tech-
niques involving deeper plane lifts, SMAS plication, or
SMASectomy have not held up over time with regards to
suitability or durable, natural-appearing outcomes that have
an acceptable recovery time.
Technical evolutions and innovations
of the original MACS lift
Barbed sutures
My current CSR technique has evolved to include the use of
barbed polydioxanone sutures, typically in the #1 or 0 size. This
has been a useful advance that seemingly has improved out-
comes by better resuspension of facial structures, including the
neck. Barbed sutures can produce a powerful lift within the
mobile SMAS and neck. I have also found that they permit
better management of tissue bunching in the cheek region by a
serpentine form of imbrication versus relying on multiple inter-
rupted 4-0 absorbable sutures. I hardly ever use the midface
loop any longer as described by Tonnard and Verpaele.
Neck relapse
One of the known shortcomings of the original MACS lift was
its propensity for neck relapse due to a single point of fixation
within the platysma below the angle of the mandible. This
became apparent in several patients who required revisionary
neck tightening after having a classic MACS lift. My lesson
that I learned out of this was that a better approach for neck
rejuvenation was required with the primary procedure.
Currently, I utilize what I would call a “hockey stick” dis-
section pattern below the angle of the mandible that allows

for more exposure of the platysma. This affords better expo-
sure of the platysma for passage of barbed suture versus a
single point of fixation as originally described. Better exposure
also offers open defatting with a flat liposuction cannula.
Now, I place the barbed sutures below the mandible in the
mobile platysma and utilize a biaxial tightening, primarily
vertical, but with some retrograde pull. The immobile mastoid
fascia offers a robust secondary anchor point for barbed
sutures used for neck tightening. My personal opinion here is
that the mastoid fascia is a stronger anchor point for the neck
than Lore’s fascia.
Management of anterior platysma
I believe that anterior platysma techniques of liposuction and
open management of platysma banding has enhanced my
outcomes for the neck. Bands must be treated openly, and fat,
whether above or below the platysma, must be managed in
order to produce a crisp, angular anterior neck outcome.
Barbed absorbable suture is useful for anterior platysmaplasty,
in my experience.
Fibrin glue avoids drains
Another advance in technique is the use of pre-diluted fibrin
glue to mitigate ecchymosis after the procedure. The combina-
tion of fibrin glue and silicone-faced liposuction foam in the
dressings has solved the bruising issues associated with
rhytidectomy. I no longer use drains.
Facial volume restoration
The matter of facial volume restoration during a rhytidectomy
deserves mentioning. I think that the use of a small amount of
autologous fat grafting to restore attritional lipoatrophy in the
submalar or suborbicularis areas during facial rejuvenation
surgery is straightforward. Newer suborbicularis compart-
ment injections of HA fillers or autologous fat as described by
Lamb, Jelks, and Surek appear promising. Equally, the microfat
injections just under the eyelid skin as described by Tonnard
and Verpaele appear to produce good outcomes. I personally
do not like to inject large volumes of autologous fat into the
face, unlike some colleagues, as I believe that it alters facial
appearance and has a long, swollen recovery for months.
Conversely, long-acting HA fillers that have been devel-
oped for facial volumization deserve a mention because they
are predictable, long lasting, and time-efficient. Personally, I
like the “what you see is what you get” with volumizing
fillers in contrast to autologous fat. I prefer a 0.9-mm cannula
for the deep layer injections of volumizing fillers in the face
and orbit, which reduces risk of accidental intravascular injec-
tion and ensuing catastrophe.
The value of non-surgical treatments to
maintain outcomes after CSR
There is much utility in the non-surgical treatments after a
CSR procedure. This includes neurotoxins for management of
dynamic rhytids, HA fillers for lines and volume restoration/
maintenance, and energy-based treatments to skin and deeper
layers. Medical skin care never stops. High-intensity micro-
focused ultrasound (Ulthera, Inc., Mesa, AZ) has been useful
to add skin tightening in the brows and neck after a CSR.
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Understanding the learning curve of CSR 163
I have found that my evolution of Tonnard and Verpaele’s
original MACS rhytidectomy has enabled me to get beyond
the shortcomings of their procedure. While there is no substi-
tution for a well-planned and performed rhytidectomy, I have
been able to holistically improve the quality, durability, and
patient satisfaction with my version of facial rejuvenation
through the addition of other complimentary non-surgical
procedures.
As far as what’s next, I would say that more thought is
needed to find a predictable way to manage the lateral brow
region and a device to help with the lateral canthopexy that is
used to help stabilize the lower eyelid during a blepharoplasty.
Understanding the learning
curve of CSR
The successful integration of a new surgical technique into
one’s armamentarium can be challenging. It involves auditory
and visual learning, bioskills, and ways to deal with events
that are normal occurrences when one performs this proce-
dure. It is a daunting task from the perspective of adult educa-
tion how surgical educators can transfer a knowledge and
skills set to intelligent individuals, especially when the
approach is counterintuitive.
Successful performance of the CSR lift demands technical
excellence in the placement of suture loops and the resolution
of bunching that occurs once the loops are tightened. The CSR
lift effect is equivalent to a gathering phenomenon on the
barbed suture loops to produce volume redistribution and
tightening of deep layer facial structures without delamina-
tion procedures seen in subSMAS procedures. You also may
want to familiarize yourself with some of the reference articles,
as they are a foundation for the procedure.
Advice for how to succeed with the CSR
Planning for a successful outcome
First start with a straightforward, relatively easy facelift situ-
ation rather than a challenging situation that would prove
difficult with any technique. Most likely, your patient will
need the CSR lift (two strands) with extended postauricular
incisions. Relatively few patients are candidates for the short
scar variant of the CSR.
Consider the range of complimentary
surgical procedures
Planning for a patient’s facial rejuvenation usually involves
additional complimentary procedures such as submental lipo-
plasty, anterior platysmaplasty, upper/lower blepharoplasty/
canthopexy, fillers (fat or non-animal stabilized hyaluronic
acid (NASHA) fillers), and management of the brow region.
Be certain that you have planned adequately with regards to
complimentary procedures and consider using a worksheet
or checklist that will help you remember the steps that you
planned for each patient.
Selection of anesthesia
From the perspective of patient safety, the CSR lift can be
performed under monitored anesthesia care, local anesthesia
164 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
with minimal/oral sedation, or general anesthesia. Find a
technique of anesthesia that you are comfortable using. Do
not forget the matter of keeping patients warm, addressing
DVT prophylaxis, and preventing eye dryness if general
anesthesia is used. I personally use tumescent anesthesia with
500 mg lidocaine per liter and 1 : 500 000 epinephrine concen-
tration. Typically, I will use ~50 ml in the anterior neck and
60–75 ml per side for the CSR. I wait 10 min after injection for
the epinephrine effect to occur. I’ll tumesce the opposite side
of the face when I start the closure on the first side.
Sequencing of the procedure
My first sequence in CSR facial rejuvenation is the lipoplasty
and open anterior neck work. I have found the VASER ultra-
sonic lipoplasty device very effective in the anterior neck and
jawline. The process of VASER ultrasonic lipoplasty is very
precise and allows for accurate removal of fat. If anterior
platysma band correction is planned, I do this first, before the
CSR.
Typically, I will infiltrate both the neck and the first face
side for the CSR with liposuction wetting solution containing
epinephrine 1 : 500 000. I find that this helps dissection. In the
case of secondary/tertiary rhytidectomy, the use of wetting
solutions facilitates creation of an accurate surgical plane
through previously operated tissue. While not every patient
needs submental lipoplasty, the combination of wetting solu-
tion and the VASER helps with dissection in this area and
access to platysmal bands and subplatysmal fat.
Next, I go on to the incisions of the rhytidectomy and flap
elevation. Once this has been accomplished, attention is
directed to the neck and cheek loops of the CSR lift. Currently,
I use 0 or #1-PDO barbed suture (Angiotech, Surgical Special-
ties Corporation, Braintree, MA) or 0 Stratafix PDS barbed
(clear) (Ethicon, Somerville, NJ) with a robust anchor point in
the temporalis fascia, approximately 1 cm anterior to the ear.
Once the loops have been placed, I will determine if the third
loop, the midface, is required. It is anchored approximately
1.5 cm lateral to the external canthal area on the periosteum
of the maxilla.
It is important, especially with the neck loop, that you place
it in the platysma below the angle of the mandible. The origi-
nal MACS lift as described by Tonnard and Verpaele has a
high neck relapse propensity, presumably due to poor engage-
ment of the platysma. This has been overcome with the use
of barbed sutures, anterior dissection below the angle of the
mandible, and a secondary anchor point in the mastoid fascia
(behind the concha of the ear). After first loop is secured, next
go on to the second cheek loop without cutting the suture at
the anchor point. This helps minimize the amount of suture
material in the temporalis region. Bidirectional barbed suture
can also be utilized for the cranial suspension of the platysma
and the cheek loop. The excess barbed suture can be placed
in a serpentine fashion in the cheek region to flatten areas of
tissue bunching.
Eyelid procedures are performed at the end of the CSR lift
because there may be a significant amount of vertical skin
recruitment after the suture loops have been placed.
Tips on how to manage bunching of tissue
Depending on the amount of tissue involved, this may require
scissor work and flattening of the ridges with 4-0 Vicryl. Small
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skin dimples underneath the flap will require scissor work to
release them. Other approaches to manage bunching use
excess barbed suture that is used to flatten bunching by
placing sutures in a serpentine pattern (very effective).
Preliminary closure
Skin excess in the CSR lift is resolved by a vertical approach.
Take the time to arrange the skin flap after you are satisfied
with the work done on the deeper layers in terms of sym-
metrical tension, resolution of bunching, and hemostasis. You
will become a believer in the vertical approach if you pull
your skin flap in the wrong (horizontal) direction. You will
rapidly realize that horizontal traction on the skin flap creates
the need for a postauricular incision versus the vertical
approach in patients with minimal/moderate face laxness.
Other patients who need extensive neck tightening will
require a “classic rhytidectomy” incision.
Skin resection is made in order to avoid skin tension on the
wound. This is crucial in order to obtain a favorable postop-
erative scar. Skin resection in the elevated skin is made to
mirror the preauricular regional incision that you made at the
start of the case. Fortunately, due to local anatomic “anchor
points”, the sideburn and tragal areas do not move and facili-
tate the closure process. A lack of facial flap tension is really
important in the closure. Tragal definition requires surgical
defatting of the skin flap with scissors.
When performing a short scar variant of the CSR, you may
find yourself in a situation of having too much loose skin and
worry about skin bunching in the preauricular area; it is
permissible to go behind the ear on its backside in order to
inset the looseness. Remember, this does come with the price
of more dissection and skin shifting to finalize the closure. If
you have to leave behind some bunching in your closure, do
it behind the earlobe and not in front.
Skin closure
Tonnard and Verpaele use small drains that come out in the
area of the earlobe. I prefer fibrin glue (Artiss, Baxter Health-
care, Deerfield, IL) that is supplied at 5 units/mL instead
of drains. I find that fibrin glue also has the advantage of
diminishing ecchymosis in the postoperative period. Fibrin
glue can produce healing problems if excessive amounts are
sprayed in the wound. I have found that a 2-mL syringe of
Artiss is adequate for both sides of a CSR lift (use <1 mL
per side).
As mentioned earlier, skin closure is performed under no
tension. I use some 5-0 Monocryl (Ethicon, Somerville, NJ)
sutures in the subdermal area to hold the wound and 5-0 and
6-0 Prolene (Ethicon, Somerville, NJ) in the skin (horizontal
mattress sutures). A few 5-0 rapid-absorbing plain gut sutures
(Ethicon, Somerville, NJ) can also be used. Be certain to
remove all silk temporary sutures that you may have used in
the planning stage of the closure.
Eye and brow procedures
I wait to perform the eyelid procedures until I have com-
pleted the CSR lift. A significant amount of skin has been
recruited into the orbit with the midface loop, and a lower
eyelid blepharoplasty will be necessary in many cases. Brow
procedures, whether a lateral temporal lift, transpalpebral

corrugator resection, or an endoscopic brow can be performed
in conjunction with the CSR lift.
Dressings and aftercare
A simple dressing afterwards is all that is needed. I use
silicone-backed foam that is used for lipoplasty procedures in
the anterior neck to control skin wrinkling after neck lipo-
plasty and anterior platysma work. Foam also is a great idea
after an endoscopic browlift to control forehead swelling.
Patients generally recover more rapidly from a CSR lift
than a “classic” rhytidectomy. In most cases, swelling resolves
in 10–14 days and the feeling of “tightness” in 4 weeks.
Additional comments regarding the CSR lift
The CSR lift represents a very flexible approach for facial
rejuvenation. It can deliver a very natural outcome without
the stigma of inappropriate tension vectors, flattening of the
face, and the telltale sweep deformity. This approach also can
address midface laxness and repositions midface fat. It is
important to avoid excessive undermining of the neck because
this separates the skin from its anatomic attachments to the
underlying platysma fascia that is being tightened.
The other remarkable thing about the CSR lift is that it can
be undone and converted back to a traditional under the
SMAS dissection and retroauricular incision if the surgeon
BOX 6.4.1  Troubleshooting
Problem: Neck loop pulls out of tissue
Solution:  Neck loop needs to be in the fascia of the platysma –
place it again, with emphasis on correct technique that includes more
anterior dissection below the angle of the mandible to expose more
of the platysma. A secondary anchor point in the mastoid fascia with
the barbed suture is useful to avoid suture pull-out.
Problem: You have placed the cheek loop, but nothing moves
when it is tightened
Solution:  You have placed too large a loop that is over tissue that
has a zone of adherence (non-mobile SMAS) to bone, e.g. maxilla.
Replace the loop in the correct location.
Problem: Midface loop does not lift midface
Solution:  Look for midface tissue that is mobile and place the loop
again.
Problem: You note a lot of lower eyelid skin has been pushed
upward
Solution:  Given the vertical nature of the CSR lift, eyelid skin is
pushed upward and a lower eyelid blepharoplasty is required. A
simple pinch blepharoplasty can be performed to address skin
excess.
Problem: You have too much skin excess to make this a short
scar facelift
Solution:  You may need to consider extending the incisions behind
the ear to address skin excess. Even though the MACS lift was
envisioned as a short scar facelift, consider the cranial suspension
part of the CSR lift as the lifting engine and the incision management
as up to the surgeon.
Problem: You are worried about neck relapse
Solution:  Neck management, both in terms of bands and tissue
laxness, requires a comprehensive approach. This encompasses
both the possibility of open anterior platysmaplasty with band
transection and the consideration of secondary anchor points in the
mastoid fascia or Lore’s fascia with the barbed sutures.
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Understanding the learning curve of CSR 165
believes that he or she cannot obtain a satisfactory outcome
with the CSR technique. Alternatively, the suture loops can be
kept in place and the skin redraped according to a traditional
approach.
After a surgeon has performed their first ten CSR lift cases,
there will be a sense of comfort in the technique and how to
deal with the nuances of the procedure versus feeling uncom-
fortable with the CSR short scar rhytidectomy technique and
its variants.
We are still not at the end of innovation and refinement in
facial rejuvenation surgery or treatments. Thanks to Patrick
Tonnard and Alex Verpaele, we have discovered a new
approach that repositions fat and deeper layers back to their
natural points of fixation in the younger face through innova-
tive use of suture loops versus surgical delamination of facial
structures. Other considerations relate to isolated necklifting
and the innovative use of HA fillers or autologous microfat
grafting in the periorbital area.
Troubleshooting CSR lift
During the time that it take for you to develop your per-
sonal approach to the CSR lift, you are bound to encounter
situations where something does not work, does not look
right, or you do not feel that subsurface lifting is occurring.
Some situations and recommended solutions are set out in
Box 6.4.1.
Problem: Dimples in skin, just beyond the zone of dissection
Solution:  Use your scissors in a vertical spreading motion to stretch
bands that are producing the dimpling. Be careful that this may
cause bleeding, if you are at the edge of where you have infiltrated
wetting solutions/local anesthesia.
Problem: Bunching is hard to correct after you have tied the
cheek loop
Solution:  Excessive tightness in the cheek loop or a small diameter
loop will produce a wad of tissue that defies imbrication. Replace the
cheek loop, but with less tension. Also, some scissors snipping is
helpful if there are small dimples of tissue that are particularly visible
through the skin. Imbrication stitches may be used to control skin
fullness in all areas underneath the flap in order to improve contour.
The “art” of the CSR lift requires that you address these as needed to
achieve the best outcome for your patient. The use of barbed suture
in a serpentine pattern is really useful to help with tissue smoothing in
the cheek or anterior sternocleidomastoid areas.
Problem: You are doing a secondary rhytidectomy and wonder
about using the CSR technique
Solution:  There are additional options with the CSR lift to utilize
the loops as your “lifting engine” for the cranial suspension of
facial structures and to redrape skin, if excessive with a traditional
postauricular approach, if needed. This also works well in
secondary rhytidectomy situations where subSMAS dissection is
challenging and dangerous. The use of uni- or bidirectional barbed
suture of similar size may be a consideration also. In situations of
neck laxness, considerations may be given for additional anchor
points in Lore’s fascia or mastoid fascia. Generally, a secondary
rhytidectomy should be planned with a sideburn incision in order to
avoid narrowing/obliteration of the sideburn. Most likely, there will be
neck laxness that require postauricular incisions and dissection to
manage.
166 SECTION I CHAPTER 6.4 • Facelift: Facial rejuvenation with loop sutures – the MACS lift and its derivatives
Summary
The MACS lift is a facelift technique that is ideally suited for
the lower and middle third of the face. By using strategically
placed sutures, deep tissues are repositioned without the
dangers of deeper dissection. The vertical vector ensures that
many patients benefit from a short scar approach with a faster
recovery. The technique is adaptable to a wide cross section
of patients, and it can be mastered by most surgeons who are
willing to learn a new technique. I present a personal evolu-
tion of the technique that expands upon the original MACS
lift principles to improve outcomes.
References
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suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109:
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2005;29:213–220.
4. Tonnard P, Verpaele A. Short scar face lift, operative strategies and
techniques. St Louis, MO: Quality Medical Publishing; 2007.
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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
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