THE MACS LIFT

The following is a description of the standard facelift vs. the MACS lift. The purpose of this brochure is for patient education and to help guide you through the process of determining the best operation for you. The standard facelift, or rhytidectomy, is the one procedure that most people readily associate with cosmetic or plastic surgery. The term facelift is somewhat misleading, since the procedure also involves the area below the chin and upper neck. The primary benefit of a facelift is the improvement of deep wrinkles and sagging tissues of the face and neck. This is done by the removal of excess skin and fat, as well as the tightening of sagging muscles of the neck. The facelift procedure alone may not solve all of the aesthetic problems of the face. Wrinkling around the lips, chin, in the forehead or eyelids may require additional procedures, such as eyelid surgery (blepharoplasty), forehead or brow lift, chemical peels, laser resurfacing and liposuction.

Everyone ages at there own inherent pace. The condition of your face and neck, as well as the rest of your body, depends upon many factors. These include those that are genetic as well as those that are environmental. Age, heredity, weight fluctuations and skin damage from sun and wind exposure all take their toll. As the skin loses its elasticity and becomes thinner, the forces of gravity act upon them to cause sagging and wrinkling. The appearance of the face as it ages is characterized by progressive wrinkling, changes in the thickness of the skin, and loss of fatty tissue. If you were to compare pictures of yourself from decade to decade you will see some very distinctive and predictable changes. The first sign of aging is usually seen in your 30's. At this time the skin begins to lose some of its elasticity and there may be some sagging of the lower eyelid skin as well as some overhanging of the skin of the upper eyelids. The folds of the cheek may begin to deepen. By your 40's some wrinkles will begin to appear in the forehead. These wrinkles will be both horizontally directed on the forehead and vertically directed between the eyebrows. There will also be a progression of the sagging of the skin of the upper and lower eyelids. The crow's foot area will begin to appear and deepen. During your 50's all of the vertical and horizontal lines of the face and forehead will become more prominent. The general sagging of the face continues with increasing overlap of the upper eyelids and bags of the lower eyelids. There is a continued downward vertical sagging of the cheek and jowl areas. Sagging of the skin of the neck becomes more obvious and may develop in to the turkey gobbler type of deformity. During the 60's all of these processes become more exaggerated. There is an increase in the number of wrinkles and an increase in the amount of redundant skin. There is sagging of the eyebrows and loss of facial fat. Adding to the problem is a general decrease in the thickness of the skin along with the loss of skin elasticity.

Who is a good candidate for a facelift?

In general, almost anyone in good health and with the correct motivation and goals is a good candidate for a facelift. Age, in and of itself, is not a contraindication for the procedure. More important than age are qualities such as the condition of the skin, the degree of wrinkling, the amount of sagging of the tissues, skin elasticity, skin type and underlying bone structure. During your consultation we will discuss and evaluate the following conditions:

· Your overall health

· Amount of wrinkling

· Bone structure

· Neck angle

· Sun damage

· Ethnic features

· Your skin type and coloring

· Muscle tone

· Amount of fat to be removed

· Amount of fat to be repositioned

· Skin elasticity

The Surgical Technique of a Standard Facelift

A facelift procedure can be done in either our office operating suite or in the outpatient area of the hospital. It is typically done under either under local anesthesia with oral sedation, twilight anesthesia (local anesthesia with intravenous sedation) or under general anesthesia. Intravenous anesthesia and general anesthesia require an anesthesiologist. When the procedure is performed in the office, we use only board certified physician anesthesiologists. The anesthesiologist is present to administer the anesthesia medications. There is not one standard facelift. Everyone is different and the facelift surgery must be individualized.

The classical facelift is done by making incisions in front of the ears, on the scalp within the hairline and behind the chin. The head is turned from side to side as the procedure is performed. The facial skin is then separated from the underlying fat and muscle. The excess fat and muscle is then repositioned as needed. Once the removal and repositioning of the tissues is complete the skin will be tightened and redraped over the new facial contours.

A two layer facelift or SMAS procedure involves the restructuring of a deeper tissue layer. By using this procedure we can sometimes achieve a better and longer-lasting result. This layer is tightened in almost all complete facelift procedures.

A more contemporary approach to the facelift is termed a limited incision facelift. In this approach the face is divided into aesthetic segments and each is treated as an individual unit. In this fashion we are able to correct the effects of aging as needed and where indicated.

The MACS lift (Minimal Access Cranial Suspension) lift was described as a modification of the S-lift by a Belgian group in 2001. It was reported in the Plastic & Reconstructive Surgery journal, which is the main scientific journal for plastic surgeons. The aim of a MACS - Lift is to lift the lower face and neck. A well planned procedure will leave you looking fresher and youthful. People may not notice that you have had surgery, just that you look well. A MACS-Lift helps to remove excessive jowling around the chin, deep creases that appear between your nose and mouth, and restores the outline of the jaw.

Who should have a MACS - Lift?

The ideal age group is between 40 to 60 years of age, and is suited to people whose neck and face has begun to sag, but they still have some elasticity in their skin.
In particular if you have:

• deep lines that run from the corner of your mouth to your nose and chin
• loss of a well defined jaw line
• deep wrinkles and sagging skin near your cheek bones
• loose skin or jowling in the neck

It is an excellent procedure for patients who have already undergone a face lift in the past and require a touch up.

Essentially, it differs from a regular facelift in the following ways: (There are many variations to the procedure, but the typical will be described)

1. The incision is limited to the skin hairline junction above the ear and anterior to the ear. There is no extension behind the ear.

2. The area of undermining, unlike a conventional facelift, is much smaller and essentially involves a portion of the cheek. Because there is less undermining, the blood supply to the skin is much more robust and there is less risk skin healing problems.

3. Permanent suspension sutures are used to elevate the underlying tissue. These pass down to the neck, jowls and malar fat pad. Unlike many other facelifts which do not include significant mid face elevation the MACS lift elevates the malar fat pad reducing the naso labial folds. These suspension sutures are not used as cables but rather weave in and out of the SMAS layer (deep layer of 2 layer facelift) in a purse string type fashion giving tremendous lift and suspension to the sagging tissues of the face. In most facial aging this is the layer that requires rejuvenation.

4. Because there is no undermining under the SMAS (superficial musculoaponeurotic system) there is less likelihood of damage to the underlying facial nerve branches.

5. Because the undermining and dissection is much more limited the post operative swelling, edema and bruising is less than in normal facelifts and recovery is therefore quicker.

6. Because the malar fat pad is elevated it combines very well with lower lid blepharoplasty. It essentially reduces the height of the lower eyelid giving a more youthful, smooth appearance.

7. If needed liposuction is performed to the neck area below the angle of the mandible, both to remove excess fat here and also to free up the skin to allow it to be re-draped by the suspension sutures.

8. In my opinion, the MACS lift produces results at least equivalent, or in most cases, better than a conventional facelift. It is ideally suited to the younger patient with a sagging mid face. In patients with really excess skin especially in the neck region, it may be necessary in some cases to make an incision posterior to the ear to take up this slack, but in most cases this is not necessary.

Details of Procedure

The operation can be performed under general anesthesia, local anesthesia with intravenous sedation, oral sedation or local anesthesia. The operation generally takes about three to four hours. When performed under local anesthesia with oral sedation plan for an extra 30 to 45 minutes for the instillation of the local anesthetic. In all cases the procedure can be combined with lower lid blepharoplasty, upper eyelid blepharoplasty, browlift and chemical peels. In some cases where it is desirable to obtain a strong lift of the the malar fat pad region (cheek), a pinch lower eyelid blepharoplasty is necessary to remove the excess skin that can bunch up in this area. Usually no additional work needs to be done to the fat pads because of the suspension of the malar area.

Recovery

During the post operative night, an elastic bandage is placed around the face and two small non-suction drains are inserted behind the ear. An iced compress is applied to decrease swelling and bruising. You will be told not to apply ice directly to the skin. No heating pads are allowed. The bandage is removed the following day, along with the drains which simply pulled out. Following this, the elastic facial bandage is worn for one week. Following this, the patient normally looks fairly reasonable, although there may be some residual bruising, particularly around the eyes. This may treated with Arnica cream and massage on a twice daily basis.

What do I do once I’m home?

There will be swelling, often including the eye region and sometimes bruising. This can be minimized by applying cool packs regularly for 24 - 48 hours and sleeping well propped up. It is important to avoid any over activity, bending over, alcohol consumption and vigorous activity for a week. Most patients are able to return to work after a two week period.

Stitches in the lower blepharoplasty incision and , those in front of the ears and alternate stitches in the hairline are removed at five to six days and the remaining sutures in the hairline at ten days.

How will I look and feel after the surgery?

By the end of the first week your face will still be swollen. Dressings can be removed so you can shower the first postoperative day. You can wear make up to conceal any discoloration.

By the end of the second week most of the bruising will have disappeared, sutures will have been removed and you can start to think about resuming normal activities including non strenuous work.

By one month you may resume exercise, your new face will start to settle. You may notice tingling as numbness around the ears subsides although numbness may persist for several months.

Results

In our opinion the MACS lift is a significant advancement in facial rejuvenation surgery as it involves relatively little undermining and consequently the recovery is quicker. It also has the significant advantage of improving the mid face and malar area which other facelift techniques do not tend to help.

This lift is ideally suited to the younger patient with mid face ageing changes and moderate changes in the neck.

How long will it last?
The positive effects of a MACS facelift last for about 10 years, but are dependent upon the elasticity of your skin as well as other considerations such as diet and exposure to UV sunlight rays.

Other Considerations in Facial Rejuvenation

The face can be divided into five aesthetic units for complete facial rejuvenation each of these areas must be assessed and their overall contribution to facial aging determined:

· The forehead

· The upper eyelids

· The lower eyelids

· The cheeks and jowls

· The neck

THE FOREHEAD

There are several aesthetic goals that will be considered in a forehead rejuvenation. The indications for a forehead lift include eyebrow sagging and vertical and horizontal wrinkles. The ideal eyebrow position in the female is for the arch of the eyebrow to be 1 centimeter above the level of the supraorbital ridge (the bone which makes up the top of the orbit). In a male the position of the eyebrow should be at the level of the supraorbital rim. Also to be considered is the distance between the eyebrow and the upper eyelashes. If this distance is narrow then no amount of removal of upper eyelid skin will open up this space. You can assess for yourself the potential benefits of a forehead lift by gently elevating the skin of the forehead with your hands. The first goal of the forehead lift will be an elevation of the eyebrow. This will open up the upper portion of the eye and create an aesthetic arch to the eyebrow.

The second goal of a forehead lift is the removal and lessening of the creases of the forehead. There are two types of creases, horizontal and vertical. These wrinkles form due to the action and location of muscles beneath the skin. The corrugator supercilii muscles act to bring the eyebrows together toward the middle. This muscle causes the vertical wrinkles and creases between the eyebrows. The procerus muscle acts to pull up the skin of the nose. This muscle causes the horizontal wrinkles between the eyebrows. As a part of the forehead procedure these muscles are modified. This eliminates these horizontal wrinkles.

The forehead lift is now done as an ENDOSCOPIC procedure. This is a recent advance in the field of plastic surgery. The endoscopic forehead lift has now almost completely replaced the open procedure. It is a very reliable way to perform a forehead lift and to correct eyebrow imbalance. The endoscope is basically a metal tube with a light and a lens at the end. It is connected to a video camera and monitor. This enables the surgeon to perform the procedure through minimal incisions which leads to decreased scarring, less pain and greater precision. The endoscope gives us greater magnification which yields greater control. The results of the endoscopic procedure are comparable to the open procedure with the advantages of shorter scars, less numbness and greater patient satisfaction.

THE UPPER EYELIDS

Next we will consider the upper eyelids. A portion of the excess skin of the upper eyelids will be removed. The aesthetic goal for the upper eyelids is to create a distinct fold above the eyelashes and to remove any excess skin and fat of the lids. This opens up the eye area and gives creates a youthful almond look.

THE LOWER EYELIDS

Lower eyelid surgery can remove bags, pouches and excess skin from the lower eyelid area. When combined with a MACS lift usually only a pinch blepharoplasty is required. This is a small lateral incision placed just under the eyelashes and extending laterally. Very fine sutures are placed to complete the procedure. This differs from a traditional blepharoplasty in that the deeper layers of the lids are not involved.

THE NECK

The wrinkling of the thin skin of the neck is one of the most visible signs of aging. It can also be significantly corrected by the facelift procedure. The unattractive "turkey gobbler neck" is due to loose skin and a sagging of the underlying platysma muscle. It creates a band of skin that extends from the lower jaw to the collarbone. As a portion of a facelift these abnormalities are corrected. The loose muscle is tightened and the sagging skin is removed as it is pulled back behind the ears. The MACS lift can correct most conditions involving sagging of the neck of the skin however in severe conditions additional procedures may be needed or a standard facelift may be a better alternative.

The Initial Consultation

During your initial consultation with the plastic surgeon we will discuss the specific details of the procedure. We will review your past medical history and perform a physical examination. Your face, neck, forehead and eyelids will be examined and then specific recommendations will be made concerning the type of facelift planned, the location of the incisions and any ancillary procedures that would be required to achieve the best possible result.

All of our fees will be discussed in a surgical cost analysis. The total cost includes the surgical procedure, the cost of the operating room, anesthesia (anesthesiologist), all supplies and medication and post-operative follow up examinations. The fees for aesthetic surgery are payable in advance. The specific details of our financial policies are available and will be included with your cost analysis.

If you decide to proceed with the facelift all arrangements will be made through the office. Our patient coordinator will arrange the time and location of the surgery with you. Once scheduled you will return for a pre-operative examination. At this time we will answer further questions that you may have. Pre-operative photographs will be taken to serve as a record of treatment. Routine laboratory studies such as a blood count will be done. You will be instructed not to drink or eat anything after midnight the evening prior to your surgery. This ensures that your stomach is empty and increases the safety of administering your anesthesia. You should not take any aspirin or aspirin containing products for two weeks prior to the surgery. Common medications that contain aspirin include: Alka Seltzer, Anacin, Ascriptin, BC, Bufferin, Coricidin, Darvon, Fiorninal, Dristan, Excedrin, Percodan and Sine Off. Tylenol may be taken during this time. If you smoke then you should stop for a minimum of two weeks before surgery and for two weeks following the surgery. Nicotine has a direct negative effect on the healing process. All potential complications are known to occur more frequently in people who smoke.

The Day of your Surgery

You should wear loose, comfortable clothing. Avoid shirts that have to be pulled on over your head. A loose fitting shirt or blouse or a jogging suit with a zipper in the front works well. You may shower or bathe as normal the day before surgery.

A facelift is done under either local anesthesia with oral sedation, twilight anesthesia or under general anesthesia. The choice of anesthesia involves a thorough discussion with your plastic surgeon as some patients are a better candidate for one type verses another. It is normal to feel anxious before surgery. If you are having oral sedation then you will be asked to take your first dose of sedation medication 30 minutes prior to the procedure. Under general anesthesia our anesthesiologist will give you medications that will make the surgery as comfortable of an experience as possible. Some of the incisions are closed with sutures that are placed under the skin and will dissolve. The other sutures are of the type that will have to be removed. The stitches in front of the ears are removed in 5 to 7 days. The stitches or staples in the scalp will be removed by the second week. Following the surgery you will be observed in the recovery area. You will be under the effects of the medications for several hours and will remain drowsy. You will need some one to drive you home. Arrangements should be made for someone to stay with you for at least the first day after surgery.

Post-operative Instructions

You will be given prescriptions for pain medications and antibiotics several days prior to your surgery. It is usually best to fill these prescriptions before the surgery so that they are available when you get home. You should take the medications as instructed. It helps to take the medications with a small amount of food. If you become nauseated be very careful with food intake. Begin with clear liquids like a soft drink or tea. You may also try saltine crackers or dry toast.

When you arrive home try to make yourself as comfortable as possible by going to bed or sitting up in a chair. Place the pillows under your shoulders and not behind your head. You want to keep your neck in a neutral position. This will prevent you from placing too much strain on the neck. Take the pain medications every three to four hours as needed. Do not eat heavy foods the evening of surgery. Slowly advance your diet until you are certain that you are not going to have a problem with nausea. If you develop nausea that is persistent then call your plastic surgeon and he will prescribe a medication for you. You may change your dressings as needed. You may use ice compresses for the first 24 to 48 hours as appropriate. Do not place ice directly on the skin. You may be instructed to apply an antibiotic ointment to the incision lines for the first few days. You may shower or bathe the day after surgery. It is not harmful to get the incisions wet after 24 hours. You will be seen in the office for a follow up examination 3 to 5 days following the surgery. If you have questions about camouflage make-up let us know and we will assist your. This can help to cover up some of the expected bruising

Over the next week you will slowly resume your normal activities. The initial discomfort usually subsides after the first 24 hours. During this initial healing phase use your commonsense. If you think that you should not do it then don't do it. You may continue to need the pain medication for the first few days. Then you will be able to get by using Ibuprofen (Advil). Stock up on foods that are soft and are easily chewed. Try to avoid excitement during the first few days as this increased the blood pressure and can lead to post operative problems.

You will be instructed to notify the doctor immediately if you experience any of the following problems.

An elevated temperature of 101 degrees or greater that is not relieved by two Tylenol

Excessive swelling or tenderness of the face

Any significant and prolonged bleeding from the incisions

Any redness along with increased warmth of the face

Risks and Complications

Risks and complications associated with a facelift are rare. We do not mention these risks to frighten you, but rather to inform you and educate you so that you can make an intelligent choice. Bleeding - The development of a post-operative hematoma or bleeding is unusual. This occurs when there is bleeding under the skin. This risk of this complication is less than 1% . If the bleeding and subsequent blood collection is severe it may require a reoperation. Unusual bleeding or marked swelling of the face should be reported to the plastic surgeon immediately.

Infection - Antibiotics are prescribed to reduce the possibility of infection; however a risk of infection always exists with surgery. Swelling and bruising - These are very common. Most of the swelling will subside within a few weeks. It will be several months until all of the swelling is gone and the "final result" is obtained. Bruising will be present and can last for a couple of weeks following surgery. Our aesthetician can assist you with camouflage make-up. DO NOT APPLY ICE DIRECTLY TO THE FACE FOR SWELLING THIS COULD DAMAGE THE SKIN FLAP.

Temporary numbness - Some numbness can be expected for a short time following surgery and may last up to a few months. Small residual areas of numbness can last for longer periods of time. It is unusual to have permanent numbness of the skin.

Hematoma - A hematoma is a collection of blood under the skin. If this is serious it may need to be surgically drained. If the hematoma is small then the body will absorb it. This complication will generally occur during the first 24 hours following surgery.

Hair loss - Hair loss to some degree is not uncommon. This type of hair loss is around the incisions and is due to excessive tension.

Scarring - All of the incisions are placed in areas that are thought to be the least conspicuous. In general, most facelift scars heal without problems and the resulting scars are barely noticeable.

Facial nerve injury - Permanent facial nerve injury is extremely rare. All efforts are made to protect the facial nerve from damage or injury. If this nerve is injured there is a loss of function of muscles to the cheek, lip or forehead.

Results

The results of a facelift are not permanent. No type of plastic surgery can stop the aging process. After a facelift, your face and neck will continue to age at a "normal rate". The goal of a successful facelift is to diminish or reduce the signs of aging that are present at the time of the surgery. It should be considered as a repair and maintenance procedure. Essentially you will be rolling back the clock. Your face will look the way it used to look 5 to 10 years ago.

Most of our patients feel that they come away from the facelift procedure with a fresher, crisper and smoother appearance. The results of a specific procedure will vary greatly from patient to patient, depending upon the degree of wrinkling and the overall quality of the skin. The importance of a good skin care program cannot be overstated. It is vital in maintaining the results of the facelift.

Cost

At the time of your consultation we will give you a surgical cost analysis. The cost of your surgery includes all professional fees, the operating room charges, all sterile supplies and medications, the operating room assistants, and anesthesia. Also included in the cost are all follow up examinations for one year. If you should require any additional procedures to repair complications you would only be charged for the cost of sterile supplies and medications. As with all cosmetic procedures, the cost of a facelift is not covered by health insurance.