The third suture in MACS-lifting: making midface-lifting simple and safe.

[BACKGROUND] The minimal access cranial suspension (MACS)-lift is a short scar rhytidectomy with vertical purse string suture suspension of the facial tissues. It exists in a simple and extended version. The simple MACS-lift achieves a vertical lifting of neck and lower half of the face with two purse string sutures. The action of a third, malar suture gives additional correction of the middle third of the face, and results in the extended MACS-lift.

[OBJECTIVE] To draw attention to the power and advantages of the 'third' malar suture in the extended MACS-lift in achieving volumetric restoration of the midface, softening of the nasolabial fold and enhancing support of the lower eyelid.

[METHODS] The core principle of this technique is the use of strong purse string sutures in a pure antigravitational direction for correction of the ageing neck and lower two-thirds of the face. In a simple MACS-lift the neck is corrected by a first narrow vertical purse-string suture. The volume of jowls and cheeks is repositioned in a cranial direction with a second, slightly oblique purse string suture. To achieve better control over the midface an extended MACS-lift is performed by adding a third malar vertical purse string suture between the paracanthal area and the malar fat pad.

[RESULTS] 557 MACS-lift procedures have been performed by the two senior authors, of which 183 were simple and 374 extended. A retrospective review of this technique revealed high patient satisfaction, only one major complication and a minor complication rate of 6%. Both versions of the technique deliver a vertical vector correction of sagged facial features. The third suture restores the volume of the midface and malar mound and provides strong support of the lower eyelid.

[CONCLUSIONS] The third suture in the MACS-lift short scar rhytidectomy produces a natural midface lifting through a short scar, with adequate softening of the nasolabial fold and good support of the lower eyelid.