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MACS Facelift with FATS
Lawrence Gray, MD, Brannon R. Claytor.
Atlantic Plastic Surgery, Portsmouth, NH, USA.

PURPOSE:
Facial aging is secondary to years of gravitational pull between skin and facial skeleton leading to facial descent, loss of skin elasticity, fat atrophy. Correction of facial aging with minimal access cranial suspension (MACS) technique has been shown to produce reliable results. Maximizing adipose tissue viability during tissue manipulation should enhance post-operative results. Hydroinfiltration of tumescent is used to provide a bloodless operative field and finger assisted tissue separation (FATS) is used to dissect the skin flaps with minimal use of cautery.
METHODS:
Retrospective review was performed of 81 facelifts by senior author from 2005 until 2011. The mean age was 57.1 ± 8.3 years old. The average follow up was 37.4 ± 25 months. The average surgery time for the MACS surgery was 118.1 ± 10 minutes. The operative area is hydroinfiltrated through a single incision using the blunt cannula with 100 cc per side of tumescent fluid. Due to the tumescent infitration, the cautery is used sparingly if at all. Once the skin is sharply elevated from the SMAS over the parotid where it is densely adherent, it is bluntly dissected down to the angle of the mandible. These tissue plains separate with finger dissection. Further digital dissection is carried medially, inferior to the true malar retaining ligaments and temporally, superior to the malar retaining ligaments. 0 PDS sutures are placed superior to the zygomatic arch in the deep temporal fascia and tied as tightly as the soft tissues will permit. Skin envelope is secured via deep dermal attachment to the helical root cartilage with 4-0 vicryl. No drain is used.
RESULTS:
The MACS procedure with FATS had an average follow up was 37.4 ± 25 months. 3 (3.7% incidence) patients had a postoperative hematoma. 2 (2.4% incidence) patients had evidence of nerve palsy. One patient had a buccal nerve palsy which resolved within 2 weeks. The second had a simultaneous genioplasty and had a marginal mandibular nerve palsy, which lasted for 9 months before complete recovery. At one year, the procedure had a tuck rate of 8.6%. Tuck surgeries included; two temporal lifts, one neck liposction, one neck skin excision, one scar revision, two procedures to remove palpable PDS sutures.
CONCLUSION:
The MACS facelift with limited cautery owing to the hydrodissection of the tumescent and the finger assisted tissue separation (FATS) maximizes tissue redistribution without inducing thermal injury and adipose tissue destruction. Facial descent may be corrected with blunt cannula hydroinfiltration of tumescent and blunt skin envelope elevation with minimal incidence of post-operative hematoma. Addressing fat atrophy with fat grafting is a useful modality; however, avoiding cautery, minimizes loss of volume due to tissue trauma. By preserving the natural fat and repositioning it, fat grafting is not needed to build up the malar eminence to achieve an aesthetic Ogee appearance. MACS facelift can be even more minimally invasive with FATS while maintaining stable long term results and few complications.


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