title: The third suture in MACS-lifting: making midface-lifting simple and safe.
abstract: 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.
authors.affiliation: Coupure Centrum voor Plastische Chirurgie, Coupure Rechts 164 C-D, B-9000, Gent, Belgium. alex@coupurecentrum.be
authors.forename: A
authors.initials: A
authors.lastname: Verpaele
authors.forename: P
authors.initials: P
authors.lastname: Tonnard
authors.forename: S
authors.initials: S
authors.lastname: Gaia
authors.forename: F P
authors.initials: FP
authors.lastname: Guerao
authors.forename: A
authors.initials: A
authors.lastname: Pirayesh
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D012060:Rejuvenation / Q000502:physiology; D015361:Rhytidoplasty / Q000379:methods* / Q000523:psychology / Q000534:rehabilitation; D013536:Suture Techniques; D016896:Treatment Outcome