Cosmetic

Minimal Access Cranial Suspension Lift:

A Modified S-Lift
Patrick Tonnard, M.D., Alexis Verpaele, M.D., Stan Monstrey, M.D., Ph.D., Koen Van Landuyt, M.D.,
Philippe Blondeel, M.D., Ph.D., Moustapha Hamdi, M.D., and Guido Matton, M.D.
Gent, Belgium

There is a strong trend at hand toward less dramatic pose a comprehensive facial rejuvenation treat-
facial rejuvenation surgery. Most of the authors’ patients ment. Most European patients want to look
want a cosmetic improvement but not at the cost of pro-
longed disfigurement or a high risk of complications. In younger without evidence of their having had a
1999, a very simple but effective rhytidectomy technique, face lift. Some patients refuse to have the plas-
termed an S-lift, was described in the literature and was tic surgeon operate on their eyebrows or eye-
adopted by the authors. Its basic principle is the suspen- lids. During consultation for facial rejuvena-
sion of sagging facial features by a strong, permanent tion, most patients demonstrate a maneuver
purse-string suture. The procedure is performed with the
patient under local anesthesia. Significant modifications that they have repeatedly performed in front of
were applied to the incision, to the purse-string suture the mirror: they push the skin of the mandib-
anchoring site, and to the direction and shape of the skin ular angle and the zygomatic region cranially
excision. The authors named the modified procedure the (Fig. 1). To fulfill the wish of these patients,
minimal access cranial suspension lift to specifically de- the S-lift, an operation that was originally pro-
scribe the concept of the technique. Through an inverted
L-shaped preauricular incision with extension below the posed by Saylan,1 has been redesigned. The
sideburn, a limited skin undermining is performed. Two term S-lift is confusing and refers only to the
strong, permanent purse-string sutures are woven into the S-shaped skin pre-excision, which belongs to
superficial musculoaponeurotic system tissues in a vertical the originally described technique and which
U and an oblique O shape, initiating from a strong an- was abandoned by us because it was not surgi-
chorage in the deep temporal fascia at the level of the
helical crus. Tying these sutures produces a very powerful cally sound. Therefore, we renamed the mod-
vertical correction of descended facial features that acts ified procedure the minimal access cranial sus-
mainly on the jowls and the upper neck. The procedure pension lift (MACS lift) to specifically describe
can be extended by continuing the dissection over the the concept of the technique.
malar fat pad, placing a third vertical purse-string suture
with strong action on the nasolabial groove, and vertically MATERIALS AND METHODS
repositioning the midfacial volumes. During 20 months,
pleasing results and a very low complication rate were The MACS lift is performed as an outpatient
obtained in 88 consecutive patients with a mean age of procedure with the patient under local anes-
551⁄2 years. In this article, the authors provide a detailed thesia and minimal sedation. A total of 2.5 mg
description of the anesthetic and surgical technique, a of midazolam is given intramuscularly before
demonstration of the results in different patient age cat-
egories, and a discussion comparing the minimal access preparation and draping. This provides a com-
cranial suspension lift with other types of facial rejuvena- fortable relaxation, without diminished con-
tion procedures. (Plast. Reconstr. Surg. 109: 2074, 2002.) sciousness. Tumescent infiltration with local
anesthesia is provided with a 22-gauge spinal
needle by using a diluted solution of 0.3%
Most patients consulting for facial rejuvena- lidocaine, 1:650,000 adrenalin, and 2 mEq of
tion have their own opinion about the desired sodium bicarbonate2 (Table I). The same solu-
result and the extent of the operation. This tion is used for any ancillary procedure, such as
may be strongly different from the vision of the liposuction of the submental region, upper or
plastic surgeon, who may be inclined to pro- lower blepharoplasty, lipofilling, or laser resur-

From the Coupure Centre for Plastic Surgery, Gent, the Department of Plastic and Reconstructive Surgery, University Hospital Gent, and the
Coupure Centrum voor Plastische Chirurgie. Received for publication May 14, 2001; revised August 6, 2001.
2074
Vol. 109, No. 6 / MINIMAL ACCESS CRANIAL SUSPENSION LIFT 2075

FIG. 1. (Left) Typical maneuver of patients between 40 and 50 years old in response to being
asked what they expect from a lifting procedure: They push the region of the mandibular angle
cranially to correct the sagging in the lower third of the face. (Right) Typical maneuver of patients
older than 50 years in reply to the same question: They push the region of the mandibular angle
and the zygoma cranially to correct the sagging of the lower and middle third of the face.

TABLE I directed upward, following the earlobe crease,

Anesthetic Solution for Tumescent Infiltration in Minimal crosses the incisura intertragica perpendicu-
Access Cranial Suspension Lift larly, makes a little indentation to go on the
tragal rim, follows the anterior border of the
helical crus, further follows the hairline in the
100 ml of 0.9% sodium chloride solution
20 ml of 2% lidocaine solution non– hair-bearing recess in front of the ear,
0.2 mg of adrenalin and then turns anteriorly along the inferior
2 ml of 8.4% sodium bicarbonate limit of the sideburn. A limited skin flap is
(0.3% lidocaine, adrenalin 1:650,000)
undermined in an oval area extending from 1
cm above the zygomatic arch to the mandibu-
facing of the central portion of the face. When lar angle caudally and about 5 cm in the ante-
performing a MACS procedure separately, an rior direction (Fig. 2, left). Undermining of the
average of 30 ml of this infiltration solution is skin flap is performed with face-lift scissors in
used on each side of the face. At least 10 min- the spreading mode. Because of the tumescent
utes is allowed for adequate blanching of the infiltration, a natural subcutaneous plane can
infiltrated skin. During this time, a closed- be found by simply spreading the scissors in a
suction lipectomy of the submental area is per- plane parallel to the skin. One centimeter in
formed in more than 95 percent of cases. This front of the anterior margin of the helical crus
is done in the supraplatysmal plane with a and 1 cm cranially to the zygomatic arch, an
2.5-mm spatula-tip cannula. Suction of the sub- additional injection of local anesthesia is given
platysmal region or the jowls is never per- down to the temporal bone. With pointed iris
formed. There are two types of MACS lifts: the scissors in a spreading mode, the deep tempo-
simple and the extended. ral fascia is exposed over about 0.5 cm2, taking
care not to injure the superficial temporal
Simple MACS Lift vessels.
An inverted L-shaped preauricular incision A first purse-string suture is made with 2-0
starts at the most caudal end of the earlobe, is Prolene monofilament on a big needle (V7
2076 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2002
freeing the retracted skin with scissors. The
excess skin is redraped in a pure cranial direc-
tion, marked, and resected. The skin is sutured
under strong vertical tension with five subcuta-
neous sutures of 4-0 Vicryl. There is no traction
in the horizontal direction. The preauricular
incision is sutured under minimal tension. The
earlobe, which is pulled cranially by putting
vertical tension on the skin flap, is simply set
back without tension as a little transposition
flap. This avoids the risk of creating an unnat-
ural, pulled-down earlobe.3 Sometimes a small
FIG. 2. (Left) Preoperative marking of the preauricular
dog-ear will appear behind the earlobe. To
and infracapillary incision (solid line) for the minimal access avoid a scar behind the ear, it is not resected.
cranial suspension lift. The dotted line indicates the extent of The patient is informed preoperatively about
undermining, and the arrow indicates the vector of traction. the possibility of this small dog-ear and about
(Right) Minimal access cranial suspension lift. Position of the its spontaneous disappearance within 2
vertical, narrow purse-string suture and the 30-degree
oblique, wide purse-string suture on the nonundermined
months. A small Penrose drain is inserted in
superficial musculoaponeurotic system, with anchoring to the lowest part of the incision at the earlobe,
the deep temporal fascia. Sutures performed with 2-0 and a further closure of the skin is performed
Prolene. with 5-0 Vicryl subcutaneously and with 5-0 and
6-0 nylon continuous and interrupted skin su-
needle, Ethicon, Inc., Somerville, N.J.). The tures. Ice cooling is applied for 2 hours after
first bite is taken deep down to the temporal the procedure, and a light compressive dress-
bone (to be sure that the deep temporal fascia ing is left on for 1 day. The patient can leave
is included) in a craniocaudal direction (Fig. 2, the office 2 hours after surgery. The dressing
right). The needle usually exits at the pretragal and Penrose drain are removed the next day,
area. The purse-string suture is continued in a and the patient can shower and wash his or her
narrow U-shape, first in a craniocaudal direc- face and hair from then on. During the first 24
tion, descending in front of the ear from the hours after surgery, patients are allowed to take
first bite down to the mandibular angle, mak- limited amounts of soft food together with oral
ing a U-turn, and returning 1 cm anteriorly in antibiotics and pain medication (paraceta-
a parallel cranial direction to the starting mol). All patients are offered the opportunity
point. A firm amount of parotid fascia in the of having daily facial lymphatic drainage mas-
cranial part and of platysma in the caudal part sage during one week, starting on postopera-
is taken with every bite of the needle. The tive day 4. All sutures are removed at day 7.
purse-string suture is then tied under maxi-
mum tension, exerting vertical traction on the Extended MACS Lift
platysma, which causes strong elevation of the To enhance the effect on the nasolabial
whole anterior neck region. Seven knots are groove and to lift the malar fat pad4 and the
tied on this monofilament suture. The knot is midface, the incision is extended along the
buried in the soft tissue to prevent it from anterior border of the temporal hairline (Fig.
being visible or palpable through the skin. 3, left). The subcutaneous undermining is ex-
A second purse-string suture is started at the tended over the area of the malar fat pad and
same point and is directed in an angle of about a third, narrow, U-shaped purse-string suture is
30 degrees anterior to the original vertical placed between the anterior part of the deep
purse string in a more open, oval shape to temporal fascia and the malar fat pad (Fig. 3,
correct the jowling and the marionette right). By putting tension on this suture, an
grooves. The suture is carried to the edge of obvious flattening of the nasolabial groove and
the undermined area and then taken back to raising of the malar fat pad will result. This
the starting point (Fig. 2, right). After tying this modification was designed in August of 2000.
suture under maximum tension, a very effec- A simple MACS lift is performed in approx-
tive elevation of the jowls is seen. At this mo- imately 11⁄2 hours. An extended MACS lift takes
ment, some dimpling will be seen at the limits 2 hours. Table II summarizes the modifications
of the undermined skin, which is corrected by made to the originally described S-lift and the
Vol. 109, No. 6 / MINIMAL ACCESS CRANIAL SUSPENSION LIFT 2077
days of swelling in the malar area. There were
no demands for surgical removal of dog-ears
behind the earlobe because they all disap-
peared within 2 months after surgery. Patient
satisfaction was very high. In all patients, the
desired correction of the aging facial features
was obtained and remained stable for the ex-
tent of our follow-up. From a surgical point of
view, the short operating time, pleasing results,
quick recovery period, and absolute absence of
major complications were considered very im-
portant advantages of this procedure. Two he-
FIG. 3. (Left) Extended minimal access cranial suspension
matomas had to be evacuated: one at the end
lift. Preoperative marking of the preauricular and infracap- of the surgery and one 8 hours postoperatively,
illary incision, which is extended along the temporal hairline, in a very active man who went to work imme-
with supplementary undermining of the malar region and diately after surgery. The resulting scars were
different vectors of traction (arrows) on the midface soft tis- inconspicuous. The effect of the surgery can be
sues. (Right) Extended minimal access cranial suspension lift.
Position of a third narrow purse-string suture, in addition to
considered stable, as demonstrated in our pa-
the two purse-string sutures described in Figure 2, between tient with the longest follow-up of 18 months
the anterior part of the deep temporal fascia and the malar (Fig. 9).
fat pad.

similarities between it and the simple and ex- DISCUSSION

tended MACS lifts. Facial aging is caused by a multitude of fac-
tors: the years of gravitational pull on the soft
RESULTS tissues between the skin and the facial skele-
Between December of 1999 and June of ton, loss of elasticity of the skin caused by
2001, 88 MACS lifts were performed (81 intrinsic and extrinsic factors, possible facial
women, seven men). The mean age was 551⁄2 deflation caused by fat atrophy,5,6 or even bony
years, ranging from 38 to 82 years (Figs. 4 resorption.7,8 These different possibilities ex-
through 9). The simple MACS lift was per- plain the multitude of therapeutic approach-
formed on 54 patients, and the extended es.9 –17 One can rejuvenate the skin by using
MACS lift on 34 patients. All procedures were resurfacing techniques, lifting the sagged soft
performed with the patient under local anes- tissues, augmenting deflated areas with autolo-
thesia, with minimal sedation, and in an office gous or other materials, or combining differ-
setting, except for four patients with a history ent procedures. The MACS lift, as described
of medical disorders (hypertension, thrombo- above, is fundamentally a pure antigravita-
embolic history). The operations for these four tional lifting procedure that will suspend the
patients occurred with the patient under local sagging soft tissues of the face and neck, to-
anesthesia, with sedation given by an anesthe- gether with the adhering skin, in a vertical
siologist, and in a hospital setting. During the direction into the place where they previously
first 3 days, all patients experienced marked belonged. When counseling candidates for fa-
but bearable pain in the temporal region and a cial rejuvenation, most of them make a maneu-
limitation of mouth opening. This was proba- ver with the fingertips on the mandibular angle
bly caused by the traction on the temporal or the malar region, pushing the skin and the
fascia by the purse-string sutures. All patients facial soft tissues in an upward direction (Fig.
showed a temporary swelling of the cranial 1). Therefore, any technique that works in a
portion of the sternocleidomastoid region that caudocranial vertical direction will have a vi-
disappeared within 2 weeks. Most of the pa- sual anti-aging effect, whether it is a lateral
tients were able to return to their normal ac- removal of the superficial musculoaponeurotic
tivities 1 week after surgery with the help of system (SMAS),12 a cranial suspension with
some camouflaging makeup. On postoperative purse-string sutures,1 a subperiosteal open14 or
day 14, all patients were able to go out without endoscopic approach,9 or a deep-plane face-lift
any makeup. Patients in whom an extended technique.16 In contrast to the most frequently
MACS lift was performed showed a few more proposed classic face lifts,10 which all have a
2078 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2002
TABLE II
Comparison of the Original S-Lift Technique with the Described Simple and Extended Minimal Access Cranial Suspension
(MACS) Lifts

S-Lift Simple MACS Lift Extended MACS Lift

Pre-excision of skin No pre-excision of skin No pre-excision of skin

S-shaped skin incision, crossing the Inverted L-shaped skin incision Inverted L-shaped skin incision following
non–hair-bearing skin at the helical following lower border of sideburn lower border of sideburn and extending
root along anterior temporal hairline
Oval-shaped skin undermining Oval-shaped skin undermining Oval-shaped skin undermining with
extension over malar fat pad
Vertical U-shaped and oblique O- Vertical U-shaped and oblique O- Vertical U-shaped and oblique O-shaped
shaped purse-string sutures on shaped purse-string sutures on purse-string sutures on SMAS and oblique
SMAS SMAS U-shaped purse-string suture between
malar fat pad and deep temporal fascia
Purse-string suture fixation to Purse-string suture fixation to deep Purse-string suture fixation to deep temporal
periosteum of the zygomatic arch temporal fascia fascia
Skin redraping at 45-degree angle Customized skin excision after Customized skin excision after redraping in
redraping in vertical direction vertical direction
Skin redraping behind earlobe No skin incision behind earlobe No skin incision behind earlobe
Effect on anterior neck and jowls Effect on anterior neck and jowls Effect on anterior neck, jowls, midface, and
nasolabial fold
SMAS, superficial musculoaponeurotic system.

strong lateral vector of displacing soft tissues, procedure, the sagging soft tissues are brought
the MACS lift is a pure vertical-vector face lift. back to their original position with a simple
In recent years, the tendency has been to- suturing technique placed directly in the ptotic
ward less invasive techniques in facial rejuvena- tissue.
tion surgery. Baker17 showed an evolution in With Baker,17 we share the disappointment
his face-lift techniques from extended classic about the morbidity and the poor long-term
dissections toward minimal incision techniques results of anterior corset platysmaplasty.19 –21 By
and from a lateral pull to more cranially di- pulling strongly on the lateral part of the
rected displacement of the soft tissues. Also, platysma at the mandibular angle in a cranial
Finger18 proposed minimal skin and SMAS dis- direction, platysmal bands will disappear in
sections, in combination with subperiosteal most cases. We limited our indications for an-
midface lifts, and demonstrated stable and nat- terior platysmaplasty to the few cases in which
ural results with minimal postoperative the platysmal bands did not disappear with
morbidity. upward traction on the platysma in the region
The ultimate determinant of a successful of the mandibular angle. The combination of
rhytidectomy is a happy patient.17 Listening to moderate-to-aggressive fine-needle liposuction
our patients’ desires is essential to be able to of the submental region with a strong cranial
fulfill them. Therefore, we believe the ideal suspension of the platysma and SMAS, as done
facial rejuvenation procedure is an interven- in the MACS procedure, offers a simple and
tion with a visible but natural change, with valuable alternative.
minimal risks, minimal morbidity, and mini- In a classic face lift, the retroauricular and
mal social discomfort. Offering the MACS lift occipital incision is used to create the posterior
as a safe outpatient office procedure is wel- part of the skin flap. The traction on this flap
comed with great enthusiasm because of the in the oblique upward direction basically only
strong resistance to hospital admission of most redrapes skin and has little or no rejuvenating
cosmetic surgery candidates and their reluc- effect. Most of the skin resection in a classic
tance to pay hospital expenses. face-lift design is done in the occipital region,
Subperiosteal procedures can produce dra- producing the classic problems of hairline dis-
matic changes with beautiful long-term re- placement or noticeable pretrichial scars, a
sults,9,14,15 but patients sometimes have swelling problem that was never encountered in our
that remains for 6 months. Also, by raising the patient group.
periosteum, tissue is moved to a position where The horizontal limb of the MACS-lift inci-
it has never been. Indeed, the periosteum is sion enables us to excise a large amount of
the only anatomic structure that stays fixed to facial skin in a vertical direction without eleva-
the bone over an entire life. With the MACS tion of the hairline.22–24 The extension of this
Vol. 109, No. 6 / MINIMAL ACCESS CRANIAL SUSPENSION LIFT 2079

FIG. 4. (Above, left and right) Three-quarter and profile views of a 45-year-old woman with
moderate jowls and moderate central anterior neck skin laxity. No visible platysmal bands. (Below,
left and right) One-year postoperative results, with correction of the jowls and neck laxity after
a simple minimal access cranial suspension procedure and minimal liposuction of the submental
area.

incision in a pretrichial cephalic direction of this incision, very inconspicuous scars can be
makes action on the midface possible in the obtained.
extended MACS lift. After meticulous closure The sagging of the midface can be treated
2080 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2002

FIG. 5. (Above, left and right) Three-quarter and profile views of a 56-year-old woman with
marked jowls, marionette grooves, and a heavy, fatty neck with clearly visible platysmal bands.
(Below, left and right) Results 14 months after a simple minimal access cranial suspension lift with
extended liposuction of the anterior neck and upper blepharoplasty. Note the correction of the
jowls, marionette grooves, cervicomental angle, and the nice volumetric augmentation of the
zygomatic region.

through different approaches. A lateral ap- Tessier,14 was recently modified by Little.15
proach was suggested by Hamra,16,25 Stuzin et Byrd and Andochick29 used the endoscope
al.,26 Owsley and Fiala,4 and Connell and through the temporal approach, and Yarem-
Semlacher.27 Hester et al.28 described a more chuk30 recently proposed a combination of dif-
vertical approach through a lower eyelid inci- ferent approaches. Disappointed by the high
sion. A subperiosteal approach, introduced by complication rate of lower eyelid approaches28
Vol. 109, No. 6 / MINIMAL ACCESS CRANIAL SUSPENSION LIFT 2081

FIG. 6. (Above, left and right) Frontal and profile views of a 52-year-old woman with marked
jowls and marionette grooves, moderate laxity of the anterior neck, and general sagging of the
midface. (Below, left and right) Results 8 months after an extended minimal access cranial
suspension lift and discrete upper and transconjunctival lower blepharoplasty. Note adequate
correction of the jowls, marionette grooves, and anterior neck skin laxity. Also note the volu-
metric lift of the whole midface. No skin resection was performed on the lower eyelids.

and the long recovery period of subperiosteal part of the deep temporal fascia and the malar
midface14,15,29 elevation, we decided to use the fat pad to lift the whole midface with an
lateral approach. An extra U-shaped purse- oblique to an almost vertical vector.
string suture is placed between the anterior The debate between limited and extended
2082 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2002

FIG. 7. (Above, left and right) Three-quarter and profile views of a 60-year-old man with marked
jowls, marionette grooves, laxity of the anterior neck skin with marked platysmal bands, and
general sagging of the midface. (Below, left and right) Results 11 months after extended minimal
access cranial suspension lift and discrete upper blepharoplasty. Note adequate correction of the
jowls, marionette grooves, and anterior neck skin laxity without platysmaplasty. There is a nice
volumetric rejuvenation of the midface area. No lower eyelid surgery was performed.

undermining of the facial skin is ongoing. ful anatomic studies about the retaining liga-
Some authors are convinced that extensive un- ments of the face have been published, to-
dermining and radical skin resection leads to gether with the statement that these ligaments
better and more long-lasting results.31 Beauti- are to be divided to be able to resect more
Vol. 109, No. 6 / MINIMAL ACCESS CRANIAL SUSPENSION LIFT 2083

FIG. 8. (Above, left and right) Frontal and three-quarter views of a 61-year-old woman with very
marked jowls, marionette grooves, laxity of the anterior neck skin with marked platysmal bands,
general laxity of the facial skin, and excessive periorbital and lower eyelid rhytides. (Below, left
and right) Early postoperative results (4 months) after extended minimal access cranial suspen-
sion lift, upper blepharoplasty, and erbium laser resurfacing of the perioral and lower eyelid area.
Note the absence of erythema shortly after erbium resurfacing.

skin.32–34 But why should we transect the only Because the original S-lift procedure as de-
supporting structures of the skin? scribed by Saylan1 has some illogical steps
Concerning the stability of the results, we against elementary plastic surgery principles, a
realize that 18 months of follow-up is short, but lot of skepticism was raised about this interven-
over that period the results have been as good tion. Some surgeons compare this procedure
and as stable as in classic SMAS-lift techniques. with a technique described in 1919 by Passot,35
2084 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2002

FIG. 9. Longest follow-up case (18 months). (Above, left and right) Preoperative frontal and
profile views. (Below, left and right) Postoperative frontal and profile view. There is a stable result
in the correction of the jowls and cervicomental angle after a simple minimal access cranial
suspension lift procedure, upper blepharoplasty, and lower orbicularis suspension
blepharoplasty.

merely consisting of an S-shaped excision of skin was abandoned. First, one can never tell
preauricular skin without any undermining, how much skin must be removed at the end of
but the purse-string sutures do much more the operation; second, after pre-excision of
than that. skin, the surgeon is forced to manipulate and
The original Saylan S-lift design was modi- pull during the surgery on skin that will be
fied as follows. The S-shaped pre-excision of sutured at the end. Purse-string sutures are
Vol. 109, No. 6 / MINIMAL ACCESS CRANIAL SUSPENSION LIFT 2085
anchored to the rigid deep temporal fascia REFERENCES
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zygomatic arch. Skin redraping is performed in 406, 1999.
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cent technique in cervicofacial rhytidectomy. J. Oral
tion at a 45-degree angle (Table II).
Maxillofac. Surg. 52: 344, 1994.
The advantages of a MACS lift compared 3. Franco, T. Face-lift stigmas. Ann. Plast. Surg. 15: 379,
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cedure, local anesthesia, no hospital admis- 4. Owsley, J. Q., and Fiala, T. G. Update: Lifting the malar
sion, a short recovery period, and an inconspic- fat pad for correction of prominent nasolabial folds.
uous, short scar without raising of the temporal Plast. Reconstr. Surg. 100: 715, 1997.
or occipital hairline. Perhaps most impor- 5. Coleman, S. R. Facial recontouring with lipostructure.
Clin. Plast. Surg. 24: 347, 1997.
tantly, it is a safe procedure.36,37 Facial nerve
6. Donofrio, L. M. Fat distribution: A morphologic study
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and hematoma and postoperative numbness 7. Pessa, J. E. An algorithm of facial aging: Verification of
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MACS lift can be performed with great safety.38 aging, scleral show, and lateral suborbital trough de-
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8. Pessa, J. E. The potential role of stereolithography in
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The original S-lift technique as described by
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mined SMAS and anchoring it to a fixed and 17. Baker, D. C. Minimal incision rhytidectomy (short scar
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and stable elevation and traction on the SMAS 18. Finger, E. R. A 5-year study of the transmalar subperi-
that is transmitted to other regions in the face, osteal midface lift with minimal skin and superficial
such as the jowls, the malar fat pad, or the musculoaponeurotic system dissection: A durable,
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