Dr. Sam Jejurikar: Good morning, everyone. Welcome to another episode of 3 Plastic Surgeons and a Microphone. I am Dr. Sam Jejurikar from Dallas, Texas and as always, I’m joined by Dr. Sam Rhee from Paramus, New Jersey. He’s at Bergen Cosmetic and also by Doctor Salvatore Pacella from La Jolla, California. He is at San Diego Plastic Surgeon. Good morning, gentlemen.
Dr. Sam Rhee: Morning.
Dr. Sal Pacella: Good morning.
Dr. Sam Jejurikar: Well, today, rather than engage in small talk, I’m just going to jump straight into the meat of it. We’re going to be talking about a very exciting topic which is festoons and malar bags and most of our audience has no idea what I just said. But basically, this is complicated lower eyelet surgery. Before we get into this though I’m going to read our usual disclaimer. The show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any you may have regarding medical care and never disregard professional medical advice or delay seeking advice because it’s something you see in this show. So, Doctor Pacella happens to be an international expert on eyelid surgery. So, we are happy to let him lead this conversation today. So, my first question to you Sal is what are festoons and malar bags?
Challenges in Treating Malar Bags and Festoons
Dr. Sal Pacella: Great question. So obviously very, very problematic issues in and around the eye and many times these things are congenital. Many times, are age related and the reason we’re sort of doing a podcast on this is this is something we’re seeing with increasing frequency in the press and patients coming in and asking for it. And like anything, if there was an easy treatment for it, it wouldn’t be so much of an issue. The thing that makes these very difficult is there’s no great treatment for this. So, what I’ve sort of put together here is a little bit of a discussion about this and kind of my approach to this and modest success with it, okay? So, I’m going to share my screen here, okay? Perfect. Okay.
So, the interesting thing this part of the face, the anatomy is this is a unique anatomic construct in our face, okay? So, if you see this gent here, he’s got these sorts of bags to his lower eyelid. We’ll call those the lid or palpable bags and then the festoon or malar bag. A festoon is sort of when the skin is a little bit looser, a malar bag is when it’s collected with a bunch of kind of swelling or edema. And in fact, I’m going to use those two terms interchangeably. Some authors may disagree with me on that, but just for simplistic sake, we’re going to kind of use those interchangeably. So, if you look at on the left side here, this is an anatomic drawing of the facial skeleton and what I want to point out is this area right here, okay?
So, the malar bag or festoon is a 3-dimensional box essentially of ligaments and structure in the middle of the face. The top of the box is caused by a ligament or is made by a ligament called the orbital malar ligament and then the bottom of the box is caused by a ligament or is made by a ligament called the zygomatic cutaneous ligament. These ligaments go from all the way to the bone to all the way to the surface of the skin. So, think about this like two shelves in a bookshelf, okay? And in that bookshelf is this area called the pre-zygomatic space. So, this is notoriously an area that doesn’t drain very well and it maintains fluid in the face and that’s truly what causes malar bags and I’m going to guess both you guys are big dudes when it comes to soft tissue fillers. How many times do you have patients come in and say, hey, I hate this bag underneath my eye, I want some filler for this?
Dr. Sam Rhee: All the time.
Dr. Sam Jejurikar: Often. Yeah, very often. Often.
Dr. Sam Rhee: Right, and so the issue with injecting fillers and I would say that, we see a lot of non-surgical providers doing fillers. Some are better than others, we see a lot of nurse practitioners, PAs, injecting fillers and notoriously what I see sometimes is that when filler gets injected into this pre-zygomatic space, it stays there and that fast tune or mailer bag will actually look a lot worse afterwards. So, big, big caution for our patients here. Injecting in and around this area can be very problematic if you get it in the right space. Comments on that, Jens?
Dr. Sam Rhee: Absolutely. This is a very sensitive and tricky area to treat and it does take experience to know where what you’re doing with it.
Dr. Sam Jejurikar: Yeah, I mean, because I loved your analogy of the 2 bookshelves. If you inject in the long place and you end up injecting so that it’s trapped between those bookshelves, you can actually exacerbate the problem as opposed to improving it. But I’ve seen many patients come in who have wanted their filler dissolved when they were injected somewhere else, try to make this in an attempt to make this better.
Dr. Sam Rhee: So, I’ve spoke on this topic quite a few times both in the US and out of country, and I did publish a few discussions on this topic for malar edema, mounds, and festoons. So, something I feel fairly comfortable, and the key here is surgical treatment is not perfect but it really sometimes is the only real option when it comes to treating this effectively. So, I’m going to show you guys, a little operative video here. So, that the key here is let’s just go back to this here. So, the key is when we are treating this area, we have to understand that that bookshelf goes all the way from the skin to the base of the bone. So, you have to as the surgeon independently remove that ligament both in the level above the bone and in the level underneath the skin. So, this orbital malar ligament has to be taken down at the level of the bone going all the way deep into the mid face and at the level of the skin. What the view may not necessarily gather for this is just how challenging sometimes this dissection and the surgery is. Jen’s thoughts on that.
Dr. Sam Jejurikar: It sounds like that would cause a ton of post-operative swelling. I understand why you would need to do that, but how long do you tell your patients it’s going to take for them for their swelling to go away?
Dr. Sam Rhee: Sometimes 6 months. I mean, it is a huge challenge. In fact, I have a patient on dealing with that I’ve treated about three months ago and we still have some residual swelling in place, and but we know this ahead of time going in. So, the key here is both the surgeon and the patient have to be committed to this operation.
Dr. Sam Jejurikar: And do you do anything postoperatively in terms of steroid injections or oral steroids to try to help it go away faster or you just sort of let time do its thing?
Dr. Sal Pacella: No, you sort of let time do its things and that’s an interesting concept here as to why the swelling persist for so line. So, if you think about it, the way the anatomy of the face is, there are two major drainage channels that occur. There’s one that’s medially right near the nasolabial fold here and another one near the malar mound right here. So, those two anatomic channels that drain postoperative fluid are disrupted from all of the surgery. So, it takes time for your body to drain the stuff and it’s going to be dependently drained into the face and that pulls tremendous amount of fluid in and around the eyelid, it pulls it in the mid face and in the cheek. So, it just takes a tremendous amount of time for this to go away. Much like say if you sprain your ankle, right?
All of that swelling is dependent. It has to go back up towards your thigh and into your abdomen to get away from your body. Same sort of thing here. It’s a dependent swelling that has to sort of find its way back to the veins of your face. So, very challenging. So, let’s kind of go into a little bit of the dissection here. So, here is a dissection of doing this is called the skin flap here. So, I’m going underneath the muscle and I’m dividing at the level of the musculature and about to divide this ligament. So, this ligament is really deep, deep, deep into the face. So, here we are and that’s right now, I’m dividing what’s called the orbital malar ligament. So, that’s right at the level of the orbital rim and you could see a nice layer of fat underneath here, okay? So, this is the extent of the dissection superiorly but we have to get this to even further down into the face and that’s what causes all the swelling.
So, here’s an example here of this gentleman. We’ve done a mailer bag slash festoon resection doing that dual plane approach to the eyelid. So, you can see him before and after. Now, clearly not completely ablated, but certainly improved. And the key here is all of these patients that have these deformities sometimes. Most of them have prominent eyes and in fact, that’s the reason why we’re in this situation sometimes is if you think about this, the skin and the soft tissue hanging off of the orbital rim. Because you’ve lost volume there, that by definition makes your eye very prominent. So, this is him before and after. I think we’ve got a really good treatment of this and it’s not so done to the point where he looks unnatural, but it just looks like that festoon and that malar bag is successfully treated.
Dr. Sam Jejurikar: It’s a really hard operation. I don’t think the viewers necessarily realize just how difficult this can be to fix. Just a couple more questions. One, so you’re dividing orbital malar ligament both deep and superficial. Are you doing the same with the zygomatic cutaneous ligament as well?
Dr. Sal Pacella: Yes.
Dr. Sam Jejurikar: And are you doing that all through the eyelid?
Dr. Sal Pacella: All so it depends. If we go, there’s really two approaches to go. One you can go through the eyelid what we call a transconjunctival approach. So, inside the eyelid, the other is what we call a transcutaneous approach. So, on top of the eyelid just underneath the lash line. In general, the majority of time I do this, it’s underneath the lash line. The reason being is, in order to bring this tissue up very higher, we have to do it in such a way that we’re going to reposition all this tissue and you can’t necessarily do that through the inside of the eyelid.
Importance of Canthofixation in Eyelid Surgery
Dr. Sam Jejurikar: So, given that everything from a superior approach and there’s so much swelling. What kind of steps are you taking postoperatively to support the eyelid position so that you don’t get malposition of your lower eyelid afterwards? It looks like you’ve done either a canthoplasty on this patient. Is that accurate?
Dr. Sal Pacella: Yes.
Dr. Sam Jejurikar: Okay.
Dr. Sal Pacella: Yeah. So, almost routinely, I’ll do a canthoplasty versus a canthopexy. So, the difference between those two is removing a little bit of lower eyelid tissue in a canthoplasty, whereas a canthopexy means we’re just putting a suture in support it. So, the tightening of the lower eyelid is an absolutely 100% critical concept to this. You have to suspend that lower eyelid to the corner of the eye that what we call the lateral canthus to the bone and you have to do it tightly. Otherwise, that eyelid will pull down. I have a little saying in eyelid surgery. The lower eyelid only wants to go one place that’s down. And so, you have to really pay attention to canthofixation. There are a lot of surgeons out there that do fairly minimally invasive eyelid surgery that don’t believe in canthofixation and I would caution them when you do an extensive malar bag or festoon resection like this.
Learning from Dr. Mark Codner’s Techniques
Dr. Sam Rhee: I will have to say when I first, okay, when I first started doing these, I incompletely cleared the ligament off the bone and I would get recurrence for my first couple cases. I will say even though I’ve done it a craniofacial fellowship and I felt very comfortable doing lower lid fixations. Like that was really part and parcel of a lot of what we did at that Spread and Butter craniofacial surgery. The Codner videos the way he does his transcutaneous lower blephs were probably the best thing I ever watched and learned from in order to clear the ligaments both under the skin and on top of the bone, how to fixate that lower lid properly. Not pull too hard and make it look pulled back, but to provide that support and still provide a natural eye shape.
Like I have to say that those are still some, I would recommend for anyone like those are some of the best videos out there that are publicly available under PRS. That sort of help me figure out how to do this properly. And for a lot of these I still have to do a transcutaneous just because I need that exposure in order to clear the ligaments properly. If you look at this picture you can see it’s well done, because the eyelid shape it’s not pulled back. He doesn’t have a really narrow like opening on his eye, like it looks very natural. If anything, it looks a little bit more naturally shaped, the lower eyelid than it did before. So that to me was so important to learn when I first started doing these.
Dr. Sal Pacella: Who Doctor Rhee is referring to is, I think we mentioned in the podcast before Doctor Mark Codner. My very close friend and mentor, who I did my fellowship in Atlanta with, who passed away tragically a couple years ago. But just an absolute inspiration for this type of operation. I’ve collaborated with him professionally many times and a good friend. He’s sorely missed. Let kind of move on to another case here. So, this is another example of a very very extensive malar bag/festoon combination. As you can see in this gal, also has quite a bit of upper eyelid swelling, upper eyelid skin and brow descent here. So, she had a direct brow lift or subcutaneous brow lift in addition to an upper lid removal/blepharoplasty and that procedure of the festoon resection malar bag resection that I described.
Two divisions of the ligaments, the orbital malar ligament and the zygomatic cutaneous ligament and an extensive subcutaneous or below the skin dissection. And as you can see here, she almost looks like a different person. Those bags are completely gone. We have maintained the eye shape and this is not without significant patient cost here. Meaning, cost from the standpoint recovery. It took at least 6 months to get this swelling under control and it is absolutely an operation you cannot take lightly as a patient or a surgeon. It’s not your grandmother’s transcutaneous or transconjunctival blepharoplasty bag removal.
Dr. Sam Rhee: It’s amazing. I mean that looks like her grandmother in the before picture and then that like it doesn’t even look, you’re right. It’s not even the same person.
Dr. Sam Jejurikar: Yeah, that’s a fantastic result. That’s a very hard to achieve a result like that. Not a lot of people could get a result like that actually.
Dr. Sam Rhee: Only a few.
Performing Full-Face Rejuvenation in One Procedure
Dr. Sal Pacella: Another example here. So, you can see this gal here. Now with all disclosure here this gal had a complete facial rejuvenation. Brow, upper lids, lower lids, festoons bags, face lift, fat transfer and chin implant, okay. And so, the key here is focusing on those lower lids. So, if you see here, face lift help to support this quite a bit which is fantastic. But just look at how smooth the skin is now compared to beforehand. And getting that shape of that eyelid, I think is really critical. That cantho suspension cantho support is key. But you really have to dissect all the way down into the…. This goes very well you get some economies of scale with healing when this is coupled with a deep plain face lift. So, if you look at her side view here or the oblique view here this chin implant really helps quite a bit with her facial.
Dr. Sam Rhee: Let me ask you this. How did you do this all-in-one shot and how long did that case take and what was the order in which you did short procedures?
Dr. Sal Pacella: So, I will say that you know I early in my career is pretty hesitant to do all of this at once just because it would take a significant amount of time. But I think I’ve figured out a way to kind of do this rather efficiently. So, I would say that if we were to do a full-face rejuvenation. Brow, quad bleph, face lift fat transfer. It probably takes me a good 6 & 1/2 hours to do. 6 to 6 & 1/2. the key is I start from top to bottom. So, I will do the dissection of the brow and again, I think we’ve talked about this before. I’ve almost completely switched my practice from doing endoscopic brows to doing subcutaneous brow lifts.
I think it’s the longevity is so much better and so subcutaneous brow lift doesn’t take a tremendous amount of time. I do the initial dissection down to the orbital rim. I then temporarily suspend the brow with staples and that allows me to sort of set the brow position to prep for the blepharoplasty. Then I’ll do the upper lids. Then I’ll do the lower lids and then I’ll go open up that same incision and connect it to my facelift incision from the brow. And that way, at the end of the case once I done with the deception of the face lift, I can support the brow position in the planned area that I did before.
Dr. Sam Rhee: Wow.
Dr. Sam Jejurikar: Yeah, I mean that makes a lot of sense. I agree with you about subcutaneous brow lifts as well just your improvement in her in her wrinkles and her forehead is amazing.
Dr. Sal Pacella: Yeah, fun operation, takes a tremendous amount of time, lot of swelling, lot of patient encouragement and they have to really be kind of engaged with the process. They got to; this is not a fix that you’re going to do before your son’s wedding kind of thing.
Dr. Sam Jejurikar: Yeah. Those are amazing results. Again, they’re dramatic changes and they’re dramatic pre-operative photos as well. So luckily not everyone needs this, but in cases like this I know that now that I’m going to send them to Doctor Pacella. Because I think I’d have a hard time dealing with 6 months of post operative selling and the hand holding that goes on with that. Oops.
Dr. Sal Pacella: Ops, lost my camera.
Dr. Sam Jejurikar: Well, anything else you want to share with us, Doctor Pacella?
Dr. Sal Pacella: That’s it, my friend.
Dr. Sam Jejurikar: Alright. Well, as always, thanks everyone for tuning in and we’ll see you in the next episode.