S04E63 FIXING UNDER EYE BAGS AND SAGS

If getting old is unavoidable, one of the biggest issues is the undereye sagging, also known as festoons and malar bags. Dr. Salvatore Pacella @sandiegoplasticsurgeon, world expert on eyelid and periorbital surgery, take Dr. Sam Jejurikar @samjejurikar, and Dr. Sam Rhee @bergencosmetic through a number of cases showing before and afters. You won't believe these are the same people after seeing the amazing rejuvenative results!

#podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S04E63 FIXING UNDER EYE BAGS AND SAGS

[00:00:00] Dr. Sam Jejurikar: Good morning everyone. Welcome to another, uh, episode of Three Plastic Surgeons and a microphone. Uh, I am Sam Jejurikar from Dallas, Texas, and as always, I'm joined by Dr. Sam Re from Paramus, New Jersey. He's at Bergen Cosmetic and also by Dr. Salvador Pacella from La Jolla, California. He is at San Diego Plastic Surgeon.

Good morning, gentlemen. Morning.

[00:00:26] Dr. Salvatore Pacella: Good morning.

[00:00:27] Dr. Sam Jejurikar: Well today, rather than engage in small talk, I'm just gonna jump straight into the meat of it.

We're gonna 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. Um, but basically this is complicated lower eyelid surgery.

Um, before we get into this though, I'm gonna read our usual disclaimer. This show is not a substitute for professional medical advice, diagnosis, or. This show is for informational purposes only. Treatment and 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 questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because it's something you see.

So, uh, Dr. Pacella happens to be an international expert on eyelid surgery, so we're happy to let him lead this conversation today. So my first question to you, Sal, is what are and.

[00:01:26] Dr. Salvatore 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, uh, 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.

And so, 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, uh, modest success with it. Okay. So I'm gonna share my screen here.

Okay, perfect. Okay. So the interesting thing about this part of the face, the anatomy is this is a unique anatomic construct in our face. Okay? So if you see this gen here, he's got these sort of bags to his lower eyelid. We'll call those the lid or papi bags, and then the Faso or Malar bag.

A Faso is sort of when the skin is a little bit. Looser a mailer bag is when it's collected with a bunch of kind of swelling or edema. And, and in fact, I'm gonna use those two terms interchangeably. Uh, some authors may disagree with me on that, but I just, for, for simplistic sake, we're gonna kind of use those interchangeably.

So the, if you look at, on the left side here, this is a, an anatomic drawing of the facial skeleton. And what I wanna point out is this area right here, okay? So the mailer bag or fast. Is a three-dimensional box, essentially of ligaments and structure. In the middle of the face, the top of the box is caused by a ligament called or is made by a ligament called the or 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.

And 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 mailer bags. And I'm gonna guess, um, both you guys are, are, uh, big. , big dudes. When it comes to, uh, soft tissue fillers, how many times do you have patients come in and say, Hey, I, I hate this bag underneath my eye.

I want some filler for this. All the time. Often.

[00:04:01] Dr. Sam Jejurikar: Yeah. Very often.

[00:04:02] Dr. Salvatore Pacella: Right. And, and so the issue with injecting fillers and you know, I, I would say that, you know, we see a lot of non, um, non-surgical providers doing fillers. Some are better than others. You know, we see a lot of nurse practitioners, PAs injecting fillers.

And notoriously when I see sometimes, um, is that when filler gets injected into this pre zygomatic space, it stays there and. Festoon 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, Jen Jenz?

[00:04:44] Dr. Sam Rhee: Absolutely. This is a very sensitive and tricky area to, to treat and it does take experience to know where what you're doing with it.

[00:04:52] Dr. Sam Jejurikar: Yeah, I mean, because I loved your analogy of the two bookshelves. If you inject in the wrong place and you end up injecting so that it's trap between those bookshelves, you can actually exacerbate the problem as opposed to improving it.

Mm-hmm. , and I've seen many patients come in who have wanted their filler dissolved when they were injected somewhere else. Try to make this, um, in an attempt to make this better.

[00:05:12] Dr. Salvatore Pacella: So I, I've, I've spoke on this topic quite a few, uh, times, uh, both in the US and out of country. And, um, I did publish a few, uh, discussions on this topic for malar, uh, 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, um, to treating this effectively. And so I, I'm gonna show you guys a little operative video here so that the key here is let, 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 midface and at the level of the skin.

And, and what the viewers may not necessarily gather from this is just how challenging sometimes this dissection and this surgery is. Um, Jen's thoughts on that.

[00:06:29] Dr. Sam Jejurikar: It sounds like that would cause a ton of postoperative swelling. I tremendously understand why, why you would need to do that, but how long do you tell your patients it's gonna take for them, for their swelling to

[00:06:37] Dr. Salvatore Pacella: go away?

Sometimes six months. I mean, it is, it is a huge, huge challenge. In fact, I, I have a patient, um, I'm dealing with, uh, that I've treated about three months ago, and we still have some residual swelling in place and you know, but we know this ahead of time going in. So you, the key here is both the surgeon and the patient have to be, To this operation.

[00:07:02] 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?

[00:07:10] Dr. Salvatore Pacella: Um, no, I, you sort of let time do its things and, and, and that's an interesting concept here as to why the swelling persists for so long. 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 nasal labial fold here, and another one near the malar mound, right. . And 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 this stuff, and it's gonna be independently drained into the face, and that pulls a tremendous amount of fluid in and around the eyelid.

It pulls it in the midface and in the cheek. So it just takes a tremendous amount of time for this to go away. Much like say if you sprained 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. Um, so let's kind of go into a little bit of the dissection here. So here is a dissection of doing, um, this is called a skin muscle 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. And 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, this is the extent of the dissection superiorly, but we have to get this dissection even further down into the face, and that's what causes all the swelling.

So here's an example here of this gentleman. Um, we've done a mailer bag slash festoon resection, um, doing that dual plane approach to the eyelid. Um, so you can see him before and after. Now, clearly, 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 the i if you think about this, the, the skin and the soft tissue hanging off of the orbital rim. Because you've lost volume there. That by definition, um, makes your eye very prominent. So this is him before and after. You know, I think we've got a really good treatment of this.

Um, and it's not so done to the point where he looks unnatural, but it just looks like that that festoon and that mailer bag is successfully treated.

[00:09:51] Dr. Sam Jejurikar: It's a really hard, hard operation. I don't think viewers necessarily realize just how difficult this can be to fix a couple, just a couple more questions.

One, so you're dividing orbital malar ligament, both, um, deep and superficial. Are you doing the same with the zygomatic zygomatic cutaneous ligament as well? Yes. Yes. And are, and are you doing that all through the

[00:10:11] Dr. Salvatore Pacella: eye? All. Um, so it depends if we go, there's really two approaches to go. One, you can go through the eyelid, um, 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 the time I do this, 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 gonna reposition all this tissue.

And you can't necessarily do that, um, through the inside of the eyelid.

[00:10:48] Dr. Sam Jejurikar: So given that everything knows 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 canop, a canopy on this patient. Is that Yes.

[00:11:04] Dr. Salvatore Pacella: Accurate. Okay. Yes, so, so almost routinely I'll do a canto plasty versus a canopy. So the difference between those two. Removing a little bit of lower eyelid tissue in a canopy, whereas a canopy means we're just putting a suture in to support it.

And so, um, 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, 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 canal fixation. There are a lot of surgeons out there that do fairly minimally invasive eyelids surgery that don't believe in canal fixation, and I, and I would caution them when you do an extensive mailer bag or fist resection like this,

[00:12:01] Dr. Sam Rhee: um, I will have to say when I first, okay.

When I first started doing these, I did not incomplete. I in completely 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, um, I. Aran facial fellowship and I felt very comfortable doing lower lid fixations, like that was really part and parcel of a lot of what we did.

That's bread and butter. Uh, cran facial surgery. The codner videos, the way he does his transcutaneous, lower BLEs were probably the best thing I ever watched and learned from in order to. Clear the ligaments, uh, both um, 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 public, publicly available under p r s that um, sort of help me figure out how to do this properly. And for a lot of these, I still have to do it transcutaneous just because I need that exposure in order to clear the ligaments properly.

And if you look at this picture, you can see it's well done because the eyelid. It's not pulled back. He doesn't have a really narrow palp like opening on his eye. Like it looks very natural. If anything, it, it looks a little bit more naturally shaped, the lower eyelid than it did before. So that's the, that to me was so important to learn.

Um, When I was, when I first started doing these

[00:13:45] Dr. Salvatore Pacella: and, and who Dr. Ri is referring to is, um, we, I think we mentioned in the podcast before Dr. Mark Codner, um, my very, very close friend and mentor who I did my fellowship in Atlanta with, um, who passed away tragically a couple years ago. But just an absolute inspiration for this type of, uh, operation.

I've collaborated with him professionally many times, and a good friend, he's, he's sorely missed. Um, well let, let's kind of move on to another case here. So this is another example of a very, very extensive mailer bag slash festoon combination. Um, as you can see in the gals, also has quite a bit of upper eyelid swelling and brow.

Uh, upper eyelid skin and brow descent here. Um, so she had, um, a direct brow lift, so a subcutaneous brow lift in addition to an upper lid removal slash breathy, and exactly that procedure of the festoon resection balor bag resection that I described. Two divisions. Of the ligaments, the orbital malar ligament, and the zygomatic cutaneous ligament and an extensive subcutaneous or or below the skin dissection.

And as you can see here, she almost looks like a different person. Those, those bags are completely gone. We have maintained the eye shape, and you know, this is not without significant patient cost here, meaning cost from the standpoint of recovery. It took at least six months to. This swelling under control and, you know, we, it, it is absolutely an operation you cannot take lightly as a patient or a surgeon.

You know, it's not, it's not your, it's not your grandmother's transcutaneous or trans, uh, conjunctival, blepharoplasty bag removal. So

[00:15:32] Dr. Sam Rhee: it's amazing. I mean, that looks like her grandmother in the before picture and then that, you know, like, it doesn't even look like you're right. It's not even the same person.

[00:15:41] Dr. Salvatore Pacella: Yeah, that's,

[00:15:42] Dr. Sam Jejurikar: that's a fantastic result. That's a very hard to achieve, uh, a result like that. Not a lot of people could get a result like that actually. So only a few

[00:15:54] Dr. Salvatore Pacella: maybe Mark, maybe Henry.

[00:15:57] Dr. Sam Jejurikar: Maybe Henry. Maybe Henry another

[00:15:59] Dr. Salvatore Pacella: example here. So, so you can see this gal here. So, um, now, um, With all, with all disclosure here, uh, this gal had a complete facial rejuvenation brow, upper lids, lower lids, FTO bags, facelift, fad transfer, and chin implant. Okay? And so the key here is focusing on those lower lids.

So if you see here, um, you know, the facelift helped to support this quite a bit, which is fantastic, but just look at how, how smooth the skin is now compared to beforehand. and you know, getting that shape of that eyelid I think is really critical. That canal suspension, canal support is key, but you really have to dissect all the way down into mid, into the minchi.

This goes very well. Um, you get some economies of scale with healing when this is coupled with a deep plane facelift. . Um, so, um, if you look at her side view here, the belief view here, this chin implant really helps quite a bit with her facial conformance.

[00:16:58] 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 I did And what was the order in which you did?

[00:17:06] Dr. Salvatore Pacella: Sure procedures. Um, so I will say that, you know, I early in my career was pretty hesitant to do all of this at once just because it would take a significant amount of time. Um, but I've, I think I've figured out a way to, to kind of do this rather efficiently. So I would say that if we were to do a full facial rejuvenation brow, quad Bluff facelift, that transfer.

It probably takes me a good six and a half hours to do six to six and a half. Um, the key is I start with the, um, I, um, I start from top to bottom. So I will do the, the dissection of the brow. And again, I've. I've, uh, 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. Um, and so subcutaneous brow lift doesn't take a tremendous amount of time. I do the initial dissection down to the orbital rim. Um, 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 lid. 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'm done with the, with the dissection of the facelift, I can support the brow position in the, the planned area that I did before.

Wow.

[00:18:33] Dr. Sam Jejurikar: I mean that, that makes a lot of sense. Um, I agree with you about subcutaneous brass as well.

Well, just your improvement in her, in her wrinkles and her forehead is, is, is amazing. Yeah.

[00:18:44] Dr. Salvatore Pacella: Fun operation. Takes a tremendous amount of time. Lot of swelling, um, lot of patient encouragement and they have to really be kind of engaged with the process.

They gotta, they, this is not a quick fix that you're gonna do before your son's wedding kind of thing, you know? .

[00:18:59] Dr. Sam Jejurikar: Yeah. Yeah. Those are amazing results. Again, um, they're, they're, they're dramatic changes and they're dramatic pre-operative photos as well. So not every, luckily not everyone needs this, but in cases like this, I know that now that I'm gonna send 'em to Dr.

Pacella, , . Cause I don't, I think I'd have a hard time dealing with six months of postoperative smelling and all the handholding that goes on with that.

[00:19:24] Dr. Salvatore Pacella: Oops. Lost my, lost my.

[00:19:28] Dr. Sam Jejurikar: Well, anything else you wanna share with us, Dr. Pacella? That's

[00:19:31] Dr. Salvatore Pacella: it, my friend. All right.

[00:19:34] Dr. Sam Jejurikar: Well, as always, thanks to everyone for tuning in and we'll see you in the next episode.