S05E77 The Art and Science of "Cheek Bag" or Festoon Treatment

Discover the subtle intricacies of facial cosmetic surgery as we unravel the complexities of "cheek bag," or festoon treatment with Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic. Together, we dissect the critical differences between lower eyelid bags and festoons, providing you with a roadmap to understanding why some traditional methods like lower eyelid blepharoplasty might not always hit the mark. Join us as we navigate the anatomy that underpins this nuanced area of expertise, delving into the delicate layering of skin, periosteum, and ligaments that are pivotal for successful management of festoons.

In our conversation, we tackle the full spectrum of festoon treatment strategies, weighing the pros and cons of both surgical and non-surgical approaches. We dissect the effectiveness of intralesional tetracycline, ultrasound, and radiofrequency for milder cases and delve into the controversial topic of fillers, a method that can often backfire when not underpinned by a comprehensive understanding of festoon anatomy and pathophysiology. This eye-opening discussion parallels festoon management with ptosis repair, underscoring the importance of setting realistic expectations with patients and highlighting that the path to aesthetic refinement is as much an art as it is a science.

Dr. Sam Jejurikar @samjejurikar @3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S05E77 The Art and Science of "Cheek Bag" or Festoon Treatment

Transcript

[00:00:00] Dr. Salvatore Pacella: Good morning, everyone. I'm Dr. Sal Pacella from San Diego, California. I'm joined by my co host, Dr. Sam Rhee from Bergen County, New Jersey, as well as our guest host, Dr. Larry Tong from Toronto, Ontario, Canada. How are you guys this morning?

[00:00:24] Dr. Lawrence Tong: I'm great. Great to see you guys.

[00:00:26] Dr. Salvatore Pacella: Dr. Jejurikar couldn't be with us today, um, but we, we are with him in spirit today.

Um, well, thanks so much for joining in, guys. Um, I got my, uh, it's Bill's playoff day. I got my Bill's gear, my Bill's swag, um, on. So, uh, we're gonna be cheering on the team later this afternoon. Uh, but before we do that, we're going to talk about a very niche topic. in Facial Cosmetic Surgery called Festoon Treatment.

Okay, um, before we get into that, let's do a little disclaimer. Dr. Tong, Tong, to tong tong tong.

[00:01:01] Dr. Lawrence Tong: Thank you, Sal. Always classy. this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes. Only treatment and results may vary based upon the circumstance, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health.

A provider with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something in this show.

[00:01:31] Dr. Salvatore Pacella: Excellent. Uh, so Gents, as we mentioned, we're going to talk about Festoons today. And, uh, this is, uh, This is a very problematic, uh, area of concern in facial aesthetic surgery and blepharoplasty. And, um, sometimes it's also very confusing. So, um, what we're referring to specifically for our viewers out there is when you look at the eye, okay, um, Obviously, we're talking about the lid here and the cheek, and there's an area that connects the lid and the cheek called the lid cheek junction, and many times as we get older, there's a little indentation there, um, what we call the tear trough space, or the, um, or the deep crevice of the eye, and Um, and there's bags that occur above that space.

We're, we're not specifically talking about the bags of the lower eyelid, because those are, those are a unique anatomic area. What we're talking about is many times there's a, a soft tissue bag or a skin bag that goes beyond the cheek line and the lid junction, sort of right in this region here. And it's traditionally very, very problematic to treat.

So, uh, gents, just, um, from your practice, what, what do you, uh, Do you see this a lot? Do you have patients come in complaining of this issue a lot?

[00:02:46] Dr. Lawrence Tong: Uh, I'll start off. Yes, uh, this is something where, um, a lot of people think that doing something to the, uh, lower eyelid, uh, will help. And in my experience, When I do a little lower lip blepharoplasty, um, it doesn't seem to completely, uh, fix it and, uh, in, in conversations with, uh, Dr. Rhee, he's, he's indicated that, uh, he's able to get good success, uh, with it.

So, um, I'm, I'm going to start off with Dr. Rhee. I, I'm very curious to, you know, hear about, um, what you have found that is successful in treating this.

[00:03:25] Dr. Sam Rhee: Yeah, so this, this topic came up because I, I found this, um, article on thecut. com written by Valerie Monroe a couple weeks ago. And it says, what is this bag under my eye? And as Sal said, so we have the under eye area, which is all, you know, we can get bags and, you know, all of us do as we get older. And then the festoons, as Sal said, are like on the cheek.

So as, uh, as you mentioned, Larry, like some people have them very prominently. If you look at Al Pacino, for example, he's someone who has these really big cheek bags that are called festoons. And so there is debate on how best to treat festoons, which are these mailer mounds or, or cheek bags. And I think if they're pretty mild, like for example, when you do a lower lid eyelid lift, I know, um.

There's debate. Can you actually get them better with a lower eyelid lift? And I think some of it is yes. Some of this, uh, area is just swelling and edema, which is very. non surgical in a lot of cases, but some of it, if you really, um, sort of extend your lower eyelid lift down to the cheek past that lower eyelid cheek junction and, uh, sort of involve the malar area and do, um, do more of a lift that extends to that area.

I think you can actually address some of those festoons. I mean, some of them are really severe and you may not be able to, but I think you can in some cases.

[00:05:06] Dr. Salvatore Pacella: Right. So, um, I think, you know, the, the problem and the, the, the tenuous nature of how plastic surgeons approach this, quite honestly, is related to the understanding of anatomy. And, you know, and I think that's very important because, uh, you know, I have a good friend in Kansas City who, uh, speaks quite a bit, Dr.

Chris Surik. He's a, he's a true. And, you know, we were just at a meeting in Scottsdale for the Aesthetic Society, dissecting some cadaver heads. And he has a great comment. He says a fear of surgery or fear of injection is a fear of anatomy. Okay. And I, and I think that that. Holds clear for this anatomic area and so, you know, when you see this festoon, a lot of injectors say, well, you know, let's, let's put some, let's put some fluid in there.

We can't treat this surgically. Let's put a filler of some sort. And that is many times the wrong thing to do. And the reason being is you have to think about this festoon like a bag. I like to think about it like a box actually. Okay, so if you think about a box, the front of the box is skin, the back of the box is periosteum, okay, so the layer over the muscle.

The top of the box is a ligament called the orbital malar ligament, which connects the, um, the eyelid space to the cheek space. And then the bottom of the box is something called the, uh, zygomatical central, zygomatical cheek, uh, ligament, depending on which anatomy text you look at, okay. And so to me, the correct treatment of this is You have to release at least two layers of this box, the front and posterior layer of the box, and by definition, you're going to go through the top and the bottom of that box to open it up.

So, if you don't routinely release the orbital malar ligament in blepharoplasty, you're not going to do anything to the malar bag or festoon. If you don't release the zygomatic ligament, You won't do anything either, and you have to really dissect in two layers. It's a bilaminar or two layer dissection at the skin and periosteum.

The second tenet to this is, I think you always have to think about, is my video going down again? Sorry. I think you always, you always

[00:07:20] Dr. Lawrence Tong: looks better

[00:07:21] Dr. Salvatore Pacella: about, okay, um, you always have to think about adding some additional, um, device or filler in that area that's going to prevent Those ligament, cheek, skin attachments from forming again.

And so, to me, that's the key to treating this area. And so, when I, when I do this, you know, it's a much bigger dissection than a blepharoplasty. It's almost a mid cheek lift. And I liberally use a lot of fat and filler. Not filler, but fat as the filler in order to treat that.

[00:07:55] Dr. Lawrence Tong: So, so Sal, is your dissection, um, subcutaneous? That's, that's one layer. And what, what's your other layer? Just on top of the

[00:08:04] Dr. Salvatore Pacella: so I, so I first start off, depending on if I'm doing a transconj or a transcutaneous blepharoplasty, usually in the treating of festoons, I'm doing a transcutaneous blepharoplasty through the skin, so my first layer of dissection is subperiosteal, that allows me to kind of release everything at the deepest layer, and then when I'm suspending everything back into position, I'm doing my blepharoplasty.

Um, Malorpexy or Obicularis Suspension. Then I will do a very, um, wide subcutaneous dissection as well. Now, I think you gotta be very careful as a surgeon when you're doing that, because that skin can be devitalized very easily. You have to leave a little bit of fat to it. Uh, the leading edge superiorly can, uh, devitalize a bit if you're not very careful.

And, you know, the skin layer, like many things in, The same concepts occur in facelifts, right? You, the deep layer you can really crank on, the skin layer, you want to close just kissing. You don't, you don't want any tension on this. And the same thing goes, you know, when I'm, when I'm treating a fist tube.

[00:09:10] Dr. Lawrence Tong: So when

[00:09:10] Dr. Sam Rhee: the key that you, the key that you hit on there is this, a pretty aggressive subperiosteal dissection. Uh, where you're really clearing that ligament, and it took me a while to figure out how much of that for something like this you really need. Way more, like you said, than, say, a typical bleph. And then, uh, and then just putting a lot of filler in there.

So, just taking that, um, septal fat and just kind of pulling it down usually isn't enough. Like, I have to put more than that in there to make sure that, that's Uh, those ligaments don't stick back down again and that you get a really nice, clean, clear, like junction. And that, that is something that, yeah, it, it took me a while to figure out how to do that, I think.

And, um, um, honestly, the, the biggest part of this is, um, suspending everything so that it's not under tension. That's really hard. Like that took a long time for me to figure out a lot of the videos that you and your, your, um, mentor. Uh, uh, uh, sort of presented really helped with taking tension off of that area and allowing for, like you said, a relatively tension free closure.

Um, I am not as aggressive with that subcutaneous dissection. I like leaving, um, orbicularis a little bit more. Like, I'm a little Concerned about that. But, um, yeah, like I'll stick a lot of fat in there to try to smooth everything out.

[00:10:38] Dr. Salvatore Pacella: Yeah, and, and, you know, um, you make a very good point about suspension and, you know, some of the videos that, uh, uh, Dr. Kodner and I made in the past, but, um, you know, where, where I'm doing things slightly differently now is I'm using, uh, laterally, a lot of. MiTek anchors, uh, to support the cheek laterally here.

And I think that's made a huge difference and you the beauty of those things. So what, uh, for our viewers out there, those are little tiny screws that you can screw in anywhere on the bony anatomy, and they have a, a two layer or two needle suture attached to them, so you can really use these as an anchor point.

Um, they originally, uh, designed for tendon repairs in the fingers, but, um, works. Uh, tremendously well, and you can use one of them, you can use five of them, you can use as many as you need to get the correct vector that you, that you want.

[00:11:27] Dr. Lawrence Tong: so when you do that, um, when you say no tension, uh, obviously when you're re suspending things, there is a little bit of tension. That's to the The deeper layers, I'm assuming. And what about the skin? Like, when you are removing, I'm assuming you're excising some degree of skin when you're doing this transcutaneous approach.

Do you try to make it, um, sort of like smooth and taut? Or are you just laying it back down and just trimming the minimal amount that you need?

[00:11:54] Dr. Salvatore Pacella: Just laying it back down, trimming the minimum amount, and I think that's where you get into really tough problems when you're not paying attention to that. Um, I think any little bit of tension pulling on the lower lid is, is a recipe for disaster. Um, give me an example. Um, You know, um, I, at one point, I was curious about what kind of force, um, can pull down a lower lid.

Okay, so I, I have these, um, gold weights that I use for ptosis repair, and I asked my nurse, young gal in her 30s, to volunteer. So I just systematically started placing, taping weights to her lower eyelid and seeing, you know, just how much, how much pull we can get from weight. So you know what the, you know what the weight limit for displacing the eyelid in a 35 year old woman was in this particular experiment?

It was 2. 5 grams. So

[00:12:45] Dr. Sam Rhee: Oh, wow.

[00:12:47] Dr. Salvatore Pacella: Okay. And then, and that's in somebody that has good lid position and good ligamentous. Um, firm positioning and somebody who's 70, 80, 90, you know, um, just think you just blow at the eyelid and it's going to, it's going to get out of position. So I think that the non tension closure is a critical tenant.

[00:13:09] Dr. Lawrence Tong: Yes. So do you think that aside from that, um, you know, that the non tension closure on the skin, um, What is the, how would you describe to the viewers as what the, the volume? is doing, because you've described it, but conceptually, what are you actually doing with that volume?

[00:13:27] Dr. Salvatore Pacella: So, so the, uh, as I mentioned, that anatomic box, right. And so, so what we're doing with, when we're putting filler in there, particularly in the cheek or the deeper periosteum, is we're just destroying all of the potential attachments of the box. The box, the pre zygomatic space is what a festoon is. What a mailer bag is.

And so if you just destroy the box and you, you recreate the space, you, you know, these attachments won't get back. Um, now, let me, let me also say this. Um, this is not a, a foolproof strategy by any means. Um, and I, anybody that comes into my office that has a fest Potential festoon that I'm planning surgery on.

I, I try to prepare them for some sort of revision if, if needed. Um, just for example, you know, two weeks ago, I had a gentleman I did a, uh, lower lid blepharoplasty on and a festoon, uh, treatment, uh, about a year and a half ago. And I've been following him and following him every couple months and hoping his swelling would get better.

And he still has a little bit of residual festoon there, you know, and I just resected those directly. And, um, you know, did I make him? 100 percent better after the festoon? No, but we probably got about 85%, 85 percent there. It's substantially improved and I'm hoping with a little bit of a direct excision, it'll, it'll get better.

And so, so I think, you know, you, we have to kind of approach this. Much like ptosis repair. I say to patients, you know, ptosis repair, it's not 100 percent science. You know, we got a revision rate of about 10%. We may have to take or adjust things a little bit more, but that's okay. We're trying to make it perfect, you know, but we got to give it the time and the swelling to go down.

So,

[00:15:17] Dr. Sam Rhee: what do you think about the non surgical treatments that this article recommends like intralesional tetracycline or, um, ultrasound or radio frequency? Like, do you feel that these are effective treatments for festoon, for festoon management?

[00:15:35] Dr. Salvatore Pacella: so excellent question. So, um, you know, I am, I am a section editor for the Aesthetic Surgery Journal and part of my job as being a section editor, as I review a lot of these articles. And so, um, If, if anybody is out there interested, if you just search my name in festoon, there's a podcast that comes up about this topic and there's several review articles about this with, with commentaries and there, there's a couple of papers out there that show some modest result improvement with minimal to modest festoons, utilizing tetracycline and radio frequency.

And I think, you know, if you have mild festoons, does it make sense to, to go through a big. Open procedure? Possibly not. I mean, you can always try a non surgical treatment. If things get worse or if things get, if things get better, that, well, that's fantastic. You know, if it, if they get worse, then you know that, you know, that the option is surgery.

In advanced festoons where people are, you know, the skin is folded, there's chronic edema, you know, it's visible from across the room. None of this non surgical treatment really works all that well, in my opinion.

[00:16:48] Dr. Lawrence Tong: I have one thing to add to that with regards to the tetracycline. Conceptually, that type of procedure is something that I have done, and it's been used most effectively, as you said, on mild festoons. Now, it's not injecting tetracycline. Now, for the viewers, tetracycline is an antibiotic, but if you inject it, um, Under the skin, it's, it's very inflammatory and it causes some scar tissue and that's how it is, um, thought to, um, improve, uh, the festoon.

And so I've done something a little bit different. I've actually used a fat grafting cannula and I've just, uh, made a very, you know, small needlepoint incision in, in that area and I've run the, the rough, um, flute of the, uh, fat graft cannula along the underside of the skin and that causes some degree of inflammation and scarring down.

And so that's something that I found is, you know, very simple and easy to do. It doesn't always work though. I would say it works in maybe about 60 percent of times. So, uh, that's also something to, uh, to consider that I've found success for that. But, um, yeah, in the, in the bigger ones. Uh, I don't think that works.

[00:18:09] Dr. Sam Rhee: Have you seen, um, Filler making these worse, like someone who has had filler treatment who comes to you and says, Oh my God, that made it like 10 times worse.

[00:18:18] Dr. Lawrence Tong: Yes, because,

[00:18:19] Dr. Salvatore Pacella: Almost weakly, almost weakly, almost weakly. I see this, right?

[00:18:22] Dr. Lawrence Tong: yeah, because it's, it seems like it's an area that just likes to swell. Patients will say that it's worse in the morning and it's better in the evening, which implies that it's, you know, because they're lying down and the fluid gets redistributed throughout the body that, um, that swelling of the face, uh, makes it worse.

So if you're going to put in filler, which is something that's. Hydrophilic, which attracts water, that's probably going to make it worse. In that article that, um, Dr. Rhee was talking about, it also mentioned that having blepharoplasty can make it worse. I think that's a byproduct of the swelling that occurs, uh, with the surgery.

I think it, it, I don't think the surgery actually, if you don't do anything specific for it, I don't think it makes it worse, but it does give you a period of time. Where the festoon may look worse, but then goes back to its original state eventually.

[00:19:11] Dr. Salvatore Pacella: But the, the act of, the act of injecting a filler inside there to me shows complete. non understanding of the anatomic problem here, right? So like, when you inject filler, all that's going to do is swell the box. You, you do nothing, you're doing nothing to open up the lid of the box or the front of the box, right?

And so it just routinely doesn't work. And that's why you see a lot of patients come into the office with, uh, you know, disappointed with, uh, you know, their dermatologist or plastic surgeon who injected it or, you know, nurse injector.

[00:19:44] Dr. Sam Rhee: I mean, in most of the cases that I've seen when I'm doing, you know, lower periorbital fill injection, filler injections. You're not injecting subcutaneous, you're injecting either right on the periosteum or right, like, basically I'm touching bone necessarily, like, when I'm injecting filler, like, I want to be right there.

Um, I can't imagine anyone actually injecting festoons with filler, you're, that, you're right, it makes absolutely no sense to me.

[00:20:15] Dr. Lawrence Tong: I think what they're trying to do is sort of inject the areas that aren't as full and sort of trying to hide it. But I think the net effect is that it just makes the festoon look worse.

[00:20:27] Dr. Salvatore Pacella: Yep. Great.

[00:20:29] Dr. Sam Rhee: Uh, any other thoughts about festoon treatment? Uh, Advice to people who have festoons, who are thinking about doing something about it, other than going to San Diego and seeing Sal, because that's what I would do.

[00:20:42] Dr. Salvatore Pacella: And Dr. T

[00:20:43] Dr. Lawrence Tong: No, more, more so, Sal.

[00:20:45] Dr. Salvatore Pacella: operate on Americans

[00:20:46] Dr. Lawrence Tong: Oh, yeah, I can. Come on up. We take your American

[00:20:50] Dr. Salvatore Pacella: really? I thought that was different. Oh, great. I thought that was a change, maybe. Oh, fantastic. Yeah, I mean, I think the key here is really, you know, understanding the problem, understanding the anatomy, and, you know, the other issue is that most of the time, patients who have festoons have other anatomic or morphologic, morphologic.

variants that make their blepharoplasty very challenging. That invariably means prominent eyes. Okay. You don't see people with deep set eyes getting a lot of festoons. People with big cheeks don't necessarily get festoons. It's people with. Retruded cheeks with very prominent eyes with loss of tissue volume that tend to get this.

And if you're not paying attention specifically anatomically to these things, you know, your, your surgeon is, is going to disappoint you potentially.

[00:21:50] Dr. Sam Rhee: Good points. All right. With that, thank you so much, Sal, Larry. Always a pleasure. Really hope the bills, uh, pull it

[00:21:57] Dr. Lawrence Tong: Go Bills!

[00:21:58] Dr. Sam Rhee: Chiefs. All right.

[00:22:00] Dr. Salvatore Pacella: right. Appreciate it guys.