Festoons

Thank you for allowing me to speak today on the treatment of Festoons. This is a very challenging topic and the anatomy is beyond us here, but suffice it to say for this lecture that they are bounded inferiorly by the zygomatic go cutaneous ligament. And I wish we could achieve results like this every time. First, I would like to talk about camouflaging a festoon with fat repositioning. So I don't have to go through fat repositioning here because you know it well. But I'll give you a few pointers that I use. Uh, here is some blunt dissection in order to expose the acus Ali. And then I make an incision about one to two millimeters inferior to the arcus through the periosteum with the monopolar cautery instrument. And I actually use the cautery instrument in order to perform the subperiosteal dissection. It works very well, it's quite elegant and it's a very quick way to undermine the periosteum here. The most important point regarding fat repositioning for treatment of festoons is the depth of the pockets. You can see here that the pockets have to be extremely deep in order to recruit fat into the area surrounding the uh, feto. Uh, here you can see the inferior oblique muscle. I do not dissect it out completely and I form a T-shaped pedicle medially. And this T-shaped pedicle allows the pedicle to be placed and it will then spread both superiorly and inferiorly along the nasal dugal groove, uh, allowing for great augmentation in that area. And again, the idea here is to use the fat to basically rise the tide around the festoon. Here you can see that T shape is starting to come into view here. I'm gonna do a little bit more dissection here in order to really get that T shape so that it will spread into the superior and inferior areas. And the idea is the pedicle really should be able to be displayed in this area without any tension at all because as I'll show later, I don't use any suture fixation. And then I do the same thing for the central pocket. And I often form a T-shaped pedicle in this area too, which again allows for concealing the festoon. Very important, although I don't show it on this video because it was made for fat repositioning, I almost always use a lateral pedicle as well when using fat repositioning to camouflage of festoon. And here you can see that these T-shaped pedicles will mesh together very nicely to form a nice smooth area all around the festoon to rise the tide, thereby camouflaging the feto. And here I drew in a little picture of the festoon to show how it will camouflage it. So I don't use any suture fixation. I basically place the pedicles into those really deep pockets. So it's a really long pedicle and a deep pocket. And then I often use the backside of a 0.5 to basically pinch the fat pedicle under that trailing edge of periosteum. And that allows for stable fixation of the pedicles without any sutures. And basically the idea here is to camouflage the festoon with fat surrounding it. And here's a patient before and after fat repositioning, also with tetracycline with a nice improvement. Next I'd like to talk about Resus suspending and effacing the festoon with a cheek lift and skin removal. And the idea here is basically to lice the zygomatic e cutaneous ligament and remove some skin in order to elevate and diminish the compartment in which the festo can exist. So I won't completely review subperiosteal cheek lifting here, but it begins with atomy and lysis and then the dissection continues under the tarsus. This can be extended all the way to the care uncle, uh, for cases where we also perform fat repositioning. This patient has had previous surgery elsewhere, so there's a bit of a scar here that we have to, uh, fight through in order to bluntly dissect towards the arcus Ali. And then similar to how we made an incision medially for fat repositioning, I'm gonna do the same thing here, one to two millimeters outside of the Arcus Ali through the periosteum with the monopolar cautery instrument. And again, I also do the subperiosteal dissection here with the monopolar. And this is awesome here because it will cauterize the zygomatic facial and zygomatic temporal, uh, foramina, which can leak a little bit. So this really speeds the dissection. And this can be done in literally a couple of minutes. The real important point here is to dissect all the way medially to the nerve all the way laterally to the zygoma and very far inferiorly up to four, uh, centimeters or so beneath the rim in order to ly the zygomatic go cutaneous ligament. And you can see here how far the dissection needs to extend. And with the dissection descending this far, we can get excellent elevation after releasing the periosteum inferiorly. So here's another case. And on the other side a little bit more robust s soThe here. And again, we, uh, make an incision through the s soThe and the periosteum, uh, towards the, uh, fronto zygomatic suture. And then we dissect with the cautery instrument. And again, this allows for an elegant, very efficient dissection Along the zygomatic cutaneous um, ligament, which we're going to lice in this area here. And it will, uh, allow for great hemostasis with, uh, the zygomatic o facial and zygomatic temporal vessels. And so again, the dissection has to proceed very far inferiorly. And then once the dissection, uh, proceeds far enough inferiorly, I then make an incision through the periosteum in order to completely free the cheek to allow for excellent mobilization of the feto and the entire dissection can be performed in minutes. So it's a really quick dissection. And then here I'm going to make an incision through the periosteum, and I apologize, it's a little hard to see. I used a case here of a larger festoon and more elderly patient in order to get a better view, uh, beneath this large flap. So I would typically use a right angled retractor here, but this makes it a little easier to see. And again, the dissection has to proceed well underneath the festoon in order to lice the zygomatic cutaneous ligament. And here you can see the festoon and watch what happens to the feto. When we grasp the s soothe and elevate it, you can see that we get a really nice elevation of the zygomatic cutaneous ligament. Uh, and again, you can see with a PDS suture how that is going to lift and then diminish the compartment in which the festoon can exist with skin removal. Here I perform a skin pinch, uh, for more aggressive cases I'll do a larger skin flap. And the combination of the elevation and skin removal basically decreases and interfaces the compartment for the festoon. And here's a patient who underwent combined cheek lift with fat repositioning. And you can see the wide dissection pocket that is created here. And here you can see by elevating and effacing the festoon and shortening the eyelid, we can get a nice overall cosmetic improvement. And in this case, cheek lifting to elevate the festoon skin removal to a face it and fat repositioning to camouflage it can also help. Now, last I would like to talk about sclerosing, the festoon with tetracycline. And I've talked about this before with a couple of papers that we've published. Looking at tetracycline as a sclerosing, this can be performed either in the operating room or in the office. And the idea is to inject the tetracycline throughout the festoon to basically create scar tissue beneath the festoon in Order to seal the fluid blister. Our previously published papers have shown about a 50% success rate, so it's not perfect, uh, but it does offer a relatively less invasive option. And when it's performed in the office, it is a bit uncomfortable. And the other issue with tetracycline is that it requires constitution in a compounding pharmacy, which is not ideal for most practitioners. Doxycycline can be used, but I do not have experience with that. And here's a patient who underwent tetracycline injection on the right side, and you can see a nice improvement in the festoon with tetracycline alone. And here's a patient from Rob Tower that shows a dramatic improvement after tetracycline injection. And finally, we can combine these techniques to yield what I think are sometimes the best results. So here's a patient with fat repositioning cheek lift tetracycline with ptosis repair. Here's another patient with fat repositioning and cheek lift. And finally, the patient that we saw before with cheek lifting, fat reposition, and skin removal. So in summary, festoon treatment is very humbling, and I hope that this has given you some options that can match the patient's level of commitment, either something as simple as in-office tetracycline injection, or more involved procedures in order to try and achieve better results to improve fe dunes. Thank you.