Festoons and lower bleph - are fillers or fat grafting better alternatives? (Photo)

Question

Hello I have loosening eyelid skin ( genetic) and a bit of cheek hollowness. I was considering lower bleph, when I suddenly developed festoons following an allergic reaction to blephex, a treatment for blepharitis. I have been subsequently told that both blepharitis and the festoons make me a poor candidate for transitional bleph. Is this correct and are fillers or fat grafting better alternatives?

Lucian Ion, FRCS · Answer

Thank you for your question and sharing your photographs. There are several points to consider in relation to your questions.

First, if the festoons have developed recently, it would be wise to avoid doing any treatments until your ophthalmologist has confirmed that your blepharitis has settled. If the blepharitis is settled and the festoons have cleared, then you can re-evaluate your options and potentially a skin pinch blepharoplasty could be a reasonable solution.

Second, if the blepharitis is settled but the festoons are still present, there is a technique for direct excision of the skin in the area of the festoons. It leaves very discrete scars and generally represents an acceptable solution.

Finally, if when the blepharitis settles, the shape of the lower eyelid appears just marginally problematic, volume enhancement in the midface can create a good contour.

Jason Emer, MD · Answer

Hello and thank you for your question. A formal evaluation would be needed to determine the best treatment. There are both surgical and non-surgical options to correct this, however, I feel you would need surgery.

For less significant puffiness and sagging UNDER the eyes, or more mild improvement, there are nonsurgical treatment options: we often use Renuvion helium plasma radiofrequency (RF) energy to achieve incredible results and take years off of your appearance. Combining RF energy and cool helium plasma, the signs of aging (wrinkles, pigmentation, skin laxity) are improved in a ‘Nonsurgical Lower Eyelid Lift.' The focused heating tightens and peels the outer skin layer with extreme precision, leaving the surrounding area undamaged, smoothing and tightening the periorbital skin, and improving the overall skin quality around the eyes. It's an aggressive treatment, and the recovery time is longer than with other nonsurgical procedures, but the results can be life-changing.​

Surgery (a lower blepharoplasty with or without canthopexy/canthoplasty or orbicularis muscle suspension) is a great option for more significant improvement- for example if there are more severe lower eyelid bags / bulging present, as in your case. Sometimes the surgery can also be used to intentionally adjust the shape and/or size of your eyes, or correct any asymmetries!

Dr. Donald Groves is an expert facial plastic surgeon that I work with, who specializes in these types of procedures. It is important that if you are considering surgery that you go to someone who is well trained and very experienced with these delicate operations to get the best results. I suggest getting a consultation with an experienced cosmetic dermatologist and facial sculpting expert, or an aesthetic facial plastic surgeon like Dr. Groves; we are both located right here in Los Angeles.

Best, 
Dr. Emer

Nelson Lee Novick, MD · Answer

The photos show evidence of volume deficit in the cheeks. If this is indeed so, then the use of a robust HA volumizing filler for contouring the cheeks (I.e. creating a more ideal, feminine heart-shaped oval face, would also very likely secondarily improve the under-eye areas and reduce the appearance of the festoons. I would suggest that the allergic reaction be dealt with first, as well as the underlying blepharitis. Once these are treated and controlled, then the filler treatment can be performed. 
I would not recommend fat injections for a number of reasons. For one, they require two minimally invasive provcedures: one to extract the fat from the buttocks, hips, thighs or abdomen, and a second procedure to inject them in the face. This is a relatively expensive approach, typically engenders significant downtime. Additionally, once injected, fat cannot be dissolved if there is an unwanted aesthetic reaction or adverse reaction. And finally, the injected fat retains the characteristics of the region from which it is taken.This means that if in time the belly fat, for example, develops a midriff bulge, it can happen to belly fat injected into the face. Make sure to consult a board certified ophthalmologist to treat the blepharitis and an experienced, board certified cosmetic dermatologist filler expert. Hope this helps.

Mark McRae, MD · Answer

This is a difficult problem and you will get incremental improvements with lower blepharoplasty, and fat grafting, but complete resolution will likely require some direct excision of the festoon itself.

One of my favourite lower blepharoplasty techniques blends the orbital fat with the cheek fat and improved the transition between the lid and cheek. The festoon however is below this transition point and will not completely disappear. Fat grafting can also fill in hollowing of the midface and you will see some benefit with that in your case also. But not complete resolution

Nonetheless the festoons will still be present (with some improvement). At that point a direct excision of what remains is required to remove the skin excess at that location on the cheek.

It is a big step to accept a scar on the cheek. It is much easier to accept a scar on the cheek in older people with more rhytids and sun changes that hide the scar. However the scar will fade with time and good skin care. And right now the demarcation causes a major shadow- a fine scar will be far less noticeable.

Hopefully this picture was taken at a point in time when you still had some inflammation that may improve more.

I hope you find this helpful. I certainly have treated many patients with this and it takes time to make sure patients understand what improvements surgery will provide. Having knowledge of the process and a step wise approach, as well as a knowledge of the pros and cons should help you as you choose your path forward.

Zoran Potparic, MD · Answer

It is very likely that transconjuctival blepharoplasty and fat grafting will improve your current situation. However, factions are very difficult to eradicate entirely and you must be aware of that. Good luck.

Eric M. Joseph, MD · Answer

Based on your photos, you appear to have excessive redundant and droopy skin along your lower orbital margin. Direct excision of this excess skin and fat maybe the best direct procedure for you, and scarring is usually minimal. I hope this helps! Sincerely, Dr Joseph

Camille Cash, MD · Answer

Festoons are difficult to treat.  Lower blepharoplasty will not have much impact on them and fillers can actually make them look worse in some cases.  You can consider lasers or treatments such as Morpheus8 to provide some improvement.  Direct excision will give the best resolution of the festoon.

Kenneth R. Francis, MD, FACS · Answer

Dear gracebenton10,
You have been told correctly.  Festoons and blepharitis are game changers for the individual seeking blepharoplasty.  The festoons require direct muscle tightening or excision in addition to probable skin removal.  You can also expect an extended period of swelling and possibly chemosis (swelling of the conjunctiva) as well.  Good luck!

Mats Hagstrom, MD (license on probation) · Answer

Festoons are notoriously difficult to treat.
Quality midface volume restoration can sometimes give very impressive results.
Personally, I’m not a big fan of facial fat grafting because the procedure tends to be imprecise, unpredictable, and potentially unforgiving if people don’t like the outcome.
Fillers can occasionally give dramatic results, but finding providers who have sufficient skill and experience is usually not nearly as easy as people think.
To get an idea of what can be accomplished using fillers I suggest you check out the website of Dr. David Mabrie MD in San Francisco.
His work is some of the best I’ve ever seen, and he has an impressive collection of before, and after pictures on his website.
His practice is devoted exclusively to the use of facial fillers only.
For this kind of work, his work is in my opinion the gold standard.
I’m not suggesting everybody fly to San Francisco to get facial fillers.
 Seeing his outcomes can give reference for what is possible with this kind of treatment when choosing among other providers.
A surgical correction is going to be challenging.
In the end provider selection is probably by far the most important variable, possibly more important than what procedure you choose.
Fundamentally facial bone structure is the primary determinant of facial aesthetics, even though it may seem like your problem is more soft tissue oriented, 
My best recommendation is to have quite a few in person consultations before considering any permanent irreversible surgical treatment.
Ask providers to show you their entire collection of before, and after pictures of previous patients who had the most similar facial characteristics.
Best,
Mats Hagstrom MD

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