How to treat 'festoons'? (photos)

Question

I have had extreme puffiness of the upper cheek/under eye area since I was a baby. I am now in my 20's and they have worsened. They seem like fluid filled sacks on top of the bone that runs beneath my eye. I am wondering how I can treat them: products, surgery, diet change, etc? I am considering having a consultation with a surgeon, I just want to know what to expect.

Adam Scheiner, MD · Answer

Dear Katharine,It appears that you have evidence of fullness in the lower eyelid region and festoons/malar mounds on the cheek as well. These changes can make a person appear tired, sick and older even when they feel fine inside. 
Many people who undergo one factor which can complicate the results from lower eyelid surgery.
Festoons and Malar mounds are a medical condition in which the skin of the lower eyelid becomes significantly damaged, usually by the sun. This damaged skin can result in folds in the lower eyelids and can lead to swollen mounds on the cheeks. They often occur with age and are more common in people with lighter skin types.
Festoons occur in many people seeking lower eyelid rejuvenation and if not corrected at the time that lower lid surgery is performed, the condition can become exacerbated and make the lower eyelids look worse after surgery.
The reason then why many people are dissatisfied after undergoing lower eyelid surgery to improve the appearance of their lower lids is the result of two main issues:
Swelling that occurs in the face after lower eyelid surgery often accumulates in the lower eyelid region and can take a while to resolve.
The subconscious brain constantly looks for balance in a face, and when lower eyelid fullness and festoons exist they are seen to belong together, as both are usually age-related phenomena. When only one is then corrected (usually the lower eyelid bags), the other is seen in even greater contrast.  The subconscious brain then focuses in on this condition and tells the conscious brain the face is out of balance.
Festoons and malar mounds have been a frustration for surgeons for many years. Thanks to the initial work of Dr. Sterling Baker (a person with whom I trained) and my own improvement and refinement on that work over the last decade, I now have a sophisticated, technically-challenging but effective treatment for festoons and malar mounds.
Many people don’t fully understand or recognize the differences between these two conditions. The first difference is in their cause or etiology; festoons are a result of sun-damaged skin on the lower eyelid and on the cheek and are believed to be affected by underlying contrasting muscle forces over the years of a person’s life.
In contrast, lower eyelid bags are due to age-related fat protruding through the skin in the lower eyelid region. New research has shown that fat can grow and atrophy during our lives in asymmetric ways. The growth of fat in the orbit around the eye along with atrophy of fat in the facial regions around the eye, as well as weakness in some of the orbital containing structures, contribute the fullness we see in the lower eyelid with age.
For some individuals, this fat shows up at a very young age and this is believed to a result of genetic changes in the development of the eye area in those individuals.
The second difference is the location on the face where they form. Lower eyelid festoons can be seen primarily on the cheek with some presence in the lower eyelid region.  Lower eyelid bags are located directly below the lower eyelid lashes and are noticed to become more prominent when someone with these bags looks upwards.  Conversely, festoons are minimally affected when a person looks upwards.
The third difference is the feel of these conditions when they are touched. Festoons are squishy and can be made to move side to side. Lower eyelid bags are firmer, deeper in location beneath the skin and can’t be moved easily side to side when touched.
 It is important to understand the differences between these two conditions. The best rejuvenation and most natural results occur when both eyelid bags and festoons are corrected simultaneously.
I'll include some links below.
I hope this was helpful.

Elliot M. Heller, MD · Answer

I WOULD TRY FILLERS BEFORE GOING IN AND DOING SURGERY , THE DIFFERENCE BETWEEN FAT TRANSFER AND FILLERS ARE FILLER ARE LESS INVASIVE AND CAN LAST 6-9 MONTHS SOMETIMES UP TO A YEAR DEPENDING ON WHICH ONES. FAT TRANSFERS ARE USUALLY SURGICALLY DONE WITH LIPO AND TRANSFERRED TO ANOTHER AREA OF THE BODY. A FAT TRANSFER CAN ALSO BE DONE THROUGH A LOCAL AFTER SURGERY FOR A REPEAT FAT INJECTION. FAT INJECTIONS OR TRANSFERS ARE USUALLY MORE PERMANENT. THIS IS SOMETHING THAT YOU MAY WANT TO SPEAK TO YOUR DOCTOR ABOUT IN A CONSULTATION AND SEE WHAT YOUR OPTIONS ARE.

Edgardo Zavala, MD · Answer

You have indeed what is called malar festoons. These festoons can be either wet or dry festoons. In your case they seem to be wet festoons that typically improve or worsen based on fluid retention. A low salt diet can have some minor effect on them. In you specific case I think that the best treatment option would be a CO2 laser treatment to tighten and shrink that area, probably requiring more than one treatment. In cases were lower eyelid surgery is indicated for other reasons such as eye bags, dry festoons can be improved with a concomitant pinch blepharoplasty. Direct removal of the festoons would leave a scar usually minimally visible if performed correctly.
In your case I would advise the laser. Good luck

Philip K. Robb Jr., MD, FACS · Answer

Good morning and thanks for your question, 
You're too young for festoons. I do appreciate the lower eyelid swelling and the valley you have in there. This valley is created by the bony attachment of your skin and could be removed with surgery. 
Without a thorough physical examination it's difficult to tell exactly what's going on. I would doubt that this can be treated with lasers and skin treatments. The cause of this is deeper than skin deep and thus would require some deeper treatments. Another short term option is to try filler in this area- this could just puff out that valley. 
Find a trained expert who you trust who tells you they can fix it. Your young and very pretty so a little fix will go a long way with you!
Hope this helps and God Bless!
Dr. Robb

Jason Emer, MD · Answer

For festoons, lasers in combination with microneedling and prp will give better results without the need for surgery. Fillers in this area help as well if placed appropriately.  Please see someone with experience in treating this area. Best, Dr. Emer.

Simon Ourian, MD · Answer

You would need a combination of treatment modalities to reduce the appearance of festoons. You will need filler for under your eyes and lateral cheeks, sub-ablative CO2 around the eyes, and ultrasound radio frequency directly on the festoons.  A combination of these treatments will tighten the skin while reducing the appearance of the festoons.

Camille Cash, MD · Answer

This area is difficult to treat.  You may try a low sodium diet to see if that has a positive effect on the area.  Laser treatments can sometimes be beneficial.  I think you are correct in having a consultation with a plastic surgeon in your area.  After an exam you can discuss your options and decide a treatment plan that is best for you.

Ivan Vrcek, MD, FACS · Answer

Thank you for your question and photo. I am sorry to hear that you are having this trouble. In terms of lifestyle modifications, cutting down on salt (and sodium) in your diet, and sleeping with your head elevated can be very helpful. Also, optimizing your blood pressure control can help if you have high blood pressure. As I am sure you have read, festoons can be a very challenging anatomic issue. Fillers would be a reasonable place to start as they are reversible. Unfortunately, fillers can occasionally make the problem worse if they are placed superficially or if a hydrophilic filler is used.
Best of luck!

How to treat 'festoons'? (photos)

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