How do I improve the appearance of my festoons and upper eyelids? (Photos)

Question

Context: ~5 years ago I had Voluma placed in my cheekbones and then decided to try Restalyne in my tear troughs. Soon after, I noticed festoons developing (more prominent on left side). I've had as much of the filler dissolved as possible, but the festoons haven't improved. I'm also unhappy with my upper eyelids. Please share recommendations for improving the appearance of my festoons and achieving a more overall youthful appearance.

Nelson Lee Novick, MD · Answer

"Puffy Pillows"  under the eyes and upper cheeks can result from lymphedema due to either inappropriate choice of filler for the location or too superficial placement of the filler within the delicate tissues of the under eye region. The problem does not typically resolve even as the filler is metabolized away, as the problem related to obstruction of the lymphatic drainage in the region.  If this is indeed the case here, this can be a very difficult problem to treat and most often the use of hyaluronidase alone is insufficient to alleviate the problem. I have personally found that the aforementioned in the appropriate concentration and amount combined with an appropriate concentration and amount of intralesional anti-inflammatory can significantly improve this problem.  Make sure to consult an experienced, board certified cosmetic dermatologist. Best of luck.

Nima Shemirani, MD · Answer

I recommend trying Morpheus 8. Morpheus8 is a non-surgical treatment for full body skin resurfacing, skin tightening, and fat reduction of stubborn areas. It uses minimally invasive fractional radiofrequency energy (RF) to penetrate the skin deeper than other microneedling devices, triggering the skin’s natural healing response to promote skin tightening and lifting.

Jeffrey Lisiecki, MD · Answer

I wouldn't call these full-blown festoons, but they do look like malar mounds, which can result from malar lymphedema after cheek or tear trough filler. After everything has been dissolved as much as possible, radiofrequency microneedling with a device like Morpheus8 can be helpful. It may take a few treatments to get to the desired point. For your upper lids, a conservative upper blepharoplasty would help. If you are missing the volume you had in your cheeks, fat grafting would be a good option.

Kenneth D. Steinsapir, MD · Answer

Most injectors use insufficient amounts of hyaluronidase to remove unwanted volume ("let me inject a squirt of enzyme"). You still have retained filler in your cheek. I would recommend as much as 300 units of hyaluronidase in both cheeks. The filler is stubborn and requires much more aggressive enzyme treatment then most injectors understand. Do not get talked into unnecessary surgery. I also recommend injecting enzyme all the way down to the jaw line. Voluma is a very runny filler. For the upper eyelid, you have mild upper eyelid ptosis with compensatory eyebrow elevation. You would benefit from a thoughtful upper blepharoplasty with fold preservation, anterior levator resection ptosis repair and anchor blepharoplasty. Your eyes can be your best feature.

How do I improve the appearance of my festoons and upper eyelids? (Photos)

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