What is going on with my cheeks/mid-face festoons? How can I improve the appearance? (photos)

Question

I had lower lid bleph approximately 13 years ago which has been my only surgery. I am 51 years old. How can the appearance of my cheeks be improved? Thank you!

Bahman Guyuron, MD · Answer

Malar bags can be improved with orbicularis muscle suspension through a facelift or eyelid incision. Injection of steroids may help but it is unpredictable.

Nelson Lee Novick, MD · Answer

A close examination of your photo shows considerable age-related fat loss in the mid-face region (the region of the mid-portion of the cheeks both below the undereye area medially and below the cheekbone region laterally. As such, the residual cheek fat pad, which has retained a more robust projection, appears to "festoon" outward and the nasolabial folds have become pronounced.  A mid-face rejuvenation using an injectable volumizer will help to reflate the mid-cheeks immediately below the "festoons" and will help to camouflage them (and will also improve the deep smile line jowls). In my Upper East Side Manhattan office, I would opt for Voluma XC for this purpose, while in my Israel satellite facility, where a far greater number of regulatory agency approved volumizers are available, I would opt for Stylage XXL. The treatment should not take more than five minutes in experienced hands. Make sure that you consult with a board certified aesthetic physician and be certain to ask to see his/her before and after photos before agreeing to proceed. Good luck to you.

Robert Sleightholm, MD · Answer

Hello and thanks so much for your question and photos. Lower lid belpharoplasty typically does not offer satisfactory results for festoons. In our practice, festoons are treated with a surgical profractional laser which offer amazing results. You would also benefit from injectable fillers to restore volume to the face. Oftentimes, combination treatments provide clients with the "wow" results they are looking for.  All the best!

Francis R. Palmer, III, MD (retired) · Answer

Hi, the festoons on your cheeks are called "malar bags" and represent areas of chronic swelling trapped within the tissues of the cheeks.  Lower on the face (on the cheek bone itself) these are not associated with lower eyelid fat bags and while removing the lower eyelid bags with a blepharoplasty might make the malar bags appear more prominent...the eyelid surgery itself has no effect on the malar bags.  The malar bags occur in individuals who are genetically predetermined to have  trapped chronic tissue swelling in that area of the face.  A low salt diet is recommended to prevent the swelling from worsening.  There is no method of removing the malar bag however, the cheek and the edges of the malar bags can be augmented and softened using an off the shelf dermal filler.  
  I have performed facelifts for over 30 years and have performed many minimally, invasive type facelifts.  Additionally, from the photos, your cheeks are quite flat anteriorly (in the front), there is excess fat in front of the cheeks and jowls are present.  These factors combine to create a rectangular shaped face. 
 Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.  Liposuction would be combined to reduce the excess fat and further shape the cheeks and face.
 When the lower face shows signs of "jowls”, these represent sagging facial tissues and are the main indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesia
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face.
Hope this helps.

What is going on with my cheeks/mid-face festoons? How can I improve the appearance? (photos)

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