Treatment of Festoons and Malar Mounds: Long Term Results
Treatment of festoons and malar bags or malar mounds are the most challenging procedures in aesthetic facial surgery.
Many plastic surgeons hesitate to treat them because of unfavorable results and potential complications.
Treatment options for festoons are direct excision, liposuction, laser, injection of sclerosing materials like tetracycline, fillers and lower blepharoplasty with midface lift.
New classification is done to plan the appropriate treatment plans according to age of the patient, anatomy and pathophysiology and etiology of congenital festoons and their treatments will be discussed.
Methods/Technique:
74 patients with festoons were treated by lower lid blepharoplasty and midface lift in the last 12 years. 71 of them had acquired festoons and 3 had congenital festoons .The mean patient age was 57.6 years (ranging from 31 to 79 years). There was 67 female and 7 male patients.
Follow up was from 6 months to 12 years. All patients ( 71 ) with acquired festoons had successful results after subciliary lower blepharoplasty with skin/muscle flap and no release of medial origin of orbital orbicularis muscle from maxilla and no release of tear trough ligaments and supraperiosteal midface lift dissection to the lower face , fat excision or transposition , canthal support and orbicularis muscle suspension . Prevention of bunching of extra skin in the lateral canthal area was done by short scar temporal lift and what we call “Temporal/ lower lid / midface tunnel “without the use of endoscope. Conservative triangular skin excision laterally, with NO SKIN EXCISION MEDIAL TO PUPILS IN THE SUBCILIARY AREA.
Preoperative confirmation of muscle laxity as the main etiology of festoons was done by “LATERAL PULL TEST “and “Botox Test “. All 3 patients with Congenital Festoons required additional treatments after the initial procedure described above to correct the residual festoons. The secondary treatments were direct excision, attempted surgical removal of the subcutaneous fat from prezygomatic space and off label use of Kybella injection to the residual puffiness.
Results/Complications:
There was no major complications like lid retraction nor ectropion .No hematoma, no infection. 3 patients (3/74= %4) required minor scar revision under local anesthesia in the office .Prolong upper lids swelling for 8-12 weeks were seen in %20 of patients. Chemosis for 4-6 weeks was seen in %5 of patients .Patient with good protoplasm were less prone to eyelids swelling and chemosis .No patient had chronic lid swelling nor chemosis after 16 weeks .All patients were very satisfied with correction of their festoons and midface laxity .Results are lasting and there was no recurrence of festoons or malar bags.
Conclusion:
Patient protoplasm is the major contributing factor for the development of postoperative swelling and chemosis .
Proper patient selection and treatment can correct the acquired and congenital festoons with no major complications and high patient satisfaction.
Periorbital swelling syndrome (POSS):
With or without festoons are resistant to any surgical treatment even direct excision.
Festoons and malar mounds are more common than we think and surgical treatment of them are ignored by plastic surgeons because of obscure pathophysiology , potential complications and morbidly .Their treatment should be considered as a reconstructive procedures rather than cosmetic .Subciliary Lower Blepharoplasty with midface lift and canthal support with orbicularis muscle suspension and management of bunching skin in the lateral canthal area with short scar “ TEMPORAL/LOWER LIDS /MIDFACE TUNNEL “ with conservative skin excision laterally and NO skin excision in subciliary area medial to pupils will give excellent results in patients with acquired festoons .Congenital festoons or malar mounds might need removal of the subcutaneous fat in prezygomatic area by surgical excision , liposuction or off label use of Kybella .
Do each part of the procedure simultaneously, bilaterally. Do not do one side completely then the other side. Put single skin hook at the corner of the lower eyelids when doing muscle suspension to make it symmetrically upward.
PERIORBITAL SWELLING SYNDROME (POSS)
Patients:
- Mario Martinz(moderate)-with allergies
- Lori Blair( mild )-with allergies
- Robert Bava( severe )-with COPD , high BP , diabetes , obesity , H/O total cystectomy for bladder cancer and Ileana’s conduit .
- A medical condition that needs medications.
- Swelling persists despite surgical treatment of Festoons.
Festoon surgery is difficult, humbling and fortunately, for giving, asymmetrical changes after surgery gradually goes away. Do not attempt to correct asymmetrical canthal positions, because soft tissues around the eyes.