Festoons are prominent, puffy areas that affect the lower eyelid and upper cheek region, creating a tired or swollen appearance. They involve the malar mound, the soft tissue overlying the cheekbone, and are distinct from typical under-eye bags. Festoons are persistent and challenging to manage, often requiring specialized approaches. This condition is classified as a chronic issue that worsens with age and certain lifestyle factors.
Identifying Festoons and Their Location
Festoons present as a distinct, often hammock-like, swelling that creates a fold or pouch on the upper cheek, separate from the lower eyelid margin. They are also referred to as malar bags or malar mounds, describing swelling over the cheekbone (malar eminence). This location differentiates them from standard infraorbital fat herniation (typical eye bags), which bulge closer to the lash line beneath the lower eyelid.
The fundamental difference lies in their anatomical composition. Typical eye bags involve the protrusion of orbital fat through a weakened septum, whereas festoons primarily involve chronic fluid retention (edema) and skin laxity in the malar septum area. Malar edema is often the precursor, a fluid collection that, when chronic, stretches the tissues and progresses into the permanent, sagging pouches known as festoons.
The Underlying Causes of Festoon Development
The formation of festoons is multifactorial, stemming from structural changes, genetics, and environmental damage. Primary factors include long-term sun exposure (photoaging), which breaks down collagen and elastin fibers. This loss of elasticity weakens supportive structures in the midface, allowing soft tissues to sag and form the characteristic pouch.
Aging also contributes through the weakening of the orbicularis oculi muscle (the muscle surrounding the eye). The weakening of this muscle, combined with the stretching of supportive ligaments, allows for the downward migration of tissue. Another element is impaired lymphatic drainage in the cheek area, known as lymphatic stasis, which leads to chronic fluid accumulation. This persistent fluid retention stretches the tissues further, exacerbating the festoon’s appearance.
Management and Treatment Options
Festoons are difficult to treat because they involve skin laxity, muscle weakness, and chronic fluid retention, meaning a single treatment is often insufficient. Initial management involves addressing underlying health factors that contribute to fluid retention, such as allergies, sleep apnea, or thyroid dysfunction. Lifestyle changes, like reducing salt and alcohol intake, can also help minimize the edema component of the swelling.
Non-Surgical and Minimally Invasive Options
For less severe cases, non-surgical options may offer improvement by tightening the skin and stimulating collagen production. Treatments like CO2 laser resurfacing can tighten the overlying skin and smooth the surface texture. Radiofrequency microneedling uses thermal energy to contract tissue and fat, which can be effective for mild to moderate festoons. Topical treatments, such as strong retinoids, can improve skin quality but are limited in resolving the underlying structural issue.
Minimally invasive approaches require caution. Injectable steroids or sclerosing agents, such as doxycycline, are sometimes used to induce tissue contraction and reduce swelling, but these procedures can be painful and may lead to bruising. Dermal fillers are generally avoided in the malar mound because they can exacerbate puffiness by worsening lymphatic flow. However, strategically placed filler in surrounding areas may occasionally be used to smooth the transition between the eyelid and cheek.
Surgical Correction
The most definitive treatment for advanced festoons requires specialized surgical correction. Surgical options may involve a lower blepharoplasty combined with a midface lift, which aims to tighten supporting structures and reposition the soft tissue of the cheek. The procedure may include releasing and suspending the orbicularis oculi muscle to improve the contour. In severe cases, a direct surgical excision of the festoon tissue may be performed, though this option is reserved due to the resulting linear scar.