Festoons, also referred to as malar bags or malar mounds, appear as a persistent ridge-like swelling on the face. These puffy formations are distinct from typical under-eye bags, affecting the midface and often giving a tired or aged look. Understanding the cause and location of these swellings is crucial for effective management. This article explores the characteristics of festoons, the mechanisms behind their formation, and the specialized treatments available.
Visual Characteristics and Location
Festoons present as a distinct, horizontal band of puffy tissue located in the upper cheek, or malar region, just below the lower eyelid boundary. They are often described as mounds or pouches that seem to “hang” down the cheek.
A festoon’s appearance is typically soft and may feel fluid-filled, contrasting with the firmness of fat found in true eye bags. This fluid retention, known as malar edema, can cause the size and prominence of the festoon to fluctuate throughout the day or due to lifestyle factors. Their location over the cheekbone, rather than directly beneath the lashes, is the defining visual trait.
Underlying Mechanisms of Formation
The development of festoons is rooted in a structural weakness of the tissues separating the lower eyelid from the cheek. A primary factor is the gradual laxity and damage to the orbicularis oculi muscle, the ring-like muscle that encircles the eye. As this muscle loses tone, it stretches, allowing the underlying tissue to sag and form a pocket.
This weakening is compounded by the attenuation of the malar septum and other retaining ligaments, which normally hold the cheek tissue firmly in place. When the septum is compromised, the boundary between the lower eyelid skin and the cheek skin fails. This structural failure leads to the accumulation of fluid, or edema, in the prezygomatic space, visible as the malar mound.
Chronic sun exposure accelerates this process by damaging collagen and elastin fibers in the skin and muscle. This photoaging effect leads to a loss of elasticity, contributing to the tissue’s appearance. Genetics also predispose some individuals to developing festoons earlier or more severely, suggesting an inherited anatomical tendency toward tissue laxity.
Secondary factors that exacerbate swelling include chronic fluid-retaining medical conditions, allergies, and smoking, which compromise tissue health and lymphatic drainage. The combination of muscle laxity, ligamentous weakening, and chronic fluid accumulation creates the persistent and challenging cosmetic presentation of a festoon.
Distinguishing Festoons from Standard Eye Bags
It is important to differentiate festoons from standard lower eyelid bags, as their underlying causes and treatments differ entirely. Standard eye bags, or palpebral bags, are located higher up, sitting directly along the orbital rim beneath the lower lashes. These bags result from the herniation or bulging of intraorbital fat pushing forward through a weakened orbital septum.
Festoons are situated lower on the face, spanning the transition zone between the lower eyelid and the upper cheek. The primary content of a festoon is often fluid (edema) and lax skin/muscle, rather than protruding orbital fat. Because festoons involve fluid dynamics and the lymphatic system, their puffiness may noticeably increase in the morning or worsen with factors like fatigue or salt intake.
True orbital fat herniation is generally static and does not fluctuate significantly throughout the day. Standard eye bags become more pronounced when a person looks upward, while festoons are minimally affected by this movement. This distinction is paramount because a surgical procedure designed only to address orbital fat will not resolve a festoon, and may sometimes make it more noticeable.
Treatment and Management Strategies
Addressing festoons is difficult due to their complex origin involving skin, muscle, and fluid dynamics, often requiring a multimodal approach. Initial non-invasive management focuses on controlling contributing factors, such as aggressive sun protection to minimize collagen damage. Patients should also manage underlying conditions like chronic allergies, thyroid issues, or sleep apnea, which exacerbate fluid retention.
For reducing the fluid component, temporary medical management may involve the use of diuretics under medical supervision to lessen the severity of malar edema. Minimally invasive procedures often target skin and muscle tightening for structural support.
Non-Surgical Procedures
Laser skin resurfacing, particularly with ablative lasers like CO2, can tighten the overlying skin and stimulate collagen production. Radiofrequency microneedling treatments deliver heat energy deep into the dermal layers, helping to contract and tighten the lax orbicularis oculi muscle and overlying tissue. In select cases, specific injectable treatments, such as off-label use of drugs like Doxycycline or Tetracycline, are used to reduce swelling by altering the tissue structure.
Surgical Intervention
When non-surgical options are insufficient, surgical intervention is considered the most definitive treatment. A direct excision involves surgically removing the excess skin and muscle of the festoon, which must be performed carefully to avoid visible scarring. More comprehensive surgical options include a specialized lower blepharoplasty combined with a midface lift or cheek lift.
These techniques often involve raising a skin-muscle flap, tightening or suspending the lax orbicularis oculi muscle, and releasing the underlying retaining ligaments to reposition the entire cheek unit. This complex approach aims to restore the supportive structure of the midface and create a smoother transition between the lower eyelid and the cheek.