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Festoons are a unique lower eyelid condition that appears as bags below the more common location of infraorbital fat herniation on the cheek. Also known as malar bags they are perceived as being abnormal collections of lymphedematous fatty tissue below the lid-cheek junction. They are particularly resistant to being removed with traditional lower blepharoplasty surgery and ancillary techniques have been described to treat it from ligamentous releases, cheek lifts and even microliposuction and direct excision in older patients. In the end the goal is to create a smooth contour between the lower eyelid and the upper cheek.

In the February 2018 issue of the Aesthetic Plastic Surgery journal an article was published entitled ‘Etiology and Treatment of Congenital Festoons’. In this paper the authors describe their ten year experience in almost 60 patients  of treating festoons and focused on three patients with more uncommon congenital festoons. All of the three congenital festoon patients had a history of puffiness of the prezygomatic space since childhood which had gotten worse with aging. Two of the patients were treated with a transcutaneous lower blepharoplasty with release of the orbicularis retaining and zygomaticocutaneous ligaments and midface lift with canthopexy and orbicularis muscle suspension. The third case had the addition of a direct excision of the fat through the orbicularis from the subcutaneous space. In addition, each patient required further treatments to address supra-orbicularis fat by various methods.

All three congenital festoon patients had residual puffiness that required surgical and non-surgical treatments. One case required two additional surgeries for complete correction. The other two cases required Kybella injections after their lower blepharoplasty surgery. A tissue specimen from one of the patients showed s localized fat collection immediately under the skin and above the orbicularis oculi muscle.

While acquired festoons can be successfully treated with lower blepharoplasty and midface lift techniques, congenital festoon patients are more resistant and do not get complete correction. They will require additional treatments which may include microliposuction, injection therapies or direct excision of the residual mounds.

Dr. Barry Eppley

Indianapols Indiana

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