Malar festoons are hammock-like folds of skin and muscle that form on the lower eyelids and hang over the cheeks, caused by severe skin laxity, weakened ligaments, and fluid accumulation over the cheekbones. There is a lack of consensus regarding the correct terminology for these folds. Different terms have been used to describe festoons, such as malar mounds, palpebral bags, lower eyelid bags, etc. Although most of these can be applied, it is important to distinguish between malar mounds or malar edema and true festoons because their treatment varies significantly.

What is the difference between malar mounds and festoons?

Malar mounds, also known as malar edema, is a term that refers to the presence of a triangular pocket of fluid in the cheekbone area. Muscle and fat may also be involved in the formation of the mound. Festoons is a more general term, referring to the whole spectrum of age-related descent of soft tissue that accumulates on the upper cheeks and lower eyelids. In most situations, the name festoon is reserved for the more severe types of tissue laxity with redundant hammock-like pleats of skin that sag over the cheek.

What is the cause of festoons?

The exact cause of festoons is unknown; however, it is evident that age plays a significant role in their formation, although they can also appear early in life. The most common hypothesis postulates that their cause is a combination of loss of skin elasticity, muscle laxity, and weakening of the ligaments that attach the lower eyelid soft tissues to the cheekbone. These lead to sagging tissue, and the formation of skin folds over the upper cheek region.

The accumulation of fluid in a triangular space located in the cheekbone region, called the pre-zygomatic space, is also involved in the formation of festoons. This fluid buildup often appears spontaneously but may also be caused by certain foods, an injection of hyaluronic acid fillers, or surgical trauma. Patients with mild festoons or malar mounds tend to swell more severely and for longer periods after surgical procedures on the lower eyelid and midface. This point suggests a lymphatic origin to festoons, which also explains why they may improve, at least temporarily, with lymphatic drainage massage.

Finally, festoons may also be associated with autoimmune disease and chronic inflammatory conditions, such as thyroid disorders, contact dermatitis, and rosacea.

Treatment options for the management of festoons

Festoon treatment is very challenging for the oculoplastic surgeon. They are arguably the most problematic eyelid conditions to treat, the results being quite frustrating. The goal is never to eliminate them entirely but rather to reduce their appearance.

Multiple treatment options exist, ranging from non-surgical intervention to surgical management.

Although hyaluronic acid fillers have long been used to conceal malar mounds and festoons, they should be used with extreme caution or avoided because they may worsen the condition. Hyaluronidase, an enzyme that breaks down hyaluronic acid, can be effective in treating filler-induced festoons.

Tetracycline or doxycycline injections to the cheek region seem to reduce malar mounds, except for those related to hyaluronic acid filler injections. These medications are part of a large group of antibiotics with anti-inflammatory properties. Not all patients are good candidates for this therapy, so a consultation with a surgeon is vital before the procedure.

Other non-surgical options are CO2 laser ablation, radiofrequency, and chemical peels. In most cases, these treatments have proved ineffective, leading most eyelid specialists to try surgical therapy to achieve better results.

Surgical management of festoons

There is a significant range of surgical options to treat festoons, although no procedure has been able to deliver good results consistently.

Direct surgical resection represents a viable surgical option, especially in older individuals, when skin and muscle laxity are the leading causes of a festoon. This approach should be avoided in younger patients and cases of fluid buildup because its success rate is low, and the risk of a visible scar is very high. Lower eyelid blepharoplasty with skin and muscle flap dissection is better for younger patients because the incision is located underneath the eyelashes and becomes less visible. A blepharoplasty allows the surgeon to smooth out the skin over the cheekbone and reduce the festoon. However, the results of this operation are unpredictable, and a good outcome cannot always be guaranteed.