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Festoons

in Avon, Connecticut

Festoons are folds of skin and muscle that look like a drape hanging from one corner of the eye to the other, with the lowest part of the sagging skin directly below the pupil. People can have a single festoon or multiple festoons under one or both eyes. Because festoons are made from folds of the lower eyelid muscle (oribicularis oculi muscle), they improve and smooth out when the patient squints and tightens the muscle.

What Causes Malar Festoons?

In youth, the skin and muscle are distributed over the full contour of the cheek. As we age, the skin around our eyes, especially the lower eyelid skin, becomes very thin and stretched out. When the lower eyelid skin gets stretched out, it sags under the eye like a drape. The thin, sagging lower eyelid skin hits the thicker cheek skin below it and gets bunched up, causing lower eyelid bags and festoons.

Festoons are made worse by the age-related loss of bone and fat below the muscle of the lower eyelid. This combination of bone and fat loss beneath the lower eyelid causes, the lower eyelid skin and muscle to become wrinkled like a deflated balloon.

FESTOONS VS. MALAR BAGS

The term “festoons” is commonly misused, even by professionals, to describe other age-related changes in the lower eyelid region. Festoons differ from a malar bag, malar mound, and malar edema. Malar bags are mounds of smooth skin below the eye’s lateral corners. Malar bags do not have wrinkles over them, but they have a sharp crease at the bottom. Malar bags do not get better when you squint and contract your lower eyelid muscles. Festoons are also different from the “bags” under one’s eyes. Bulges immediately below the eyelashes of the lower eyelid are caused by collections of fat below the lower eyelid muscle. This is called pseudo-herniation of orbital fat.

FESTOON TREATMENT

When patients with festoons have very thin and very stretched-out lower eyelid skin, it is often best to start by trying to tighten and improve the skin quality around the eyes. The simplest and easiest way to do this is to start an at-home skincare regimen. A good skin regimen consists of topical retinoids (retin-a or retinol) and mild acids around the thin, wrinkled skin of the lower eyelid.

A stronger treatment consists of a chemical peel or series of chemical peels applied to the lower eyelid skin of the festoons. However, not everyone is a good candidate for chemical peels strong enough to stimulate tightened skin. For example, you may not be a candidate for a strong chemical peel if your skin is dark.

Currently, available laser skin resurfacing treatments that claim to tighten the skin without any downtime are typically not cost-effective treatments. You spend a lot of money and time for very little, if any, improvement. Older laser technologies, such as CO2 lasers, work but have a long downtime and higher risks of scarring and pigmentation issues.

Therefore, Dr. Stanislaw rarely uses these older, stronger lasers on lower eyelid skin or for treating malar bags. This overhanging skin is just too sensitive and delicate.

HOW TO TREAT FESTOONS WITH SURGERY

The last treatment option for significant amounts of excess skin associated with festoon surgery is cosmetic eyelid surgery to remove the folds of excess skin. There are two different ways of improving festoons with surgery.

One way of surgically improving festoons is to perform a lower eyelid blepharoplasty using a skin-muscle flap. In this procedure, an incision is made in a wrinkle below the eyelashes. The incision is made through the lower eyelid skin and muscle and then the skin and muscle are re-positioned, smoothing out the festoon. The excess skin and muscle are then removed.

Another surgical procedure is called a lower blepharoplasty using a “skin pinch”. In this procedure, the festoon itself is removed via direct excision, and the skin is sewn together. In both procedures, there is a fine scar that is hidden in naturally occurring wrinkles under the eyes. Both surgical procedures can be done under local anesthetic.

For a non-surgical intervention for treating malar bags and the lower eyelids, injectable filler can be placed in the cheek and below the eyelid muscle (orbicularis oculi muscle). The filler replaces the lost support structure of the lower eyelid muscle and skin and therefore smooths out the festoons and other wrinkles around the lower eyes.

Oftentimes, patients need a combination of these treatments to get the best results.

The term “festoons” is commonly misused, even by professionals, to describe other age-related changes in the lower eyelid region. Festoons are different from malar bags or malar mounds. Malar bags are mounds of smooth skin that are below the lateral corners of the eye. Malar bags do not have wrinkles over them, but they do have a sharp crease at the bottom of them. Malar bags do not get better when you squint and contract your lower eyelid muscles. Festoons are also different from the “bags” under one’s eyes. Bulges immediately below the eyelashes of the lower eyelid are caused by collections of fat deep into the lower eyelid muscle. This is called pseudo-herniation of orbital fat.

TREATMENT OF FESTOONS

When patients with festoons have very thin and very stretched-out lower eyelid skin, it is often best to start by trying to tighten and improve the skin quality. The simplest and easiest way to do this is to start an at-home skin regimen. This skin regimen consists of applying topical retinoids (retin-a or retinol) and mild acids to the thin wrinkled skin of the lower eyelid.

A stronger treatment consists of a chemical peel or series of chemical peels to the lower eyelid skin of the festoons. You may not be a candidate for a strong chemical peel if your skin is dark. Currently, available laser treatments that claim to tighten the skin without any downtime, in my opinion, are not cost-effective treatments. You spend a lot of money and time for very little, if any, improvement. Older lasers, such as a CO2 laser do work, but they have a long downtime and higher risks of scarring and pigmentation issues. Therefore, I rarely use these older, stronger lasers on lower eyelid skin. This skin is just too sensitive and delicate.

The last treatment option for significant amounts of excess skin associated with festoons is surgical excision of the folds. There are two different ways of improving festoons with surgery. One way of surgically improving festoons is to perform a lower eyelid blepharoplasty using a skin-muscle flap. In this procedure, an incision is made in a wrinkle below the eyelashes. The incision is brought down through the lower eyelid skin and muscle and then the skin and muscle are re-positioned superiorly, thus smoothing out the festoon. The excess skin and muscle are then excised.

Another surgical procedure is called a lower blepharoplasty using a “skin pinch”. In this procedure the festoon itself is excised and the skin is sewn together. In both procedures, there is a fine scar that is hidden in naturally occurring wrinkles. Both surgical procedures can be done under local anesthetic.

Festoons can be made worse when there is a significant amount of bone loss and/or fat loss from the area under the eyes. In youth, the skin and muscle are distributed over the full convexity of the cheek. As we get older and the supporting structures involute, the skin and muscle bunch up like a deflated balloon. In these situations, injectable filler is placed in the cheek and below the eyelid muscle (orbicularis oculi muscle). The filler replaces the lost support structure of the lower eyelid muscle and skin and therefore smooths out the festoons.

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