Festoons, also known as malar mounds or malar bags, are a common cosmetic concern distinct from typical under-eye puffiness. These pronounced swellings appear on the upper cheek, creating an aged or fatigued appearance that is difficult to conceal. Unlike simple fluid retention, festoons are structural changes requiring specific, targeted treatments for lasting reduction. This article explores the anatomical basis of festoons and details the available treatment methods.
Defining Festoons and Their Causes
Festoons are folds of loose skin and muscle tissue that form a bulge over the cheekbone (malar region), just below the lower eyelid. They differ from traditional eye bags, which are caused by the bulging of orbital fat pads. Festoons are primarily composed of weakened orbicularis oculi muscle, excess skin, and chronic fluid accumulation, known as malar edema.
The primary structural cause is chronic sun damage (photoaging), which degrades the collagen and elastin fibers needed to keep the skin taut. This degradation is compounded by the weakening of the orbicularis oculi muscle, the circular muscle surrounding the eye, which loses its tone with age. The resulting laxity allows fluid and tissue to collect in the space above the cheekbone, often exacerbated by a compromised lymphatic drainage system.
Genetics and lifestyle factors also influence their severity. Systemic issues that promote fluid retention, such as allergies or high sodium intake, can worsen the appearance by increasing the malar edema component. When compressed, festoons feel squishy due to this fluid content, distinguishing them clinically from the firmer, deeper fat pads of true eye bags.
Non-Surgical and Minimally Invasive Treatments
For mild to moderate festoons, non-surgical procedures focus on tightening the skin and reducing the fluid component. Prescription-strength topical retinoids, such as tretinoin, improve skin quality by boosting Type I collagen production and promoting epidermal turnover. This addresses the chronic photodamage contributing to skin and muscle laxity over the long term.
Energy-based treatments offer a direct approach to tightening the affected tissue. Carbon dioxide (\(\text{CO}_2\)) laser resurfacing delivers thermal energy that ablates superficial skin layers while causing contraction of deeper collagen fibers. This controlled damage stimulates a robust healing response that effectively shrinks redundant skin, leading to a smoother contour.
Radiofrequency (RF) microneedling combines fine needle punctures with RF energy delivered deep into the dermis. This controlled thermal injury promotes fibrotic remodeling and new collagen formation, tightening the overall tissue structure in the malar region.
Injectable treatments, particularly hyaluronic acid fillers, require caution, as improper placement can worsen the condition by attracting more fluid. However, careful placement of specific, less hydrophilic fillers in the deep cheek or tear trough can sometimes camouflage the festoon by restoring volume to adjacent hollows, thereby smoothing the transition zone.
Surgical Repair and Advanced Interventions
Surgical intervention is the most definitive treatment for severe festoons that do not respond to less invasive methods. These procedures focus on removing excess tissue, tightening weakened muscle, and repositioning descended mid-face structures. The most comprehensive approach is often an extended lower blepharoplasty combined with a mid-face lift.
This procedure typically uses a subciliary incision, made just beneath the lower lash line, to access and lift a skin-muscle flap. The surgeon performs a dissection extending well over the cheekbone to mobilize descended soft tissue, including the malar fat pad. This step allows for the release of retaining ligaments, which are often the underlying anatomical barrier to proper repositioning.
A primary component of the repair involves reinforcing the weakened orbicularis oculi muscle through orbicularis suspension or plication. The muscle is tightened and secured with sutures to a stable structure, such as the lateral orbital rim or temporal fascia, to provide vertical support and efface the festoon.
In select, localized cases where the festoon is a prominent fold of excess tissue, direct excision may be performed. This involves surgically removing the festoon itself and is reserved for specific anatomy, requiring meticulous attention to scar revision to minimize the resulting line.
Reducing Recurrence Through Lifestyle Changes
Maintaining treatment results requires minimizing the environmental factors that contribute to festoon formation. Since chronic photodamage is a leading cause, strict sun protection is the most important preventative measure. This involves the daily application of broad-spectrum sunscreen with a high Sun Protection Factor (SPF), sunglasses, and wide-brimmed hats.
Managing fluid retention is an effective strategy for reducing the edema component of malar mounds. This is achieved by limiting sodium intake, particularly in the evening, to reduce overnight fluid accumulation. Individuals with chronic allergies should work with a healthcare provider to manage their symptoms, as chronic inflammation and swelling exacerbate lymphatic congestion in the area.
Avoiding smoking is also crucial, as nicotine and toxins in smoke cause vasoconstriction and further degrade the skin’s collagen and elastin. This accelerates tissue laxity and increases the risk of festoon recurrence.