Festoons and malar bags

What it treats

• Furnas separated true festoons, caused by orbicularis oculi muscle laxity, from malar mounds and bags, which involve skin, fat and interstitial edema (PMID 635044), (PMID 8485946).
• The malar septum runs from the orbital rim periosteum to cheek skin 2.5-3 cm below the lateral canthus and traps edema and hemoglobin pigment above its insertion, defining the lower boundary of malar mounds, malar edema and festoons, based on dissection of 18 cadavers (PMID 19327681). The same fascia traps fluid at the site where a black eye forms after trauma (PMID 9579587).
• The prezygomatic space, a glide plane over the zygoma bounded by the orbicularis retaining ligament above and zygomatic ligaments below, allows the orbicularis to move independently of the cheek and explains the shape of malar mounds (PMID 12172155). Dissection of 44 hemifaces identified a tear trough muscle fiber and other connective tissue bands anchoring orbicularis oculi directly to skin in the infraorbital area (PMID 38036923).
• Orbicularis and ligament anatomy varies by ancestry, with a hypertrophied orbicularis oculi reported in African populations and attenuated fat pads in Europeans (PMID 40668178).
• Extended blepharoplasty was first described for infraorbital, or malar, bags seen in as many as 10% of blepharoplasty candidates (PMID 2036181). In 114 consecutive patients seeking correction of eyelid bags, triangular cheek festoon accounted for a mean 13% of the cumulative cause score, behind cheek descent and tear trough (52%) and orbital fat prolapse (48%); festoon and tear trough were significantly more common after age 50 (PMID 15809605).
• Festoons can be precipitated by infraorbital botulinum toxin injection in a patient whose orbicularis was already weakened by prior lower lid surgery, reported as a single case (PMID 12752529).
• Congenital festoons, present since childhood, were described in 3 of 59 patients treated for festoons or malar mounds over 10 years (PMID 29671023).
• In a 75-patient festoon surgery series, patients identified genetics (51%), pets (51%), prior hyaluronic acid filler (54%), neurotoxin injection (62%), facial surgery (40%), alcohol use (49%), allergies (46%) and sun exposure (59%) as possible contributing factors on survey (PMID 36877611).
• Infraorbital hollows, above the orbital rim, overlap in appearance with malar mounds, festoons and dark circles but are a separate deformity needing differentiation (PMID 36998744), an approach also framed as mapping alternating elevations and hollows of the lower eyelid and cheek (PMID 27398004).

How it is done

Filler-related and fluid causes

• Hyaluronic acid filler placed in the tear trough can cause malar edema that presents up to 7 years after injection; hyaluronidase resolved it completely in a reported case (PMID 28837381).
• Post-hyaluronic acid recurrent eyelid edema was treated with serial hyaluronidase and fractionated radiofrequency microneedling, with carbon dioxide laser added in 2 of 5 patients; all 5 resolved with no recurrence over a minimum 24-month follow-up (PMID 38828092). A review of the same complication describes the same treatment ladder: corticosteroids, hyaluronidase, then radiofrequency microneedling or surgery once the filler has dissolved (PMID 39395232).
• In 23 patients (46 eyelids) with periocular filler-related contour problems, hyaluronidase (15-30 U/cm2) dissolved the filler in one session in 15 patients and two sessions in 8; mild edema persisted in 4 patients despite absence of visible filler (PMID 30298348).

Direct excision

• Furnas's original technique excised the redundant orbicularis oculi muscle and supported the remaining muscle with periosteal and muscular sutures (PMID 635044). Later series applied direct skin excision to the malar festoon as part of facial rejuvenation surgery (PMID 7598032), with lower lid tightening (PMID 22690920), and under the umbrella term malar bags for malar edema, mounds and festoons (PMID 39354229).
• Mini-incision direct festoon access, cauterization and excision (MIDFACE) uses a 1-cm office-based incision instead of wide flap dissection (PMID 36877611). Another technique uses an infraorbital curvilinear incision at the base of the lowest festoon, with the orbital septum left intact and no fat manipulation (PMID 40327813).

Extended lower blepharoplasty and midface lift

• Extended blepharoplasty carries the skin-muscle flap dissection of standard lower blepharoplasty below the infraorbital rim, usually with a lid-shortening procedure (PMID 2036181). Direct transcutaneous lower blepharoplasty through an infraorbital incision has been extended to tear trough deformity, suborbicularis oculi fat and festoons in high-grade lower eyelid deformity (PMID 39104922).
• Extended lower blepharoplasty with subcutaneous and sub-orbicularis dissection plus canthoplasty removes larger amounts of skin than standard technique allows (PMID 41198888). Combined festoon excision with transmalar lower blepharoplasty gives direct access to the inferior orbital fat pads when festoons and fat herniation coexist (PMID 42130916).
• A surgical protocol of subciliary skin-muscle flap, release of the orbicularis retaining and zygomaticocutaneous ligaments, midface lift, canthopexy and orbicularis muscle suspension is used for both acquired and congenital festoons (PMID 37256298), (PMID 29671023).

Laser, energy-based and injection treatment

• Fractional microneedle bipolar radiofrequency combined with a medium-depth 15% TCA peel has been used alongside blepharoplasty (PMID 32985067); radiofrequency microneedling alone was evaluated by blinded photographic review (PMID 41092094); microfocused ultrasound with visualization (MFU-V) uses 1.5, 3.0 and 4.5 mm transducers (PMID 40763772); a thermomechanical device (Tixel) delivers topical tetracycline 1% percutaneously (PMID 38605495).
• Intralesional tetracycline 2% injection was the first reported sclerotherapy for lower eyelid festoons (PMID 24841733); intralesional doxycycline hyclate 10 mg/ml has also been used (PMID 30882591); tetracycline injection has been combined with the pinch technique and canthopexy 3 months later for severe festoons (PMID 35156019).

Results and evidence

• MIDFACE direct excision, 75 patients, no major complications: grading of 39 patients' photographs (78 eyes) by 3 physicians showed sustained improvement in festoon score up to 12 years after surgery, incision scars undetectable by photography, and mean patient satisfaction 9.5 of 10 (PMID 36877611).
• Infraorbital curvilinear direct excision, 54 eyes of 27 patients: mean 15 mm of skin excised, no lagophthalmos, corneal staining or eyelid retraction, minor complications in 2 patients, recurrence 3.7% at a mean 11-month follow-up (PMID 40327813).
• Direct excision of malar bags (53 patients) and direct excision with lower lid tightening (15 eyes of 8 patients) each reported no major complications and high satisfaction (PMID 39354229), (PMID 22690920).
• Subciliary flap with ligament release, midface lift, canthopexy and muscle suspension, 89 patients (81 acquired festoons, 49 with a prior failed correction), mean follow-up 11.2 months: persistent malar edema beyond 6 weeks in 14 patients, mostly resolved with a steroid taper and hydrochlorothiazide; 2 needed reoperation (PMID 37256298).
• Extended transcutaneous lower blepharoplasty for high-grade deformity, 21 patients: all satisfied, good scar quality (PMID 39104922). A series removing 6-16 mm of skin (mean 10 mm) reported low complications with satisfactory outcome (PMID 41198888).
• Radiofrequency microneedling, 43 patients, the largest study to date on this treatment: festoon score fell significantly by both surgeon and layperson grading, with improved undereye skin quality reported in 41% (surgeons) and 60% (laypeople) of cases and improved steatoblepharon in 43% and 63% (PMID 41092094).
• Tixel plus topical tetracycline, 20 patients: masked-reviewer grading improved from 2.81 to 1.6 (p<0.001), self-reported disturbance fell from 4.7 to 1.7 (p<0.001), 85% reported moderate to significant improvement, and 90% reported improvement lasting at least 4 months (PMID 38605495).
• Intralesional tetracycline 2%, 11 patients: mean festoon grade fell from 2.1 to 1.2 (p<0.001), no cutaneous ischemia or necrosis (PMID 24841733). Doxycycline sclerotherapy, 20 treatment areas in 11 patients: mean grade fell from 2.5 to 0.9 (p<0.001) at a mean 22.5-week follow-up (PMID 30882591).
• Long-term follow-up of tetracycline injection, 61 of 102 treated patients responding to survey at a mean 3.6 years: 59% reported improvement (82% of those within 2 months) and 67% would repeat the treatment; men were more likely than women to consider repeating it (92% versus 58%, p=0.005) (PMID 33234952).
• MFU-V (5 patients) and combined RF microneedling with 15% TCA peel (1 case) each reported visible improvement with no complications at follow-up (PMID 40763772), (PMID 32985067).

Risks and complications

• Furnas described festoons and malar mounds as notorious for persisting despite surgical treatment (PMID 8485946).
• In a 59-patient festoon series, all 3 patients with congenital festoons had residual puffiness requiring further surgery or off-label deoxycholic acid injection, against 3 of 56 acquired cases (PMID 29671023).
• In the 89-patient surgical series, persistent malar edema beyond 6 weeks occurred in 14 patients, 2 required reoperation, and 1 developed transient lid retraction after a prior facelift with facial nerve injury (PMID 37256298).
• Infraorbital botulinum toxin injection can precipitate festoon formation when the orbicularis oculi has already been weakened by earlier lower lid surgery (PMID 12752529).
• Hyaluronic acid filler-related malar edema can present years after injection; proposed mechanisms include the impermeable malar septum trapping fluid, disrupted eyelid lymphatics, and immune reaction to hyaluronic acid fragments (PMID 38828092). Among 23 patients who had hyaluronidase before lower blepharoplasty for filler-related problems, 4 had prolonged postoperative edema, resolving by 6 months in 3 (PMID 30298348).
• In the infraorbital curvilinear excision series, minor complications occurred in 2 of 27 patients and recurrence was 3.7% (PMID 40327813).
• With tetracycline or doxycycline sclerotherapy, no cutaneous ischemia or necrosis was reported; pain, bruising and swelling were the complications recorded, in up to 18% of patients on long-term follow-up (PMID 24841733), (PMID 30882591), (PMID 33234952).

Recovery

• MIDFACE is performed through a 1-cm office-based incision with a minimally invasive recovery course (PMID 36877611).
• Tixel with topical tetracycline was given at 5.4-week intervals, mean 5.0 sessions, with improvement beginning at a mean 11.2 days after the first treatment (PMID 38605495).
• After tetracycline injection, 82% of patients who improved noticed the change within 2 months (PMID 33234952).
• After direct infraorbital excision, results were durable at a mean follow-up of 11 months with no lagophthalmos or eyelid retraction (PMID 40327813).

With a facelift

• Malar bags are a recognized challenge within blepharoplasty patients, and treatment reviews build midface lift and ligament release into the surgical algorithm rather than treating festoons separately (PMID 24431347), (PMID 31051517).
• The 89-patient and 59-patient Asaadi series both combine subciliary lower blepharoplasty, midface lift, canthopexy and orbicularis muscle suspension in one operation (PMID 37256298), (PMID 29671023). Combined festoon excision with transmalar lower blepharoplasty addresses concurrent orbital fat herniation (PMID 42130916); 12 of 21 patients in the extended transcutaneous series also had upper blepharoplasty in the same operation (PMID 39104922).
• Extended lower blepharoplasty adds deep and superficial canthoplasty for support when large amounts of skin are excised (PMID 41198888).
• When periocular filler has caused malar edema, hyaluronidase dissolution is completed before lower blepharoplasty with fat repositioning and skin resurfacing (PMID 30298348).

Current questions

• Terminology is unsettled: reviews still note inconsistent use of the terms malar mound, malar edema and festoon (PMID 39354229), (PMID 42165449), (PMID 40105778).
• No single dominant technique has emerged; a systematic review proposed an updated algorithm but noted management remains individualized (PMID 31051517), and a later review concluded no nonsurgical treatment yet meets the ideal of minimal invasiveness with predictable improvement (PMID 33906762).
• Direct excision and extended lower blepharoplasty series report high satisfaction and low complications, but the largest published series are under 100 patients and mostly retrospective (PMID 36877611), (PMID 37256298).
• Energy-based devices show measurable improvement in small series but remain useful mainly for mild to moderate festoons, per the largest radiofrequency microneedling cohort to date (PMID 41092094), (PMID 40763772).
• Hyaluronic acid filler is an increasingly recognized cause of malar edema, but its exact pathophysiology is still under study (PMID 38828092), (PMID 39395232).
• Congenital festoons were only first described as a distinct entity in 2018; whether their pathophysiology and recurrence risk differ from acquired festoons is not established (PMID 29671023).

Terms

• Festoon: a hanging fold of skin, orbicularis oculi muscle and fluid on the lower eyelid or cheek, caused by muscle laxity (PMID 635044).
• Malar mound: puffiness over the cheekbone in the prezygomatic space, often congenital (PMID 24431347).
• Malar edema: fluid accumulation over the malar eminence, trapped by the malar septum (PMID 19327681).
• Malar bags: umbrella term for festoons, malar mounds and malar edema as one spectrum (PMID 39354229).
• Malar septum: the fascial barrier from the orbital rim to cheek skin that traps edema and defines the lower border of festoons (PMID 19327681).
• Orbicularis retaining ligament (ORL): ligament bounding the prezygomatic space above (PMID 12172155).
• Zygomaticocutaneous ligament (ZCL): ligament released with the ORL during midface lift for malar mounds (PMID 37256298).
• Prezygomatic space: the glide plane over the zygoma where malar mounds form (PMID 12172155).
• Steatoblepharon: fat-related lower eyelid bulge, distinct from but often co-present with festoons (PMID 41092094).
• Sclerotherapy: intralesional tetracycline or doxycycline injection intended to scar down and flatten a festoon (PMID 24841733).
• MIDFACE: mini-incision direct festoon access, cauterization and excision, an office-based technique (PMID 36877611).
• MFU-V: microfocused ultrasound with visualization, a non-invasive skin-tightening device (PMID 40763772).

Papers