LOWER EYELID “BAGS” AND MALAR “FESTOONS”

Lower eyelid “bags” and malar “festoons” are very unsettling signs of mid-face aging that occur in some people.  As we all know, one of the first areas affected by the aging process is the mid-face.  This area comprises the middle third of the face and includes the area whose upper limit is delineated by an imaginary horizontal line drawn at the level of the glabella (between the eyebrows), and whose lower limit is delineated by another imaginary horizontal line drawn below the tip of the nose.  In this mid-facial area, we find the eyes, the nose and the cheeks.  This area of the face ages soonest, and causes deformities that are the most difficult to correct.

In a young face, there is no step-off at the curvature of the cheek where it joins the lower eyelid.  Youthful, healthy fullness in this area is attributable to the presence of fat under the orbicularis oculi muscle (the muscle that surrounds the eye), and the fat that is inherent in the cheek itself.  During the aging process, this fat is resorbed by the body and disappears.  Although the reason for this is unknown, it happens to everyone at some point.  The timing is different for different people, presumably based at least partially on one’s genetic tendencies.  As a result of these changes, one of the first signs of mid-face aging is the appearance of a fold that divides the lower eyelid from the cheeks, referred to by plastic surgeons as the “tear trough.”  This “valley” visually separates the lower eyelid from the cheek.  Depending on the patient, it may be accompanied by protrusion of the lower eyelid fat pad, creating what people describe as lower eyelid bags.  However, in other people, there is residual fat accumulation on top of the cheekbone, bordered by a depression created in the tear-trough area and in the center of the cheek.  Having this condition, a sulcus is also formed in front of the malar bone/cheek eminence, causing a festoon.  This condition makes the residual fat accumulation on top of the cheek bone even more noticeable.  Many people consult physicians because they think they have bags under their lower eyelids.  Unfortunately, many times they are misdiagnosed, and end up undergoing a lower eyelid blepharoplasty that does little, if anything, to solve the problem of the festoon.  In these cases, what the patients need, in addition to a special technique to release and re-shape the lower eyelid, is removal of the residual fat on top of the malar bone eminence with filling of the tear-trough indentation, in order to create a smooth surface and for the indentation to disappear. In Figure 1, arrows highlight the malar festoons, the tear troughs and the lower eyelid fat bags.

In order to correct these deformities, we need to remove the fat from the malar festoons, fill the tear troughs, secure and tighten the lower eyelids and remove some redundant skin from the lower eyelid as well.  This delicate surgery is performed with a very tiny micro-cannula used to suction the unwanted fat from the malar festoon; the fat is then injected into the tear troughs, where it is needed.  A lower blepharoplasty with a transconjunctival approach is performed in addition, in order to remove the lower eyelid bags and release the muscles and fibers that put traction on the lower lid and pull it down.  The lateral aspect of the lower eyelid, which is tethered to the orbital bone via the canthal tendon, needs to be tightened with a procedure called a canthoplasty, during which the canthal tendon is secured to the periosteum of the lateral orbital rim. Finally, the redundant skin of the lower eyelid can be safely removed to further tighten the area and to correct any possible festoon that is secondary to excess skin and loose orbicularis oculi muscle.

In the case presented in this blog, you see the “before” photos of a patient who then underwent the above-described combined procedure, and the “after” photos that show her results 2 months postoperatively. Recovery from this surgery is similar to the recuperation from a lower blepharoplasty.  The patient needs to apply ice over the course of the first 3-4 days.  Once the stitches are removed, the patient can resume regular activities.

Again, a malar festoon is not corrected with traditional lower eyelid surgery.  This is a more complex condition that requires several surgical maneuvers in order to completely correct it, and to return a youthful appearance to the mid-face.