5 New Treatments for Patients with Malar Mound And Festoons

July 25, 2018

Festoons and malar mounds are terms used to describe skin folds and swelling of the lower eyelid and cheek. Festoons, along with lower eyelid bags, can make patients appear tired or sick even when they feel energetic and alert. Patients with this condition often report that others think they are perpetually tired. It can be frustrating for someone who feels perfectly fine to be perceived as tired when they are not. These conditions pose great difficulty for aesthetic practitioner to identify and treat non-surgically with hyaluronic acid fillers. Thus, in this week's newsletter, we would be sharing some of the tips in identifying these conditions to help aesthetic practitioners in deciding a suitable treatment for their patients with the relevant problems.


                     Patient with mild malar and skin laxity at lid



                 Patient with familial upper and lower lid festoons



Possible Causes of Malar Mound and Festoons


  1. Genetically predisposed with family history of festoons and malar mound

  2. Aging which leads to decrease in orbicularis oculi muscle thickness and increase orbital fat prolapse

  3. Complication from excessive dermal filler injections in infraorbital hollow and tear trough

  4. Post surgical trauma as the lymphatic drainage from preorbital area is limited to superficial channels on the conjunctiva and eyelid skin

  5. Chronic skin elastosis due to solar damage and smoking


Tips in Assessing Patients

  • Detailed Medical history of patient (Ensure patients do not suffer from chronic allergies, thyroid eye diseases or renal dysfunction) in which blood tests are required

  • Relevant history of filler injections, type of filler used, material of filler used, duration of swelling

  • Since lower eyebags are caused by fat that are. 'protruded outwards', they appear more obvious when patients look upward. To differentiate fat and fluid, request patient to 'squeeze' their eyes shut. When the patient forcibly smiles, they contract the orbicularis oculi muscle, intraorbital fat get pushed back into The eye socket by a tautened muscle and only redundant skin laxity of festoon is visible.

  • High variability in eyebags of patients with festoon. Fluctuation of swelling after a high sodium meal.

  •  Swelling will not conform to the contours of the demarcated fat compartments of the lower lid (the fat appearing on the upper cheek/lower eyelid). 


Types of Suitable Treatments

  • Acute history of malar mounds related to allergies: Treat the patient with systemic antihistamines

  • A pink or reddish eyelid margin should alert the clinician to a blepharitis, which can be treated by warming, mechanical massage, and topical or systemic immune modulating measures.

  • If the malar mound is secondary to acute oedema following surgery, then oral steroids with or without diuretics have been indicated to be beneficial.

  • For malar oedema secondary to hyaluronic acid fillers, hyaluronidase should be used to dissolve it

  •  Malar mounds are improved or completely effaced by surgical lower lid blepharoplasty and mid-face-lift procedures that elevate and tighten the soft tissues of the malar area, or by direct excision of the festoon


Newer therapies, including intralesional tetracycline 2% injection, which acts as a sclerosant to seal the cavity of the festoon 12 or carbon dioxide (CO2) and Erbium-YAG (Er:Yag) laser which create a wound in the area of the festoon, allowing the new healing skin to be of better quality10 may offer less invasive options to treat lower eyelid festoons.



Reference: https://aestheticsjournal.com/cpd/module/anatomical-basis-of-festoons-and-malar-mounds

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