Festoons

Gregory E. Rauscher

Festoons are described as a decorative chain of flowers hanging or suspended between two points (1). Upper and lower eyelid festoons do not engender such an appealing vision. Eyelid festoons are redundant folds of lax skin and muscle that hang from canthus to canthus when the patient is seated upright (Fig. 4.2.1). In severe cases, the redundant folds include excess intraorbital fat, as well as skin and muscle, which obscure the normal eyelid folds. Patients with festoons are characterized as exceptionally tired and aged (2). According to Furnas (3), 10% of patients seeking cosmetic blepharoplasty present with malar mounds and 5% have festoons.

With aging, attenuation and involution of orbital supporting structures occur. Attenuation of the orbital septum combined with the constant pressure of the intraorbital fat predisposes the upper and lower lids to develop eyelid bags. Preoperative evaluation of the patient and assessment of the patient’s expectations is essential in the treatment of festoons. Several techniques are available to treat upper and lower festoons. Individualization and the skill of the surgeon frequently determine the surgical approach.

The etiology of upper and lower eyelid festoons has provoked extensive anatomic studies. Reports have indicated that the orbicularis oculi muscle is the major component in eyelid festoons (4, 5 and 6). The pathologic anatomy of pure muscle festoons can be demonstrated in the operating room. During the aging process, the skin and orbicularis oculi muscle of the upper and lower eyelid separate unevenly; in certain patients a festoon is produced. Classification of festoons and malar bags have been ascribed and defined by numerous authors (7, 8 and 9). Creation of a lower eyelid festoon is determined by the level of orbicularis oculi muscle weakness and the eyelid bag involved (Fig. 4.2.2) (9).

Lower eyelid bags initially develop at the palpebral level (10). The lower eyelid bag generally descends to the next dependent location, which is the pretarsal orbicularis muscle. The constant pressure of the intraorbital fat upon the attenuated orbital septum initiates stretching of the lower lid eyelid skin into a full festoon. The sequence of lower eyelid skin stretching and subsequent development of
lower lid bags follow the principles of gravity. The most superior tissues weaken and sag first; the foundation (most inferior eyelid tissue) sags last. Consequently, after the pretarsal muscle in the lower eyelid stretches, the preseptal muscle, orbital orbicularis oculi muscle, and malar zone follow (11).

Figure 4.2.1. Sketch of eyelid. Upper eyelid festoon (1), pretarsal lower lid festoon (2), orbicularis oculi festoon (3), and malar (jugal) festoon (4).

Figure 4.2.2. Sketch of lower eyelid festoon containing skin, muscle, and fat.

The differences in diagnosis and treatment of upper eyelid and lower eyelid festoons are considerable. The festoons of the upper lateral eyelid can be treated by numerous techniques, and preoperative study of the periorbital area is mandatory.

Upper Eyelid Festoons

Careful diagnosis and assessment of the upper eyelid festoon are necessary. Preoperative assessment of the eyebrow position is essential before upper lid festoon surgery (12). Eyebrow ptosis can be a significant factor in an apparent upper eyelid festoon. The laxity of the eyebrow and the aesthetic consideration of eyebrow position are ascertained from a number of factors. Certain patients have congenitally low eyebrows. Similarly, degenerative changes in the scalp and forehead skin may result in a low-lying eyebrow and apparent excess upper eyelid skin (13). Photographs of the patient’s face, history of eyebrow position, and mobility of the eyebrow on palpation lend clues to eyebrow descent or lack thereof. A ptotic eyebrow may be misdiagnosed as an upper eyelid festoon. Similarly, a patient may present with a ptotic eyebrow and upper eyelid festoon. If eyebrow elevation is necessary, numerous techniques can be performed. Direct forehead skin excision, browpexy (14), coronal forehead lift, lateral temporal lift, and endoscopic brow lifts have considerable
success in treating excess upper eyelid skin and upper eyelid festoons (see Chapter 4.6).

Apart from ruling out subtle degrees of eyebrow ptosis, eyelid ptosis and upper lid retraction must be considered before correcting an upper eyelid festoon. Prior to more extensive surgical procedures, which elevate the eyebrow, Baker (15) definitively proved that correction of a simple upper eyelid festoon could be accomplished with judicious excision of skin and muscle. With excision of the skin and muscle, not only is the upper eyelid festoon rectified but potential visual obstruction also corrected. Excision of excess upper eyelid skin, herniated orbital fat, and a strip of upper eyelid orbicularis oculi muscle generally corrects an upper eyelid festoon when eyebrow position is satisfactory (15).

If the patient has pseudoblepharoptotic skin cascading over the upper eyelid margin due to a ptotic eyebrow, the patient will experience an unaesthetic outcome with excision of upper eyelid skin. Compensatory chronic spasticity will develop and release of the Müuller muscle or a levator recession may be necessary to correct the unappreciated preoperative problem (16).

The advent of coronal, endoscopic, and extended brow lifts has altered the treatment of upper and lower eyelid festoons (12). Release of the eyebrow laterally and detachment of retaining retinacular ligaments between the orbicularis oculi muscle and the orbital rim allow redraping of the lateral upper eyelid skin over the rim (17). In 1997, Byrd (18) outlined the appropriate aspects of endoscopic technique to the eyebrow and upper eyelid. Understandably, the amount of upper eyelid skin resection would be considerably diminished with eyebrow elevation. A minimal amount of overhanging upper eyelid skin, muscle, and orbital fat can be treated with a coronal brow or endoscopic eyebrow elevation. Likewise, endoscopic midcheek lifting can reduce the need for skin and muscle removal in lower eyelid festoons as the entire cheek-eyelid malar modiolus is lifted with appropriate fixation (19).

Correction of upper eyelid festoons described has become more individualized with aggressive surgical techniques. Enthusiasm for extensive endoscopic procedures has been tempered by significant documented complications, such as prolonged healing, chronic facial edema, and temporary and permanent forehead muscle paralysis (20,21). The surgeon’s skill as well as the patient’s anatomy and anticipated postoperative appearance must be considered in correction of upper eyelid festoons. Overaggressive elevation of the eyebrow may result in a startled or alarmed appearance that is objectionable to many patients (22). Similarly, aggressive overresection of upper eyelid skin and muscle may mar the aesthetics of the upper eye, with obliteration of the gentle slope from the upper eyelid lashes to the eyebrow.

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