Key points

Introduction

Aging of the midface and lower lid complex can be evident even in the late 30s, making this one of the earliest detectable areas of facial aging and frequently requested sites for surgical rejuvenation. When present, malar festoons can complicate successful rejuvenation because they present a difficult problem to treat. Festoons occur when portions of the orbicularis oculi muscle attenuate, thereby undergoing a progressive course of sagging muscle that becomes visible to even the most casual observer. Beyond aesthetic concerns, severe festoons can cause visual field obscuration on downgaze, leading to difficulty with near-vision tasks. Although typically seen and referred to in the lower eyelid, because the orbicularis oculi encircles the eye, festoons can occur in the upper or lower eyelid. Because upper eyelid festooning is uncommon and the emphasis in the literature is on lower eyelid festoons, the latter are the focus of this article.

Although a genetic basis for the etiology of festoon formation is suspected, the precise reason why some individuals are susceptible to this condition whereas others are not is largely unknown. When present, festoons can impart the appearance of being excessively tired and when more severe can be deforming, resulting in issues of self-confidence. Every effort should, therefore, be made to improve the appearance of patients with this condition to enhance self-image and social well-being. Limitations in surgical correction are, however, a genuine challenge confounded by their unclear cause.

Anatomy

The midface is a complex anatomic area that separates the orbital cavity from the oral cavity. It is often defined as the area of the cheek medial to a line extending from the frontal zygoma to the oral commissure and the medial border defined by a line extending from the medial canthus to the nasolabial fold. The midcheek is composed of 2 functionally distinct parts :

• 1.
  

  The prezygomatic part that overlies the midcheek skeleton

  
  
• 2.
  

  The infrazygomatic part that covers the vestibule of the oral cavity

The prezygomatic area can be considered a transition zone where the skeletal attachments of the lower lid, including the ORL, are attached to the upper border of maxillary bone. The ORL (or malar septum) is the structure responsible for defining the palpebromalar groove; the junction between the preseptal portion of the lower lid and the cheek and is a key structure in the appearance of aging of the midface ( Fig. 1 ). The ligament acts as a functional and structural barrier defining the lower extent of several clinical entities, including malar mounds, malar edema, periorbital ecchymosis, and malar festoons.

Cross-sectional anatomy of the lower eyelid with graphical representation of the orbital septum, suborbicularis oculi fat (SOOF), and ORL (or malar septum). The ORL extends from the periosteum deep to the skin superficially, is responsible for defining the palpebromalar groove, and is critical in the characteristic appearance of the aged lower eyelid.

Patients presenting for periorbital rejuvenation commonly complain of eyelid bags with a resulting tired look. The anatomic basis of eyelid bags is multifactorial, where orbital fat prolapse, eyelid fluid, tear trough depression, loss of skin elasticity, orbicularis prominence, and malar mounds and festoons can each contribute to their development. Correct diagnosis of the cause of eyelid bags is, therefore, critical when addressing this problem, with festoons one possible unique clinical entity among the possible causes.

A major anatomic basis for the appearance of festoons seems to be the downward descent of the tissues superior to a lax ORL and orbicularis muscle against the resistance of the stronger lower border, effectively creating a surface trough ( Fig. 2 ). The festoon phenomenon can affect any part of the upper or lower eyelid, with 5 distinct type of festoons described. They are divided bythe level of the orbicularis that they affect ( Figs. 3–5 ):

• 1.
  

  Upper eyelid

  
  
• 2.
  

  Pretarsal

  
  
• 3.
  

  Preseptal

  
  
• 4.
  

  Orbital

  
  
• 5.
  

  Malar

Graphical representation of the pathologic features and different anatomic variations of lower lid festoons. ( A ) Pure muscle-skin festoon: muscles have gravitated away from orbital septum due to lax skin and muscle creating a simple fold due to descent over the rigid ORL. ( B ) Muscle-skin festoon with orbital fat and cutaneous dewlap: the orbital septum has sagged into a skin-muscle festoon forming the lining of a pouch. A cutaneous dewlap (skin only) then sags beyond the muscle edge over the ORL. ( C ) Muscle-skin festoon with suborbicularis oculi fat (SOOF) sagging beyond the edge of the sagging orbicularis muscle over the ORL.

Classification scheme of orbicularis oculi festoons based on the site and composition of the defect. ( A , B ) Sites of festoons: A, upper lid; B, pretarsal; C, preseptal; D, orbital; E, malar; and F, cutaneous dewlap (no muscle).

Orbitomalar festoons composed purely of muscle and skin, corrected by extensive subperiosteal dissection, with obliteration of the ORL followed by aggressive tightening of the orbicularis muscle and limited skin excision (see Fig. 5 for operative views). ( A , B ) Preoperative appearance of patient. ( C , D ) Postoperative result.

Festoon correction through indirect redraping. Operative technique (operating room pictures of patient pictured in Fig. 4 ). ( A ) A skin-only flap is developed through a subciliary incision and elevated for 6 to 8 mm. ( B ) An incision is made in the orbicularis oculi muscle down to the level of the orbital rim and a subperiosteal dissection carried inferiorly to the inferior border of the festoon, releasing the ORL while avoiding injury to the neurovascular bundle. ( C ) Muscle and malar fat pad are sutured to the periosteum from deep to superficial elevating the midface and simulating the orbitomalar ligament. ( D ) Lateral canthotomy and cantholysis are performed. ( E ) The orbicularis oculi muscle is pulled above the lateral canthal angle and sutured to the lateral orbital rim periosteum.

The outward appearance of this process can differ among individuals and can range from the sagging of individual levels in a cascade of festoons with overlapping folds to the coalescence of layers together, sagging into a single festoon. When present in the malar region, a festoon is defined superiorly by the ORL over the previously described prezygomatic area and inferiorly by the stout zygomatico-cutaneous ligament, which is considerably stronger than the ORL. The ORL is also important because it is the inferior boundary of the inferior orbital fat compartment and provides an area of fixation against which the prolapse of fat can lead to the appearance of eyelid bags and be confused with malar festoons.

The focus of treating festoons involves addressing the laxity of the ORL along with redistribution of muscle, skin, and fat within the lid-cheek junction to re-establish a smooth and youthful contour.

Evaluation

Prior to surgical intervention, a full examination of the periorbital and malar contents and anatomy should be performed. Patients should be evaluated with the head in neutral position, while they are either standing or sitting upright in good lighting. Examination should occur initially with the eyes at neutral gaze followed by upward and downward gaze to evaluate for any vision obstruction.

During evaluation, as well as preoperative marking, the surgeon should manipulate the periorbital skin with fingers or forceps. This allows for proper diagnosis as to the level of orbicularis affected and the amount of tension in the skin. Pinching the festoon (the pinch test) allows a surgeon to judge the composition of the festoon (skin muscle or skin only) (see Fig. 2 ). A lower lid snap test should be performed as well to assure the integrity of the tarsoligamentous complex to determine if a canthoplasty is required. Finally, patients should also be instructed to squinch (the squinch test [ie, tightening and lifting the lower lid]) to determine the integrity of the orbicularis muscle and its relationship to the underlying orbital and suborbicularis fat as well as the laxity of the orbital septum. In cases of lax septum, orbital fat can be seen protruding anteriorly into a separate septal pouch. In these cases, a squinching motion causes orbicularis contraction, which elevates and compresses the fat back into the orbit. It can, therefore, be appreciated how correction of festoons will improve the lower eyelid, whereas correction of the lower eyelid alone will not correct the festoon.

Surgical procedure

Currently there is no standard treatment of effective management of malar festoons, a fact that reflects the difficulty and dissatisfaction with repair. Nonsurgical options, including radiofrequency thermoplasty, carbon dioxide laser resurfacing, trichloroacetic acid peels, and the use of dermal fillers, have been reported, all with mixed results. Historically, operations were designed with the intent of maximizing excision of the skin-muscle responsible for the visible appearance of the festoons. Currently, surgical approaches can be divided into techniques involving direct excision of the affected tissue versus indirect redraping of the affected soft tissue. These indirect redraping techniques have in common limited skin excision and aggressive tightening as opposed to excision of the lax orbicularis muscle to optimize results with variations on those themes reported.