What are festoons and what causes them?
A festoon is defined as “a curtain of fabric draped and bound at intervals to form graceful curves.” A patient with festoons would hardly call them “graceful!” Festoons, also called malar mounds or cheek bags, are redundant folds of loose skin, muscle, fat, and/or fluid that appear at the lower eyelid-cheek interface. They are extremely difficult to treat and often misdiagnosed. Allergies, sinus problems, sun damage, facelifts, salt, alcohol, blocked tear ducts, and injected fat or filler can all lead to this unsightly condition.
It is paramount to have a trained ophthalmic as well as cosmetic surgeon who has experience and expertise in properly diagnosing and treating festoons. Many doctors are unaware of contributing factors or are afraid to treat festoons because of the high failure rate in unskilled hands. Dr. Gupta has over 20 years’ experience with festoons of all sizes, shapes, and etiologies. She incorporates a “holistic approach” and often recruits help from allergists, otolaryngologists, medications, as well as the patient himself/herself (limit alcohol/salt/sun exposure) in an effort to obviate the need for cosmetic surgery or to help ensure long-lasting results. When festoon repair is required, Dr. Gupta employs her unique triple laser technique (1444 nm fat melting laser, 1064 Nd: YAG vessel laser, Erbium: YAG skin resurfacing laser) to treat festoons at the skin, vascular, and deep levels simultaneously. With her team approach, Dr. Gupta boasts a very high long-term success rate for this very difficult to treat condition.
Preliminary Evaluation
A thorough history of contributing factors is just as important as a physical examination, or else festoons may recur or never completely regress. Thus, long-term festoon management requires lifestyle modification and treatment of underlying conditions. A patient with nasal congestion, sinus headaches or post-nasal drip may benefit from a thorough evaluation by an ear-nose-throat surgeon. A patient with chronic tearing may benefit from an evaluation of the nasolacrimal duct with an irrigation test. A patient whose festoons enlarge with alcohol or salt should recognize this and try to control their consumption. A patient who has undergone filler or fat injections near the lower lid/cheek area needs to disclose this to Dr. Gupta.
What to Expect
Festoon Repair is performed in the office under local anesthesia. It is often combined with a lower lid blepharoplasty procedure. Based on the location and the size of the festoon, Dr. Gupta may recommend an internal shrinkage of the festoon or a direct excision. With the former approach, there is no external scar (other than the lower bleph incision under the lash line). With the latter, there is a fine line (about 1 cm long) that is “hidden” meticulously in a natural skin line along the lower lid/cheek interface. With either approach, a barrier or wall is created to prevent further fluid accumulation in that area. The skin is further strengthened with laser resurfacing on top. There is some localized bruising and swelling which dissipates over 7-10 days. Though the improvement becomes evident a few weeks after the procedure, the final result may take 6-12 months for all the internal healing and remodeling to take place. To ensure optimal results, patients are advised to avoid direct sun exposure as well as to modify their salt/alcohol intake.
Schedule an appointment Online
BEFORE/AFTER GALLERY: FESTOON SURGERY
For more before/after photos and updated photos, please visit our dedicated website: FestoonSurgery.com
Age: 57 years
Condition: Hereditary festoons along with heavy upper lids and baggy lower lids.
Solution: Direct Festoon Repair, Laser Upper and Lower Blepharoplasty. Nice improvement of upper and lower lids with resolution of fluid bubbling (festoons) sustained 4 years later. No-flash photos are included to facilitate visualization of the festoons before surgery and their absence after surgery.
Age: 52 Years
Condition: Tired look as a result of hereditary festoons exacerbated by hyaluronic acid (HA) filler injections performed elsewhere. Patient was also bothered by early loss of elasticity in her eyelid skin as well as bagginess in her lower lids.
Treatment: Beautiful, sculpted look after Laser Upper and Lower Blepharoplasty and Direct Festoon Repair.
FLASH PHOTOS:
NO-FLASH PHOTOS:
Age: 55 Years
Condition: Tired, aged look due to hooded upper lids, baggy lower lids, hereditary festoons, midface and lip volume loss, early jowling, and neck banding.
Treatment: Beautiful, refreshed look after laser upper & lower blepharoplasty, festoon repair, Radiesse cheek injections, lip injections, PDO threadlifting (to lift jowls), Dermafirm (to tighten neck skin), and Botox (for neck bands).
FLASH PHOTOS:
NO-FLASH PHOTOS:
Age: 52 Years
Condition: Hereditary, fluid-filled festoons creating a tired look.
Solution: Direct Festoon Repair resulted in resolution of her festoons. She remains thrilled with her result 9 years later.
NO FLASH PHOTOS:
Age: 44 Years
Condition: Tired, drawn look from hereditary festoons and lower lid skin laxity exacerbated by hyaluronic acid injections in the tear trough (performed elsewhere). This patient consulted with 7 other surgeons prior to flying to New York to be treated by Dr. Gupta.
Solution: Beautiful, refreshed look after laser lower lid blepharoplasty and direct festoon repair. Photos were taken 2 months after surgery and though she is not completely healed, the transformation is already dramatic!
A complete set of flash and no-flash photos at different angles are presented for this patient for optimal comparison.
FLASH PHOTOS:
NO-FLASH PHOTOS:
Age: 57 Years
Condition: Unsightly complication after patient received Radiesse injections 15 months prior, performed elsewhere, to masquerade festoons and volume loss in the undereye area. The injections were done incorrectly and indiscriminately, resulting in hard, painful deposits, prompting social isolation and “hiding” behind her sunglasses for over a year.
Treatment: This patient got her life and livelihood back after lower lid blepharoplasty, direct festoon repair, and meticulous removal of all filler material which was firmly adherent to the skin of her eyelids.
Age: 52 Years
Condition: Tired look resulting from severe dark circles, extensive syringomata lower lids (white lesions), festoons, and upper lid hooding. He underwent unsuccessful laser treatment of syringomata elsewhere a few years ago.
Treatment: He looks years younger and much more refreshed after extremely complex procedures involving upper lid blepharoplasty, direct festoon repair, lower lid blepharoplasty, and excision of numerous syringomata, which created large defects in the lower lids. This required placing skin grafts procured from the upper lids and meticulously “recreating” a new lower lid on each side. He is enjoying a beautiful result with excellent healing. Note the improvement of the upper lids, dark circles and festoons, as well as retention of the natural shape of the eyes.
Age: 40 Years
Condition: Massive festoons after injection of excessive amounts of hyaluronic acid (HA) in the lower lid/cheek area 5 years ago by an inexperienced injector. Several local specialists in Georgia stated they could not help her. She no longer enjoyed having her photos taken and her self-confidence waned, HA filler is very hydrophilic, holding up to a 1000x its weight in water. Moreover, there is a Tyndall effect, a bluish discoloration of the skin due to light scatter of HA particles just under the skin. Please note that some of the injected HA filler may never dissolve and become “trapped” creating chronic swelling.
Treatment: After suffering for 5 years, this patient recouped her face and self-confidence shortly after laser lower lid blepharoplasty, direct festoon repair, and removal of all HA filler. She had minimal bruising/swelling as seen in the photo taken 4 days postoperatively. By 3 months, she is already showing a nice improvement and restoration of her beautiful face. Healing will continue to fine-tune over the ensuing 9 months.
DIAGRAMMATIC AND NO-FLASH PHOTOS:
FLASH PHOTOS:
Age: 48 Years
Condition: Longstanding history of hereditary, large fluid-filled festoons and lower lid bags exacerbated by severe seasonal allergies. She has some hooding in the upper lids but this does not bother her at this time.
Solution: Incredible improvement after laser lower blepharoplasty and direct festoon repair.
Please Note: The 6 days after surgery photo is typical of the extent of bruising and swelling patients experience after Dr. Gupta’s advanced lower bleph/festoon procedure. At 7 weeks, this patient looks incredible but there is still some swelling which will continue to dissipate and lead to further improvement of her result. It is important to remember that complete healing takes up to one year, but most patients start enjoying their new, refreshed look as early as 2-3 weeks postoperatively.
Age: 63 Years
Condition: Hereditary orbicularis (loose muscle) festoons ( patient’s left side greater than right), loss of skin elasticity lower lids, hooding upper lids, and laxity of jawline and neck skin.
Treatment: Amazing transformation of eyes and face after laser upper and lower blepharoplasty, direct festoon repair, and short scar mini SMAS facelift. All procedures were performed on the same day in the office under local anesthesia. Profile photos demonstrate improved contouring of upper lids, lower lids, jawline/neck and resolution of the festoons.
Age: 46 Years
Condition: Tired, drawn look from lower lid puffiness and festoons. She underwent Restylane injections (HA filler) in her tear troughs and cheeks 6 years ago elsewhere and developed painful festoons as a consequence 3 years later.
Treatment: Laser lower lid blepharoplasty and direct festoon repair gave this patient a more refreshed, rejuvenated look. The procedures were performed in the office under local anesthesia. Both flash and no-flash photos are provided. Note that festoon visualization is easier in the photos without flash.
FLASH PHOTOS & DIAGRAMMATIC:
NO-FLASH PHOTOS:
Age: 61 Years
Condition: This patient was advised her festoons were a result of “lymphedema” from a facial herpes infection she contracted 10 years prior and that she would have to live with her festoons. Prior to consulting Dr. Gupta she underwent an upper and lower blepharoplasty and a repeat “exploratory” lower blepharoplasty with no improvement of her festoons.
Solution: After suffering for 10 years, this patient attained a beautiful transformation just 2 weeks after Dr. Gupta performed revision upper and lower blepharoplasty and direct festoon repair. Intraoperatively, copious amounts of Juvederm were encountered in the upper and lower lids, which was removed. The diagrammatic nicely illustrates in the before photo the Juvederm-induced upper lid edema and festoons (right greater than left) from a worm’s eye view. Note the improved contour of the upper lids and almost complete resolution of the festoons. As healing proceeds, the result will continue to fine-tune and further improve.
FLASH PHOTOS:
NO-FLASH PHOTOS:
Age: 56 Years
Condition: Genetic festoons; upper eyelid hooding; lower lid bags and loose skin; forehead lines; loss of mid-face volume (deflated cheeks).
Solution: Refreshed, rejuvenated look after laser direct festoon repair, laser upper and lower blepharoplasty, and liquid, non-surgicial facelift (to improve forehead lines and improve deflated cheeks).
A complete set of no-flash and flash photos are provided for optimal comparison:
Please note in the profile views: excellent healing of all laser lines (upper lids, lower lids, festoon repair), resolution of festoons, and beautifully sculpted, “high” cheekbones.
FLASH PHOTOS:
NO-FLASH PHOTOS:
Age: 55 years
Condition: Fluid-filled festoons that resulted after lower lid blepharoplasty and full face CO2 laser resurfacing done elsewhere 6 years prior. Patient has been hiding behind her glasses and has become very self-conscious about her appearance. She is also bothered by loose, excess skin in her upper lids.
Solution: Resolution of festoons and improved eyelid appearance after direct festoon repair, laser upper and lower blepharoplasty.
A complete set of before/after non-flash and flash photos are provided for optimal comparison.
NO FLASH PHOTOS:
Age: 44 Years
Condition: Tired look from hooded upper lids, baggy lower lids, hereditary festoons exacerbated by hyaluronic acid fillers.
Treatment: Refreshed look after laser upper blepharoplasty, lower blepharoplasty, and direct festoon repair. Note that her festoons are easier to visualize in no flash photography.
A complete set of flash and no-flash photos at different angles are presented for this patient for optimal comparison.
NO FLASH PHOTOS:
Age: 55 years
Condition: Tired look from hereditary festoons slowly enlarging over the past few years.
Hooded upper lids and and loose skin in the lower lids.
Solution: Refreshed look after direct festoon repair, upper and lower laser blepharoplasty. Non-flash photos have been included to facilitate visualization of festoons.
Age: 52 years
Condition: Fluid-filled festoons exacerbated by Voluma injections in the upper cheek/lower tear trough area. The festoons were non-responsive to hyaluronidase injections. This patient is also bothered by lower lid bags and skin laxity.
Solution: Lower lid laser blepharoplasty and direct festoon repair. Nice improvement of lower lid bags and flattening of festoons. The non-flash pictures are included to facilitate visualization of the festoons.
Age: 62 years
Condition: Hereditary festoons exacerbated by sinus disease. Patient also had heavy upper lids and baggy lower lids. No-flash photos are included to enable easier visualization of the festoons before surgery.
Solution: After Laser Upper and Lower Blepharoplasty and Internal Festoon Repair, this patient had a beautiful result that has been sustained over the past 7 years. She has also benefited from judicious use of Radiesse injections in the cheeks to build collagen and to enhance the result of the surgery.
Age: 66 years
Conditions: Festoons exacerbated by Hyaluronic Acid filler injections in cheeks; Ptosis Upper Lids (weakened muscles), Droopy Upper Lids (loose skin), Baggy Lower Lids, Bottom Heavy Face with Mild Jowling (gravitational descent), Down-turned Lips.
Solution: Beautifully refreshed and lifted eyes and face after Festoon Repair, Ptosis Repair, Laser Upper and Lower Blepharoplasty, Liquid Facelift (Cheek and Jawline Lifting/Sculpting). No-Flash photos are included to enhance visualization of festoons.
Age: 60 Years
Condition: Tired, drawn look from lower lid bags, loose skin, and hereditary festoons. (This patient’s testimonial on right).
Solution: Refreshed, brighter look after laser lower lid blepharoplasty (removal of excess skin and fat) and direct festoon repair. The photos below were taken 3 months after the procedure. There is still some swelling but her healing is beautiful thus far and she should expect continued improvement over the next 9-12 months.
Please note that flash photos tend to “wash out” visualization of lower lid bags and festoons and as such, pictures with and without flash from different angles are provided for optimal comparison.
NO FLASH PHOTOS:
FLASH PHOTOS:
Age: 58 years
Condition: Festoons (molar or cheek mounds); heavy upper lids; baggy, lower lids, and a white, hypopigmented scar above her left brow. Her festoons have been enlarging over the past 7 years and are most likely genetic in nature as she has no history of fillers, allergies, or facial surgery. A no-flash before picture is included for better visualization of her cheek festoons.
Solution: Upper and lower blepharoplasty with internal festoon repair and PRP injections to her forehead scar. Given her skin type, an external incision as well as laser resurfacing were not viable options for festoon improvement. As she flew in from the West Coast, later postoperative photos will be posted once available, but even at 2 weeks she is showing nice improvement of her upper/lower lids, festoons, and scar!
Age: 56 years
Condition: Festoons resulting from improper placement of Restylane injections in tear trough done elsewhere. Over the ensuing 4 years, the festoons enlarged despite no further Restylane injections and were non-responsive to enzyme injections to break up the filler.
Solution: A lower blepharoplasty with internal laser festoon repair was performed with a significant, sustained reduction in the size of the festoons.
