Festoons and Their Noninvasive Treatment: A Broadview

Introduction

Festoons, also known as malar mounds, are skin folds that droop and enlarge beneath the lower eyelids and the upper cheek region. Some individuals refer to them as swollen eyes or severe bags. Festoons frequently have the appearance of a drape that hangs from one of the eye's corners to the other, with the bottom portion resting on the cheek. Patients may experience one festoon, several festoons, or both under one or both eyes. These under-eye bags may make individuals appear worn out, older, and even unwell. It is vital to understand that these are bags underneath the eyelids rather than under the eyes.

What Is the Difference Between Eyebags and Festoons?

Festoons frequently receive the wrong diagnosis because many people mistake them for eye bags. There are some definite differences, and these include:

• Bags affect the lower eyelid and are visible as fat that protrudes through the thin skin. Festoons still protrude, affecting the cheek's upper portion.

• When touched, bags can feel almost hard and puffy. Festoons have a softer, almost mushy feeling.

• Festoons and bags can combine to form what appears to be a single protrusion.

How Are Festoons Caused?

Festoons are caused due to the following reasons:

• Age: The flexibility of the skin gradually declines with age, which can cause fatty pockets to form around the chin, neck, eyes, and lips.

• Genetic Factor: Festoons can be genetically predisposed in certain people.

• Smoking: It causes continued accumulation of lymph fluid caused by inflammatory reactions within the skin tissue, which may increase swelling.

• Sun Damage: Festoons develop due to forces under the skin brought on by opposing muscle movement and years of sun damage.

• Loose muscles: Festoons can also be brought on by other things like flexible muscles and delicate skin around the cheeks and behind the lower eyelids.

• Structural Issues: Festoons may also be the consequence of structural issues that lie below the eyelid's surface, which is why eye creams and other exterior therapies are ineffective if these issues are the root cause.

What Are the Benefits of Treating Festoons?

Treatment for festoons has the following advantages:

• Reducing swelling around the eyelids.

• Removing lower bags and circles.

• Giving the skin a smoother, brighter aspect.

• More youthful appearance.

How Is Presurgical Evaluation Made?

• Festoons can be challenging to treat, and only a trained and certified professional should do as it is readily mishandled with either an overcorrection or an under-correction.

• It is critical to distinguish between the many causes of lower eyelid bags.

• One approach to assessing festoons is the pinch test. To determine the amount of orbicularis oculi involvement contributing to the festoon, the physician pinches the festoon skin at several locations.

• Another test is the squinch test; the specialist evaluates the orbicularis oculi muscle, where the patient tightly squeezes their eyelids shut during the test.

• Doctors will be able to identify the cause of the festoons and choose the most effective course of therapy after consultation and a complete examination with the specialists and proceed with treatment.

What Are the Non-Surgical Options Available for the Treatment of Festoons?

• HAG Fillers: HAG (hyaluronic acid dermal fillers) can aggravate festoons, but with proper application, they can also be used to hide them. Injections of the filler substance can be made around places with volume loss. To enhance the appearance of festoons, highly viscous filler material may also produce a "posterior girdle" effect. Overcorrection can increase the distension of nearby weak ligaments and potentially result in post-injection edema that exacerbates festoons, especially if the lymphatics are already disturbed. Because inevitable festoon deterioration associated with fillers may not be reversed with hyaluronidase, the advantages and disadvantages of this technique should be carefully discussed with the patient.

• Hyaluronidase: Festoons unrelated to fillers have been treated with hyaluronidase. With the injection of hyaluronidase, several individuals with idiopathic edema who had no prior history of filler usage saw some reduction in their festoons. In contrast, this effect appears at best transient in doctors' experience. Another alternative is oral diuretics, but doctors have not seen any consistent improvement in patients who have tried this. Usual doses of Spironolactone range from 25 to 100 milligrams per decilitre.

• Lasers: For the treatment of malar bags, laser therapy using CO2 (carbon dioxide) and Er: YAG (erbium-doped yttrium-aluminum-garnet) ablative lasers have been described. The procedure is best suited for modest festoons or mild extra skin laxity because soft tissue is not repositioned. Risks include alterations in pigmentation, scarring, ectropion, and retraction of the eyelids.

• Radiofrequency: Festoons have been treated using radiofrequency microneedling. The benefit of the noninvasive process is that it can be repeated. By inflicting heat harm on the dermis and fat, bipolar radiofrequency microneedling is thought to decrease wrinkles by boosting collagen and elastic fibers. Trichloroacetic acid, other chemical peels, and radiofrequency thermoplasty are other non-surgical therapy alternatives.

• Tetracycline Injections: Festoons have been reduced by Tetracycline injections. The sclerosing effects of Tetracycline have been applied to different body parts. Although the precise mechanism of action is unknown, it is believed that Tetracycline's ability to block matrix metalloproteinases and growth factor-like activity to drive fibroblast proliferation both play a role in the festoon space's ability to sclerose. Ischemia (restricted blood flow to a body part), necrosis (death of body tissues), chronic post-injection discomfort, and sensory palsies were not observed as complications. The doctors administer Tetracycline two percent, 0.2 to 0.5 milliliter per lesion. Tetracycline injections had to be injected in some festoons several times, at least 90 days apart, so it could take weeks to see the results. The injection seems to work better on festoons which cannot be treated by hyaluronic acid filler injection.

What Are Post-operative Instructions Given to Patients?

• Patients should anticipate a few weeks of recovery time and some restrictions on their usual routine.

• Individuals are advised to accompany a friend or member of the family to drive them to and from surgery.

• Limiting reading, television viewing, and technology use may be necessary to lessen strain and give the eyes time to recover.

• The particulars of the surgery will determine the length of the recovery.

• The doctor will provide the post-operative care instructions and let the patients know when it is safe to return to the routine.

Conclusion

Festoons can negatively affect a person's appearance and self-confidence. Fortunately, there are non-invasive treatment methods available to properly address this cosmetic issue. HAG fillers, radiofrequency therapy, and laser treatments are some of the procedures that have shown promise in reducing puffiness and enhancing skin texture. These methods can help every patient and cater to their individual requirements. The treating physician will be better able to manage festoons if they are familiar with the basic anatomy, clinical traits, and clinical evaluation.