Combined Festoon Excision With Transmalar Lower Eyelid Blepharoplasty

Summary:

Festoons present a significant aesthetic challenge, requiring a tailored surgical plan for each patient depending on examination findings. We describe 3 cases of severe herniation of orbital fat in combination with festoons and report a novel approach to festoon excision with direct access to the inferior orbital fat pads. This case series includes 3 consecutive patients presenting with lower lid fat herniation and mature festoons. We describe the surgical technique and outcomes for combined festoon excision and transmalar lower blepharoplasty. All patients experienced resolution of the festoon and fat herniation with minimal scarring and high satisfaction. Direct festoon excision with debulking of inferior orbital fat pads is a novel approach to dealing with this dual pathology and is a safe and effective treatment in selected cases.

Festoons present a challenging aesthetic problem, requiring customized management. Festoon formation is multifactorial; lower eyelid fat herniation can worsen edema.¹ We describe 3 cases of patients with orbital fat herniation and festoons who underwent direct festoon excision with simultaneous inferior fat pad resection. This small case series outlines a novel combined approach; larger future studies are required.

METHODS

This study followed the Declaration of Helsinki. As a retrospective case series, ethics approval was not required. Inclusion criteria were the presence of both lower eyelid festoons and significant inferior fat herniation, good lateral canthal support, and willingness to undergo combined direct festoon excision and transmalar lower eyelid blepharoplasty. Exclusion criteria were previous lower eyelid surgery, periorbital infection, poor canthal support, or keloid/hypertrophic scarring.

Preoperative evaluation included clinical examination, documentation of eyelid position and festoon size, and standardized photographs. Surgical marking, anesthesia, operative steps, and postoperative care were standardized. Patients were reviewed at 1 week, 6 weeks, and 6 months. All patients consented to the publication of anonymized photographs.

CASE REPORT

A 69-year-old man with Fitzpatrick type II presented with progressive lower eyelid bags and intermittent swelling. Examination showed bilateral festoons, significant fat herniation, and a negative vector, with no canthal laxity. Surgery proceeded as planned.

A 63-year-old man with Fitzpatrick type II presented with a 20-year history of lower eyelid bags. He had significant fat herniation, festoons, a negative vector, and canthal laxity; he proceeded with direct festoon excision and lateral canthoplasty.

A 69-year-old man with Fitzpatrick type III presented with bilateral fat herniation and a right-sided festoon. He elected to undergo bilateral lower lid blepharoplasty and direct festoon excision.

SURGICAL TECHNIQUE

Markings were made with the patient upright (Fig. 1A). A conservative skin pinch defined the excision area, ensuring both incision borders lay within thin lower eyelid skin. The inferior incision was placed at the lower lid–malar junction. Prolapsed fat pads were marked.

Fig. 1.

Combination approach to inferior orbital fat resection via direct festoon excision access. A, Skin excision marked. B, Following excision of the skin and muscle, the orbital septum may be incised, providing direct access to the medial, central, and lateral fat pads. C, The fat pads are opened and allowed to drape over the orbital rim. Any fat extending over the rim may be excised. D, Layered closure.

Local anesthesia with bupivacaine and adrenaline was infiltrated. A No. 15 blade incision was made, and a strip of skin and orbicularis muscle was excised (Fig. 1B). The tissue excision was tapered, with a relatively conservative skin excision and a more generous width of orbicularis and malar fat excessed in deeper planes. The orbital septum was opened to expose the medial, central, and lateral fat pads; fat prolapsing beyond the inferior orbital rim was conservatively excised to avoid hollowing (Fig. 1C).

In the patient with canthal laxity, lateral canthoplasty was performed with a 3-mm wedge excision and fixation of the tarsus to the lateral orbital rim. Festoon excision was closed in layers using buried 6-0 Vicryl for the orbicularis and 6-0 Prolene placed subcutaneously (Fig. 1D). Steri-Strips maintained incision flattening. The operating time was approximately 1 hour. Postoperatively, chloramphenicol ointment and lubricants were used.

RESULTS

All patients experienced significant improvement in festoon appearance with no complications such as lid retraction, malposition, or chronic edema. Scarring was minimal, and all patients were followed-up for at least 6 months.

DISCUSSION

“Malar bags” is a broad term encompassing malar edema, malar mounds, and festoons, entities that may represent separate processes or points on a pathological spectrum. These changes occur between the orbicularis retaining ligament (ORL) superiorly and the zygomaticocutaneous ligament/malar septum (MS) inferiorly.² Age-related attenuation of the ORL allows descent of the orbicularis muscle and skin. Chronic edema above the MS and reduced skin elasticity further contribute to festoon formation.³ Impaired lymphatic drainage may promote adipogenesis, increasing festoon bulk.⁴

Various surgical strategies exist, including skin-muscle flap blepharoplasty, midface lifting, and direct festoon excision. ³Skin excision carries a risk of postoperative lower eyelid retraction. Direct festoon excision is appropriate for significant skin and muscle excess with good canthal support. In patients with festoons compounded by fat herniation, debulking the inferior fat pads may reduce edema and improve outcomes.

Extended blepharoplasty with midface lift involves subperiosteal or supraperiosteal dissection to release the ORL and MS.^5–7 This mobilizes the suborbicularis oculi fat, malar fat pad, and subcutaneous tissues for resuspension. However, for established festoons with tissue hypertrophy, extended approaches are less effective. They also involve longer operating times, deeper anesthesia, and greater risk, including sensory/facial nerve injury, lateral canthal distortion, eyelid malposition, and persistent edema.^3,6,7 Large series report complication rates of 19% and 15%, with up to 9% being severe cases requiring further surgery.^7,8 In addition, cautious skin excision during midface lift may leave residual festoons, whereas extensive surgery may exacerbate edema. Thus, extended techniques are not ideal for all patients.

Direct festoon excision remains underused due to concerns over cheek scarring. However, in properly selected patients, older individuals with Fitzpatrick type I–III skin and preexisting facial lines, the scar is typically inconspicuous. The incision, placed at the junction of aesthetic units, minimizes visibility. Direct excision also places less tension on the lower lid than subciliary incisions, reducing retraction risk. Aggressive skin removal must still be avoided.

Our innovation lies in combining direct festoon excision with access to and conservative excision of inferior orbital fat pads via the same incision. This approach has not previously been described. Prior studies reported only skin-only excision with sparing of the orbicularis.^9,10 We propose that removing deeper tissues, including hypertrophic orbicularis or malar fat, optimizes outcomes, especially where fat herniation contributes to festoon bulk.

This technique carries limitations, notably the possibility of visible scarring and only partial resolution of festoons in some patients. The study itself is limited by its small sample size, absence of validated patient-reported or objective outcome measures, and short 6-month follow-up. Future research should incorporate larger cohorts, standardized assessment tools, and extended follow-up to better define long-term safety and efficacy.

We present a novel combined technique for patients with both lower eyelid fat herniation and festoons. Careful assessment and patient selection are essential. Ideal candidates have good canthal support, established festoons, and significant orbital fat herniation. Our approach offers a targeted alternative to midface lift procedures and may reduce postoperative edema while avoiding the morbidity of more extensive dissection. Further studies are needed to assess long-term outcomes and potential complications.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of his image.