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J Cosmet Med 2017; 1(1): 1-7

Published online June 30, 2017

https://doi.org/10.25056/JCM.2017.1.1.1

The troublesome triad: festoons, malar mounds, and palpebral bags

Lam Kar Wai Phoebe, MD

Dr. Lam's Clinic, Kowloon, Hong Kong

Received: August 30, 2016; Revised: March 9, 2017; Accepted: March 12, 2017

© Korean Society of Korean Cosmetic Surgery

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The ill-defined lid-cheek junction continues to be one of the most challenging regions for rejuvenation. Malar mounds, festoons or palpebral bags, may occur alone, or in combination, in the infraorbital area. These pathological variants are distinctly different and may contribute to patients’ perception of their eyebags. Traditional lower blepharoplasty (fat repositioning/ removal) with skin adjustment alone may be insufficient in addressing all of these pathologies, and recurrence may occur. This literature review aims to look at current definitions and treatment of festoons, malar mounds, and palpebral bags in Asian blepharoplasty. A Medline literature search for articles with anatomic descriptions of malar mounds, palpebral bags and festoons, particularly in Asian eyelids, was performed. This was supplemented by a manual search of the references of articles obtained. The details of all of the different surgical options for eyelid rejuvenation are beyond the scope of this review article. Thus, only the basic concepts that illustrate the anatomical relationship and the natural progression of malar mounds, festoons, and palpebral bags will be discussed in this article. Some of the treatment options, both invasive and non-invasive, will also be reviewed. There is no singular treatment for malar mounds, festoons, and palpebral bags. Standard lower blepharoplasty with skin excision is ineffective to lift and re-drape malar mounds or festoons. Repositioning of the malar septum, on the other hand, allows for resolution of the edema (malar festoons) above its cutaneous insertion. A number of liposculpturing techniques to volumize deficient areas, such as fat repositioning (cheek, suborbicularis and descended malar fat pad) with lifting of the midface, can be beneficial to restore a smooth lid-cheek junction.Non-invasive techniques like laser resurfacing and Ultherapy? (Ulthera, Inc., Meza, AZ, USA) may be useful in periorbital rejuvenation in selected cases.

Keywords: festoon, malar mound, palpebral bag, orbitomalar septum, periorbital rejuvenation

  1. Kotlus BS, Schwarcz R. Malar festoons: anatomy and treatment strategies. Am J Cosmet Surg 2010;27:1-10.
    CrossRef
  2. Chuang AC, Lian SL. Periorbital rejuvenation surgery in the geriatric population. Int J Gerontol 2010;4:107-14.
    CrossRef
  3. Amrith S. Oriental eyelids--anatomical and surgical considerations. Singapore Med J 1991;32:316-8.
    Pubmed
  4. Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg 2005;31:1604-12.
    CrossRef
  5. Doxanas MT, Anderson RL. Oriental eyelids. An anatomic study. Arch Ophthalmol 1984;102:1232-5.
    CrossRef
  6. Kakizaki H, Jinsong Z, Zako M, Nakano T, Asamoto K, Miyaishi O, et al. Microscopic anatomy of Asian lower eyelids. Ophthal Plast Reconstr Surg 2006;22:430-3.
    Pubmed CrossRef
  7. Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg 1974;1:157-71.
    Pubmed
  8. Weingarten CZ. Blepharoplasty in the oriental eye. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol 1976;82:ORL 442-6.
  9. Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg 1981;8;725-37.
    Pubmed
  10. Cho WK, Paik JS, Han SH, Yang SW. Microscopic characteristics of lower eyelid retractors in Koreans. Korean J Ophthalmol 2011;25:344-8.
    Pubmed KoreaMed CrossRef
  11. Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg 2008;121:258-68.
    Pubmed CrossRef
  12. Pessa JE, Garza JR. The malar septum: the anatomic basis of malar mounds and malar edema. Aesthet Surg J 1997;17:11-7.
    CrossRef
  13. Goldberg RA, McCann JD, Fiaschetti D, Ben Simon GJ. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 2005;115:1395-402.
    Pubmed CrossRef
  14. Hoenig JF, Knutti D, de la Fuente A. Vertical subperiosteal mid- face-lift for treatment of malar festoons. Aesthetic Plast Surg 2011;35:522-9.
    Pubmed KoreaMed CrossRef
  15. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek. Clin Plast Surg 1993;20:367-85.
    Pubmed
  16. Rosenberg GJ. Correction of saddlebag deformity of the lower eyelids by superficial suction lipectomy. Plast Reconstr Surg 1995;96:1061-5.
    Pubmed CrossRef
  17. Carter SR, Seiff SR, Grant PE, Vigneron DB. The asian lower eyelid: a comparative anatomic study using high-resolution magnetic resonance imaging. Ophthal Plast Reconstr Surg 1998;14:227-34.
    Pubmed CrossRef
  18. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993;20:403-15.
    Pubmed
  19. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg 1999;15:225-9.
    Pubmed CrossRef
  20. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications. Dermatol Surg 2007;33:572-8.
    CrossRef
  21. Seiff SR. The fat pearl graft in ophthalmic plastic surgery: everyone wants to be a donor! Orbit 2002;21:105-9.
    Pubmed CrossRef
  22. Farrior RT, Kassir RR. Management of malar folds in blepharoplasty. Laryngoscope 1998;108:1659-63.
    CrossRef
  23. Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid ectropion repair. Ophthal Plast Reconstr Surg 2009;25:1-6.
    Pubmed CrossRef
  24. Roberts TL 3rd. Laser blepharoplasty and laser resurfacing of the periorbital area. Clin Plast Surg 1998;25:95-108.
    Pubmed
  25. Glasgold M, Lam SM, Glasgold R. Volumetric rejuvenation of the periorbital region. Facial Plast Surg 2010;26:252-9.
    Pubmed CrossRef
  26. Hoenig JA, Shorr N, Goldberg RA. The versatile SOOF lift in oculoplastic surgery. Facial Plast Surg Clin North Am 1998;6:205-19.
  27. De la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg 1998;81:677-87.
    CrossRef
  28. Massry GG. Comprehensive lower eyelid rejuvenation. Facial Plast Surg 2010:26:209-21.
    Pubmed CrossRef
  29. Niamtu J. Surgical treatment options for lower eyelid aging. Cosmet Dermatol 2008;21:652-7.
  30. Ross GL, Whitby DJ. Trends in aesthetic facial surgery: the hamra lower lid bleopharoplasty [Internet]. Gary Ross;
    Available from: http://www.garylross.com/trends-in-aestheticfacial-surgery-the-hamra-lower-lid-blepharoplasty/.
  31. Pilkington SJ, Belden S, Miller RA. The tricky tear trough: a review of topical cosmeceuticals for periorbital skin rejuvenation. J Clin Aesthet Dermatol 2015;8:39-47.
    Pubmed KoreaMed
  32. Pak CS, Lee YK, Jeong JH, Kim JH, Seo JD, Heo CY. Safety and efficacy of ulthera in the rejuvenation of aging lower eyelids: a pivotal clinical trial. Aesthetic Plast Surg 2014;38:861-8.
    Pubmed CrossRef
  33. Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol Anat 2002;24:183-9.
    Pubmed CrossRef
  34. Bucay VW, Day D. Adjunctive skin care of the brow and periorbital region. Clin Plast Surg 2013;40:225-36.
    Pubmed CrossRef
  35. Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg 1993;20:323-30.
    Pubmed
  36. Small RG. Extended lower eyelid blepharoplasty. Arch Ophthalmol 1981;99:1402-5.
    Pubmed CrossRef

Article

Review Article

J Cosmet Med 2017; 1(1): 1-7

Published online June 30, 2017 https://doi.org/10.25056/JCM.2017.1.1.1

Copyright © Korean Society of Korean Cosmetic Surgery.

The troublesome triad: festoons, malar mounds, and palpebral bags

Lam Kar Wai Phoebe, MD

Dr. Lam's Clinic, Kowloon, Hong Kong

Received: August 30, 2016; Revised: March 9, 2017; Accepted: March 12, 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The ill-defined lid-cheek junction continues to be one of the most challenging regions for rejuvenation. Malar mounds, festoons or palpebral bags, may occur alone, or in combination, in the infraorbital area. These pathological variants are distinctly different and may contribute to patients’ perception of their eyebags. Traditional lower blepharoplasty (fat repositioning/ removal) with skin adjustment alone may be insufficient in addressing all of these pathologies, and recurrence may occur. This literature review aims to look at current definitions and treatment of festoons, malar mounds, and palpebral bags in Asian blepharoplasty. A Medline literature search for articles with anatomic descriptions of malar mounds, palpebral bags and festoons, particularly in Asian eyelids, was performed. This was supplemented by a manual search of the references of articles obtained. The details of all of the different surgical options for eyelid rejuvenation are beyond the scope of this review article. Thus, only the basic concepts that illustrate the anatomical relationship and the natural progression of malar mounds, festoons, and palpebral bags will be discussed in this article. Some of the treatment options, both invasive and non-invasive, will also be reviewed. There is no singular treatment for malar mounds, festoons, and palpebral bags. Standard lower blepharoplasty with skin excision is ineffective to lift and re-drape malar mounds or festoons. Repositioning of the malar septum, on the other hand, allows for resolution of the edema (malar festoons) above its cutaneous insertion. A number of liposculpturing techniques to volumize deficient areas, such as fat repositioning (cheek, suborbicularis and descended malar fat pad) with lifting of the midface, can be beneficial to restore a smooth lid-cheek junction.Non-invasive techniques like laser resurfacing and Ultherapy? (Ulthera, Inc., Meza, AZ, USA) may be useful in periorbital rejuvenation in selected cases.

Keywords: festoon, malar mound, palpebral bag, orbitomalar septum, periorbital rejuvenation

References

  1. Kotlus BS, Schwarcz R. Malar festoons: anatomy and treatment strategies. Am J Cosmet Surg 2010;27:1-10.
    CrossRef
  2. Chuang AC, Lian SL. Periorbital rejuvenation surgery in the geriatric population. Int J Gerontol 2010;4:107-14.
    CrossRef
  3. Amrith S. Oriental eyelids--anatomical and surgical considerations. Singapore Med J 1991;32:316-8.
    Pubmed
  4. Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg 2005;31:1604-12.
    CrossRef
  5. Doxanas MT, Anderson RL. Oriental eyelids. An anatomic study. Arch Ophthalmol 1984;102:1232-5.
    CrossRef
  6. Kakizaki H, Jinsong Z, Zako M, Nakano T, Asamoto K, Miyaishi O, et al. Microscopic anatomy of Asian lower eyelids. Ophthal Plast Reconstr Surg 2006;22:430-3.
    Pubmed CrossRef
  7. Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg 1974;1:157-71.
    Pubmed
  8. Weingarten CZ. Blepharoplasty in the oriental eye. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol 1976;82:ORL 442-6.
  9. Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg 1981;8;725-37.
    Pubmed
  10. Cho WK, Paik JS, Han SH, Yang SW. Microscopic characteristics of lower eyelid retractors in Koreans. Korean J Ophthalmol 2011;25:344-8.
    Pubmed KoreaMed CrossRef
  11. Owsley JQ, Roberts CL. Some anatomical observations on midface aging and long-term results of surgical treatment. Plast Reconstr Surg 2008;121:258-68.
    Pubmed CrossRef
  12. Pessa JE, Garza JR. The malar septum: the anatomic basis of malar mounds and malar edema. Aesthet Surg J 1997;17:11-7.
    CrossRef
  13. Goldberg RA, McCann JD, Fiaschetti D, Ben Simon GJ. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 2005;115:1395-402.
    Pubmed CrossRef
  14. Hoenig JF, Knutti D, de la Fuente A. Vertical subperiosteal mid- face-lift for treatment of malar festoons. Aesthetic Plast Surg 2011;35:522-9.
    Pubmed KoreaMed CrossRef
  15. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek. Clin Plast Surg 1993;20:367-85.
    Pubmed
  16. Rosenberg GJ. Correction of saddlebag deformity of the lower eyelids by superficial suction lipectomy. Plast Reconstr Surg 1995;96:1061-5.
    Pubmed CrossRef
  17. Carter SR, Seiff SR, Grant PE, Vigneron DB. The asian lower eyelid: a comparative anatomic study using high-resolution magnetic resonance imaging. Ophthal Plast Reconstr Surg 1998;14:227-34.
    Pubmed CrossRef
  18. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993;20:403-15.
    Pubmed
  19. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg 1999;15:225-9.
    Pubmed CrossRef
  20. Kranendonk S, Obagi S. Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications. Dermatol Surg 2007;33:572-8.
    CrossRef
  21. Seiff SR. The fat pearl graft in ophthalmic plastic surgery: everyone wants to be a donor! Orbit 2002;21:105-9.
    Pubmed CrossRef
  22. Farrior RT, Kassir RR. Management of malar folds in blepharoplasty. Laryngoscope 1998;108:1659-63.
    CrossRef
  23. Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid ectropion repair. Ophthal Plast Reconstr Surg 2009;25:1-6.
    Pubmed CrossRef
  24. Roberts TL 3rd. Laser blepharoplasty and laser resurfacing of the periorbital area. Clin Plast Surg 1998;25:95-108.
    Pubmed
  25. Glasgold M, Lam SM, Glasgold R. Volumetric rejuvenation of the periorbital region. Facial Plast Surg 2010;26:252-9.
    Pubmed CrossRef
  26. Hoenig JA, Shorr N, Goldberg RA. The versatile SOOF lift in oculoplastic surgery. Facial Plast Surg Clin North Am 1998;6:205-19.
  27. De la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg 1998;81:677-87.
    CrossRef
  28. Massry GG. Comprehensive lower eyelid rejuvenation. Facial Plast Surg 2010:26:209-21.
    Pubmed CrossRef
  29. Niamtu J. Surgical treatment options for lower eyelid aging. Cosmet Dermatol 2008;21:652-7.
  30. Ross GL, Whitby DJ. Trends in aesthetic facial surgery: the hamra lower lid bleopharoplasty [Internet]. Gary Ross; Available from: http://www.garylross.com/trends-in-aestheticfacial-surgery-the-hamra-lower-lid-blepharoplasty/.
  31. Pilkington SJ, Belden S, Miller RA. The tricky tear trough: a review of topical cosmeceuticals for periorbital skin rejuvenation. J Clin Aesthet Dermatol 2015;8:39-47.
    Pubmed KoreaMed
  32. Pak CS, Lee YK, Jeong JH, Kim JH, Seo JD, Heo CY. Safety and efficacy of ulthera in the rejuvenation of aging lower eyelids: a pivotal clinical trial. Aesthetic Plast Surg 2014;38:861-8.
    Pubmed CrossRef
  33. Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol Anat 2002;24:183-9.
    Pubmed CrossRef
  34. Bucay VW, Day D. Adjunctive skin care of the brow and periorbital region. Clin Plast Surg 2013;40:225-36.
    Pubmed CrossRef
  35. Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg 1993;20:323-30.
    Pubmed
  36. Small RG. Extended lower eyelid blepharoplasty. Arch Ophthalmol 1981;99:1402-5.
    Pubmed CrossRef

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