Updated Management of Malar Edema, Mounds, and Festoons: A Systematic Review

More Than Under-Eye Bags: Treatment of Formidable Festoons

A 64-year-old male with no medical care over the last decade was transferred from his local emergency room to a level 1 trauma center following an unwitnessed fall. Upon ophthalmic evaluation, he was noted to have significant lethargy and bilateral large festoons with secondary ectropion. Laboratory workup revealed severe hypothyroidism, consistent with myxedema coma, and his lethargy improved with medical treatment. The festoons were surgically removed to address the ectropion, and the patient was satisfied with the results following a single procedure. This case report features the largest reported festoons to date in the literature and emphasizes the importance of balancing cosmesis with function during surgical excision and correction of ectropion.

Post-Hyaluronic Acid Recurrent Eyelid Edema: Pathophysiologic Mechanisms and a Proposed Treatment Protocol

Background

Hyaluronic acid (HA) filler injections for facial augmentation are commonly administered but can lead to post-hyaluronic acid recurrent eyelid edema (PHAREE). The pathophysiology of this condition has not been fully understood.

Objectives

To report the successful treatment of PHAREE using serial hyaluronidase and fractionated radiofrequency microneedling, with additional carbon dioxide laser skin resurfacing in selected patients.

Methods

Five patients with PHAREE were treated with serial hyaluronidase injections and fractionated radiofrequency microneedling, with 2 patients receiving carbon dioxide laser treatment. The patients were followed up for a minimum of 24 months.

Results

All patients reported a resolution of PHAREE signs/symptoms with no adverse effects or recurrence. One patient demonstrated complete resolution after a single treatment; 4 required a series of treatments.

Conclusions

The proposed treatment protocol may provide advantages over hyaluronidase alone for PHAREE. The impermeable malar septum, vulnerable eyelid lymphatics, and potential immunogenicity of HA fragments likely contribute to PHAREE pathophysiology. Further research on pathophysiologic mechanisms is warranted.

Level of Evidence 4

Periorbital venous stasis may be involved with filler induced malar edema-A duplex ultrasound-imaging-based case series

INTRODUCTION

Filler injections in the periocular region are regarded as a challenging and advanced maneuver in a high-risk area. Adverse events as malar edema due to filler treatment may occur. To evaluate the possible reasons, the ultrasound images, and medical data of patients that were prospectively referred with malar edema were evaluated.

MATERIALS AND METHODS

A total of 17 patients (26 eyes) with malar edema after hyaluronic acid filler treatment were included. All cases were assessed with an 18 MHz linear ultrasound device. Exact location of the filler material was noted. Relations with clinical data were analyzed using chi-square tests.

RESULTS

Onset of malar edema after treatment showed a wide range from immediate (0 days) to 3 years. Most patients had an early onset N = 13 (76%), a minority showed late onset N = 4 (24%). In 23 eyes, the filler material was found to be located inside the SMAS. In 3 cases filler material was located on the periosteum of the orbital rim. After duplex-ultrasound guided filler removal, restored venous flow could be seen in the superficial and/or deep fatty layer often accompanied by flow piercing through the SMAS. Minutes after treatment, clinical improvement of malar edema was observed.

CONCLUSION

Malar edema after by filler treatments in the periocular region may be caused by veno-lymphatic compression by filler deposits.

Mini-Incision Direct Festoon Access, Cauterization, and Excision (MIDFACE): A 12-Year Analysis of a Novel Festoon Surgery

BACKGROUND

Surgical festoon management often entails aggressive dissection, flaps, unsightly scars, prolonged recovery, and high recurrence rates. The authors present outcomes with subjective and objective evaluation of an office-based, novel, minimally invasive (1-cm incision) festoon repair: mini-incision direct festoon access, cauterization, and excision (MIDFACE).

METHODS

Charts of 75 consecutive patients from 2007 to 2019 were evaluated. Photographs of 39 patients who met inclusionary criteria were evaluated by three expert physician graders for festoon and incision visibility (339 randomly scrambled preoperative and postoperative photographs taken with and without flash and from four different views: close-up, profile, full-frontal, and worm's eye) using paired t tests and Kruskal-Wallis tests for statistical evaluation. Surveys returned by 37 of 75 patients were evaluated for patient satisfaction and possible contributing factors to festoon formation or exacerbation.

RESULTS

There were no major complications in the 75 patients who underwent MIDFACE. Physician grading of photographs of 39 patients (78 eyes, 35 women; four men; mean age, 58 ± 7.7 years) demonstrated statistically significant sustained improvement in festoon score postoperatively up to 12 years regardless of view or flash. Incision scores were the same preoperatively and postoperatively, indicating incisions could not be detected by photography. Average patient satisfaction score was 9.5 on a Likert scale of 0 to 10. Possible factors for festoon formation or exacerbation included genetics (51%), pets (51%), prior hyaluronic acid fillers (54%), neurotoxin (62%), facial surgery (40%), alcohol (49%), allergies (46%), and sun exposure (59%).

CONCLUSION

MIDFACE repair results in sustained improvement of festoons with an office-based, minimally invasive procedure with high patient satisfaction, rapid recovery, and low recurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of Surgical Treatment of Malar Mounds and Festoons

BACKGROUND

Malar mounds (congenital) and festoons (acquired) are persistent puffiness in the prezygomatic space between the orbicularis retaining ligament (ORL) and zygomatico-cutaneous ligament (ZCL). Non-surgical treatments often yield unsatisfactory results. This paper aims to demonstrate a surgical approach for the treatment of malar bags by outlining the author's surgical technique of treating malar mounds and festoons and reviewing outcomes in 89 cases.

METHODS

Correction of malar mounds and festoons was achieved with subciliary skin-muscle flap, release of the ORL and ZCL, midface lift, canthopexy, and muscle suspension. We performed a retrospective study of 89 patients, all of whom had surgical correction of malar mounds or festoons in the past 10 years and a follow-up period of at least 6 months. This study was conducted over the course of the past year and involved reviewing patient charts in the office. Specifically, patient data spanning 2012 to 2022 were analyzed. The predictor variable in this study is the specific class of malar bags the patient has, as determined by the underlying pathophysiology. Outcome variables include the presence or absence of prolonged lid or malar edema, necessary re-excision of excess orbicularis oculi of the subciliary area, lid malposition, permanent visual changes, the need for additional non-operative treatment, and recurrence requiring reoperation.

RESULTS

The majority of patients presented with acquired festoons (81/89) with prior attempts of correction (49/89). The mean follow-up is 11.2 months. Persistent malar edema (> 6 weeks) was documented in 14 patients and mainly resolved with Medrol Dosepak (methylprednisolone) and hydrochlorothiazide. A two-proportion Z-test was conducted, comparing the proportion of patients with poor protoplasm who experienced postoperative malar edema to the proportion of those with excellent protoplasm who experienced postoperative malar edema. A p-value of 3.414e-7 was obtained, indicating a statistically significant difference of proportions between the two groups. Five patients received additional injections of deoxycholic acid and two needed fillers for smoother contour of the lower eyelids. Two patients with severe malar mounds required multiple reoperations including direct excision in one patient. One incidence of transient lid retraction was reported in a patient with previous facelift and facial nerve injury.

CONCLUSION

Malar mounds and festoons present a unique challenge to plastic surgeons. They are persistent in nature and require close-interval, long-term follow-up as additional injections and reoperations are warranted. Our approach to malar mound and festoon correction is safe and effective and provides long-lasting results.

LEVEL OF EVIDENCE IV

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