Lower Lid Festoon Blepharoplasty 

Updated: Jun 07, 2019
Author: Andrew Jacono, MD; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

Festoons of the eyelids are redundant folds of lax skin and orbicularis muscle of the upper or lower eyelids that hang, in hammocklike fashion, from canthus to canthus when the face is upright.

Malar mounds are discrete soft tissue convexities that protrude from the lateral part of the malar eminence. They retain a relatively stable shape during usual facial movements, but can be worsened with smiling.

Palpebral bags or baggy eyelids are also known as herniated intraorbital fat. They are the result of intraorbital fat bulging outward against an attenuated or weak orbital septum of the upper or lower eyelid.[1] They are the most common aesthetic deficiency of the eyelids.

These 3 variations of eyelid anatomy may be present in a minor degree at an early age, but they increase in severity as time passes and are generally associated with the appearance of aging. Each presents an aesthetic defect in a region that is the center of attention during face-to-face contact.

The eyes and eyelids are the most potent vehicle of nonverbal communication. The subtlest movements of the eyelids are subjected to constant interpretation or misinterpretation. In a first impression, these eyelid features may cause one to underestimate the patient's vigor, enthusiasm, or friendliness. The image the patient sees in the mirror may lower his or her personal esteem. Skillful correction of these defects has the promise of removing an impediment to everyday social interaction.

For expert viewpoints, information, and CME on aesthetic procedures, visit Medscape's Aesthetic Medicine Resource Center.

History of the Procedure

Palpebral bags were described as baggy eyelids by Castanares in 1951. He provided a detailed anatomic classification of herniated intraorbital fat in 1977 and described the pattern of protruding intraorbital fat.[2] His described pattern was 3 compartments in the lower eyelid and 2 compartments in the upper eyelid. Castanares outlined an operative technique for excising the unwanted fat, and, for decades, this technique became the universal method for treating baggy eyelids. Recent anatomic observations and newly available instrumentation have led to modifications of Castanares' technique and to the development of completely different procedures that are now widely applied. At this time, no standard technique exists, but several apparently effective methods are in use and ultimately await the test of time.[3]

Festoons of the eyelids had initially been dealt with as undescribed appendages to baggy eyelids. The anatomy of festoons was delineated, the types were classified, surgical strategies were developed, and the descriptive name was coined by the author in 1978.

Malar mounds had also been noted over the years, but they had not been well defined anatomically and had not been given consistent or unambiguous names. The terms bags, pouches, and pads were used, but these terms were also used interchangeably for sagging or protruding skin of the cheek, perioral area, and elsewhere in the orbit. They are now termed malar bags, yet Castanares' original nomenclature included them as a component of baggy eyelids.

A specific anatomic foundation for these structures was detailed, a morphological spectrum was described, and they were named malar mounds by the author in 1993. Substantial anatomic details were added by Pessa in 1997 and by Mendelson in 2001.[4] Knowledge of the surgical anatomy and surgical correction of these entities continues to improve.

Problem

Festoons of the orbicularis oculi muscle

Over time, predisposed individuals develop attenuation of the orbicularis oculi muscle and laxity of the attachments between the orbicularis and the deep fascia. The orbicularis progressively sags until folds of muscle are suspended across the lid, emulating gathered bunting. Some patients cite a history of familial occurrence of these folds. This phenomenon can affect any part of the upper or lower eyelid. However, the unmodified word festoon, without anatomic specification, has come to refer most often to sagging of the orbital and malar segments of the orbicularis oculi muscle of the lower eyelid.

Commonly, protruding intraorbital fat and septum accompany festoons; however, occasionally, festoons are composed solely of muscle and skin. Corrective surgical steps are directed at tightening the slack muscle and skin.

Occasionally, iatrogenic festoons occur. If skin with diminished elasticity is subjected to a temporomalar lift, the changes in the geometry and biomechanics of the advancing skin cause a redundancy that the inelastic structures may not be able to accommodate. Such festoons can be minimized by a concomitant or subsequent lower blepharoplasty, which incorporates carefully calculated skin or skin/muscle undermining and excision. The proclivity for induced festoon formation can be identified during the initial examination. This allows both the patient and the surgeon to be prepared.

Malar mounds

A malar mound is a discrete, stable prominence of skin and fat that bulges directly outward from the malar prominence. In younger patients, malar mounds are subtly delineated. Precursors of mounds are occasionally observed in children. In older patients, the mounds are more prominent. With aging, creases delineate the upper and lower borders of malar mounds. The creases form an acute angle, with the apex over the medial canthal area. The creases diverge as they pass over the malar eminence. Tracing laterally, the widening convexity of the mound fades into the convexity of the cheek, with only a suggestion of the furrow where the 2 convexities meet.

Protruding intraorbital fat

Bags or pouches of the lower eyelids and heavy or hooded upper eyelids occur when intraorbital fat bulges forward against an attenuated orbital septum. Castanares' term herniated intraorbital fat indeed has merit. Palpebral bags are the most common aesthetic problem observed in eyelids, excluding laxity of the skin alone.

A combined palpebral bag and festoon forms when bulging intraorbital fat protrudes into the muscular hammock. When the orbicularis oculi contracts, the fat is compressed into the orbit.

Epidemiology

Frequency

Among patients who seek consultation for advanced aging changes of the eyelid-orbit area, an estimated one tenth have significant malar mounds and one twentieth have significant festoons. The incidence increases with the severity of aging changes. In virtually all of these patients, protruding intraorbital fat is part of the problem.

Etiology

See also Problem.

Over time, the aging process of the periorbital area is marked by attenuation and atrophy of connective tissue structures, muscles, and skin, resulting in a multitude of undesirable changes. Some of these changes cause functional problems, some cause aesthetic problems, and some cause a combination of both. If skin and muscle are disproportionately affected, festoons occur. If the orbital septum is lax, protruding palpebral bags occur; in the presence of festoons, a combined palpebral bag/festoon results. If the pattern of fibrous-retaining elements in the malar area predisposes to malar mounds, these mounds become increasingly evident as time passes.

A study by Mally et al suggested that gravity-associated volume displacement is a more important factor than volume loss in periorbital and midfacial aging. The investigators found that in persons with signs of midfacial aging, assumption of a supine position restored a more youthful appearance as measured using various anatomic features—including brow position, tear trough length and depth, steatoblepharon, cheek volume, malar mounds/festoons, and nasolabial folds—with more volume seen midfacially and periorbitally than when subjects were in an upright position.[5]

Pathophysiology

See Etiology.

Presentation

See also Problem.

Two steps in the clinical evaluation of festoons are the squinch test and the pinch test.[6] If the patient with festoons forcibly contracts (squinches) the orbicularis oculi muscle, the laxity of the muscular component of the festoons is overcome and the muscle component is no longer obvious. Only the skin demonstrates persisting redundancy. Even protruding intraorbital fat disappears as the taut orbicularis forces it back into the orbit.

As an aid in evaluation, the redundant skin of the festoon is grasped between the index finger and thumb and the laxity of the skin is judged with gentle traction; this is performed in both a relaxed state and with the orbicularis contracted. This pinch test is a means of judging the magnitude of the redundancy of skin and muscle as a unit before the orbicularis is contracted and a means of judging the laxity of the skin alone when the muscle is taut. In addition, if gentle lateral traction is similarly applied with the thumb and forefinger, passively tightening the festooned skin, the surgeon can judge the probable response to surgery and can gain insights for his or her surgical technique.

Indications

If palpebral or malar festoons, mounds, or bags create an appreciable aesthetic defect in a psychologically and physically sound patient, surgical correction is a gratifying procedure for both patient and surgeon. If the connective tissue supporting structures of the lids is weak, lateral canthal support must be provided as part of the procedure.

Evaluation should include a search for other problems associated with aging periorbital structures, such as involutional ptosis, senile ectropion, senile entropion, trichiasis, dry eye, or epiphora. A complete ophthalmologic examination is an important step, as is clearance by the patient's personal physician.

Relevant Anatomy

Festoons

The positions of the festoons are designated by the level of the affected orbicularis oculi, ie, (1) upper eyelid, (2) lower eyelid (pretarsal), (3) preseptal, (4) orbital, and (5) malar (see the image below).

Sites of festoons include (A) upper lid, (B) preta Sites of festoons include (A) upper lid, (B) pretarsal, (C) preseptal, (D) orbital, (E) malar, and (F) cutaneous dewlap (no muscle).

Commonly, a festoon of the upper eyelid is formed from a single muscle fold composed of pretarsal, preseptal, and some orbital orbicularis fibers. Upper eyelid festoons hide the lid fold and burden the lashes with extra weight, often causing mechanical blepharoptosis and constriction of the upper and lateral visual fields. Some pendulous festoons sag beyond the eyelashes, obstructing the visual fields even more.

Individual festoons of the lower eyelid may involve any single level or a combination of levels; all levels may sag in a cascade of festoons with overlapping folds.

If the orbital septum is firm and the orbital fat does not bulge, the festoon may be composed of muscle and skin alone, without orbital fat. Occasionally, a dewlap of lax skin alone sags even lower than the muscle festoon.

The pathologic anatomy of festoons can be observed in the operating room by elevating a skin flap to expose the anterior face of the lax bundles of orbicularis muscle. The author's current technique consists of exposing the anterior face of the orbicularis only minimally; therefore, demonstration of the pathologic anatomy of the festoon is no longer a routine part of the operation. Bear in mind that significant branches of the facial nerve pass near the deep surface of the orbicularis, particularly where the orbicularis overlaps the origin of the zygomaticus major. When the selected sector of muscle is excised, the deepest layer of orbicularis muscle fibers and the attached orbicularis fascia are kept intact to protect the vulnerable nerve branches.

Malar mounds

Malar mounds are pillowlike, somewhat triangular soft tissue convexities that project from the malar eminence. The upper border of the mound is outlined by a curving transverse fold or groove, the orbit-cheek fold, which delineates the structures of the orbit from those of the cheek. The inferior border of the mound is marked by the midcheek fold. This fold, or groove, separates the malar eminence and malar mound from the fat pad of the cheek and other soft tissues. Starting from the medial-canthal area, the midcheek fold crosses the cheek obliquely and downward, bisecting the cheek. These 2 folds diverge from medial to lateral (cheek eminence). They impart an underlying triangular configuration on the rounded malar mound.

Malar mounds present a morphologic spectrum that ranges from a shadowy hint of a bulge to a large pendulous bag, sagging below the edge of the orbicularis, to an occasional medial blending with an even more saggy malar festoon.

Fine connective tissue fibers anchored in the deep malar fascia travel outward through the suborbicularis fat, the orbicularis oculi muscle, and the subcutaneous fat and gain purchase in the deep dermis. Some appear to be fine telae subcutaneae. These fibers support and shape the malar mound. Pessa, in his anatomic study of the orbitomalar region, identified a specific connective tissue band, the malar septum, that delineates the inferomedial aspect of the malar mound.[4] After orbital trauma, the malar septum arrests the migration of ecchymotic fluid beyond the orbital area, creating the typical pattern of a black eye.

If upward traction is applied to the cheek and the temple, the malar mounds are flattened. Similarly, upward traction from a facial rhytidectomy may flatten a malar mound if the lift is substantial and the mound has been released from underlying connective tissue fibers.

The orbicularis oculi and malar mounds are related anatomically. Peripheral fibers of the orbital portion of the orbicularis oculi traverse the base of the malar mound. Furrows, fenestrations, and defects often characterize the orbicularis fibers in the region of the muscle; even orphaned muscle segments isolated from the main muscle belly have been recorded. The associated malar fat is firmly attached to the outer face of the orbicularis. When the muscle-fat interface is separated, the surface of the fat shows finely lobulated ridges and nubbins that match the contour defects of the muscle. Where the muscle is fenestrated, fat penetrates the aperture and subcutaneous fat blends with the subjacent suborbicularis orbital fat.

When only the cephalad portion of the mound is traversed by orbicularis, the fat in the remainder of the mound presents a confluence of subcutaneous and orbicularis fat. These may be incidental morphologic findings. Conversely, they may contribute to the shape or stability of the mounds—a point not determined at this time.

Palpebral bags

The upper eyelid has 2 fat compartments, medial and central. The lower eyelid has 3, medial, central, and lateral. The medial compartments of the upper and lower lids contain pale-yellow fat with multiple complex lobules, which is continuous with the fat surrounding the ocular globe. The upper and lower medial fat pads appear to truly herniate through a small aperture in the orbital septum.

The fat of the medial and lateral compartments has a deeper, richer yellow hue. The lobules of fat are larger, and most have simple ellipsoid or spherical shapes. The fat of this compartment is confined to the anterior orbit. The fat of the central compartment bulges forward against the septum rather than truly herniating. In the lower lid, the inferior oblique muscle separates the medial compartment from the central compartment. The central compartment of the upper lid has similar fat.

The lateral compartment of the lower lid is small and is on a higher level than the central compartment. The character of the fat and the bulging configuration are similar. In the upper lid, the fat of the medial compartment extends well laterally but does not occupy a separate compartment. The lacrimal gland usually lies just posterior to this lateral extension of fat.

Contraindications

A pathologic condition of the eyelids or orbital structures is a contraindication for blepharoplasty, but the patient's ophthalmologist may be able to overcome the problem with treatment or protective measures.

Medical conditions that may jeopardize the patient's response to anesthesia or sedation or that may interfere with the patient's healing response are relative contraindications. The surgeon's sense that the patient has unrealistic expectations about the surgery, despite explanations, is a reason to hesitate and to proceed only if this issue is corrected.

 

Treatment

Medical Therapy

A retrospective study by Godfrey et al indicated that doxycycline hyclate injections (10 mg/mL) can significantly reduce lower eyelid festoons and malar edema. Eleven patients (20 treatment areas) with malar edema and/or festoons underwent an average of 1.4 injections per side, with the mean volume per injection being 0.72 mL. Using a grading scale of 0-3, representing a range from no festoon to large festoon, the investigators found, at mean 22.5-week follow-up, that the average festoon grade had fallen from 2.5 to 0.9.[7]

Surgical Therapy

Surgical treatment of festoons is directed at improving the tone of the orbicularis oculi muscle by taking up the redundant muscle in a way that avoids compromise of muscle function. Excision and closure of a wedge of excess orbicularis oculi muscle is the basic step.

Initially, this author imbricated the wedge of orbicularis, but the muscle folds added unnecessary bulk; thereafter, a carefully plotted orbicularis myectomy was used. Isse developed a strategy of treating festoons of the upper eyelid (hooded eyelid); endoscopically, he separated the skin from the orbicularis muscle down to the superior tarsal border. He then elevated the lateral brow; consequently, the skin, freed from the muscle, became seated at a higher level, unfurling the festoon. No eyelid incision was used.

Malar mounds are improved or completely effaced by procedures that elevate and tighten the soft tissues of the malar area. The temporomalar portion of a facelift can serve this purpose. A study by Makhoul et al indicated that malar mounds can be treated by direct incision. In a case series of eight patients, the investigators found high patient satisfaction with the results and no scleral show, ectropion, or hematoma.[8]

Concomitant to a lower blepharoplasty in which the lateral canthus is secure, the incision can be extended laterally and a modest lenticular excision of orbitotemporal skin can be performed; in a properly selected case that is carefully planned, closure of the wound generates enough skin tension to efface the festoon.

Protruding palpebral fat, particularly if present in great excess, is still excised by modifications of Castanares' operation; however, a transconjunctival incision in the inferior fornix is often chosen as the approach, avoiding a skin incision. Instead of removing intraorbital fat, Hamra separates the orbital septum from the bony rim and translocates some of the fat from the orbit to the concavity that is often present between the lower orbit and the cheek. A number of innovative blepharoplasty techniques have been developed recently in which the basic strategy is to tighten or strengthen the orbital septum to restrain the bulging fat.

Preoperative Details

Preoperative photographs

During the initial office visit, the eyelids are photographed to record the patient's problem and for preoperative study. Full-face, three-quarter, and profile views; a full-face view with oblique lighting from above; and a full-face view with the orbicularis oculi contracted (eyelids squinched) comprise the basic set. In addition, photographs of preoperative markings are useful for reference in the operating room.

Markings

Prior to preoperative sedation, the patient is seated and the operative plan is marked out with a gentian violet marking pen. The patient's head is upright, oriented in the line of gravity. The surgeon manipulates the eyelid and periorbital skin with fingers and forceps, estimating tension and observing side effects; incision and excision lines are marked. Excision of skin and muscle of the upper eyelid is plotted to correct mechanical ptosis and to clear the visual fields.

The area of skin-muscle excision is wider and longer than that of the usual blepharoplasty; occasionally it includes the lower lateral aspect of the eyebrow. If brow ptosis is a significant component, Flowers' advice is heeded. He urged surgeons to plan a browlift as the primary surgical step for hooded upper eyelids (festoons) associated with ptotic brows. Then, any persisting festoons are addressed.

In the lower eyelid, a subciliary incision line is marked 2-3 mm below the lash line. At the meridian of the lateral canthus, the line angles laterally and downward, parallel to the skin creases. This lateral extension forms the upper border of a segment of skin to be excised. The size, shape, and position of the skin excision and the orbicularis myectomy are carefully planned. With severe festoons, the excised skin may take the form of a wedge 25-30 mm in length and 8-10 mm in width. Only a modest amount of pretarsal skin is marked for excision. An oblique chord is drawn across the base of the lateral wedge. This marks the pilot cut with which the skin excision plan is tested during surgery. The lower border of the lowest festoon is marked as a guide to undermining.

If concomitant procedures such as a brow lift and face lift are to be included, the biomechanical and geometrical interplay between the orbital field and other facial fields are taken into account.

Preparation

A coaxial fiberoptic headlamp and 4.5X loupe aid in visualizing the surgical anatomy. Corneal protectors are placed. The preoperative markings are gently dabbed with aqueous povidone-iodine solution (Betadine), avoiding any smudging of the marks. A small amount of local anesthetic solution is infiltrated. The markings are scored with a blade to prevent erasure. The eyelids, face, and neck are prepared with aqueous Betadine. Sterile drapes are placed.

Intraoperative Details

Upper eyelid operative technique

The surgeon performs his or her preferred steps for an upper blepharoplasty. Pretarsal muscle is preserved. The outline and depth of the excision of the preseptal and orbital fibers is an individual judgment for each patient; however, usually the outline of the muscle resection delineates a somewhat smaller area than the outline of the skin excision. Judgment as to excision of lateral fibers of orbicularis oculi of the upper lid is based on the need for reducing bulk, not on increasing muscle tone. Layered closure completes the upper blepharoplasty.

Lower eyelid operative technique

The lower eyelid incision parallels the lash line. At the area of the lateral canthus, it angles downward and laterally, following the markings. The outer face of the orbicularis is exposed in 2 areas. The pretarsal fibers are exposed in preparation for elevating a skin-muscle flap from the orbital septum. The anterior face of the inferolateral orbicularis is exposed far enough that the orbicularis myectomy can be performed safely and effectively under direct vision. A split-level dissection is developed. Elevation of the skin-muscle flap is begun at the lower border of the pretarsal orbicularis. Scissors-spreading dissection develops the interval, separating the pretarsal muscle fibers from the preseptal muscle fibers. Bridging neurovascular bundles are cut with bipolar cautery.

The medial part of the final field is a skin-muscle flap, and the lateral part is a skin-only flap. These 2 flaps overlap each other centrally, with a bridge of bare orbicularis oculi intervening. Where the skin-only flap overlaps the skin-muscle flap, the bare segment of orbicularis oculi forms a partition between the 2 dissection pockets. This segment is readily retracted, and its mobility allows visualization of both fields.[9]

Segmental myectomy/myorrhaphy of the orbicularis oculi

The segment of orbicularis muscle to be excised is plotted. The excision is centered on an axis crossing the orbicularis approximately at the 8-o'clock position on the right lower eyelid and the 4-o'clock position on the left lower eyelid. With 2 pairs of forceps, the orbicularis is gathered and folded along the proposed myectomy axis. The effects of this maneuver on the festoons and on the surrounding structures are studied. The best axis (eg, 7:30-, 8:00-, 8:30-position) and the best pattern for muscle excision (eg, rectangle, trapezoid, triangle) are chosen, and the plan is marked out with methylene blue. The orbicularis is excised as marked, removed layer by layer, and tested for the effect of approximating the edges until only a thin layer of muscle fibers and the deep orbicularis fascia remain.

The cut edges of the orbicularis muscle are approximated with simple and horizontal fine monofilament mattress sutures. Immediate effacement of the festoons is observed.

Canthal suspension suture

If a skin-muscle flap has been elevated as part of the procedure, a canthal suspension suture is placed from the most convenient part of the cut edge of the orbicularis to the periorbita of the lateral canthal area with fine polypropylene or nylon sutures. Alternatively, dermis rather than orbicularis may be suspended from the lateral canthus. The needle is passed through the dermis several millimeters below the edge of the skin incision (where thicker dermis is engaged). If the overall connective tissue support to the lower lid is exceptionally lax, then a formal lateral canthopexy, or lateral canthoplasty such as a Jelks dermo-orbicular pennant flap, is performed.

Skin closure

A pilot cut is made in the skin flap of the lower lid, guided by the initial skin markings. A trial suture is placed subcutaneously, closing the skin wedge. The tautness of the lid and the level of the lid margin are adjusted as needed. Closure of the lateral wedge is completed with fine absorbable sutures, and the skin is closed with a continuous 7-0 monofilament polypropylene suture.

Correction of orbicularis festoons concomitant to a facial rhytidectomy

When a transverse facial wedge excision is incorporated in the rhytidectomy plan, festoons can be corrected with great effectiveness. The lower eyelid incision is placed slightly lower than usual. The skin excision pattern of the cheek and eyelid is altered to minimize encroachment of the thicker cheek skin on the eyelid. An orbicularis myectomy-myorrhaphy is performed as usual.

Hamra has described alterations of the aging orbicularis muscle of the lower eyelid by means of access through a standard facelift incision combined with a lower eyelid incision.

Intraorbital fat

If intraorbital fat protrudes, it is addressed by conventional fat excision or septal reinforcement. If the preaponeurotic fat demonstrates no bulging, the surgeon simply proceeds with the orbicularis myorrhaphy and superior lateral skin advancement as described below.

Malar mounds overview

Usually, the surgeon corrects a malar mound as an incidental step with a blepharoplasty, a facial rhytidectomy, or other facial aesthetic procedure. However, in certain advanced malar festoons associated with advanced malar mounds, the 2 structures coalesce and correction of the mound is integral to correction of the festoon.

Effacement of the malar mound by indirect skin stress

The author's approach to malar mounds is an evolving one. One step that has proved effective is excision and closure of skin that is superior and lateral to the malar mound as part of a facial rhytidectomy or a lower blepharoplasty procedure. This transmits force to the skin of the malar mound. If the stress is sufficient (not much is needed), the malar mound flattens. Dividing the fibrous connections between the subcutaneous fat of the mound and the underling fascia allows more effective effacement of the mound by the indirect stress.

The author has also performed the added steps of directly altering the soft tissues of the mound. The procedure involves closing the gaps and grooves of the orbicularis oculi muscle, trimming the corresponding ridges and knobs of subcutaneous fat, and cautiously thinning the subcutaneous fat of the mound. At the time of this writing, the effectiveness of these maneuvers remains uncertain.

Liposuction by needle aspiration appears to be a useful means of flattening a protruding festoon, but the author has no experience with this technique.

Postoperative Details

The postoperative regimen for these patients is identical to that of patients undergoing blepharoplasty. Protective ophthalmic ointment such as Lacri-Lube is applied at night, and artificial tears are applied as needed during the day. Skin sutures are removed at 5-7 days, and subcuticular sutures are removed at 7-14 days. Steri-Strip supports are applied as needed.

Follow-up

The patient is examined at 1 week, 1 month, 3 months, 6 months, and 1 year and as needed thereafter. Progress is recorded with standardized photographs.

Complications

Residual or recurrent festoons

An occasional complication has been persistence or reappearance of a vestige of the original festoon. Possible causes are inadequate resection or undermining of skin, failure to release orbicularis attachments, or hyperextensibility of the skin and muscle.

The author's mainstay in correcting residual festoons is reexcision of a wedge of skin at the same site as the original skin wedge. The lateral limb of the previous closure line is marked as the superior border of the skin wedge. The dimensions of the wedge are judged in the same manner as in the primary procedure. The plane of dissection, the amount of undermining, and the manner of dealing with the orbicularis are judged on a case-by-case basis. Occasionally, a residual festoon defies secondary revision, and the problem is solved by direct excision using external incisions. Patients in whom the festoons are this resistant to treatment usually have sufficient imperfections in the skin such that the scar is imperceptible.

Residual or recurrent malar mounds

Residual malar mounds have been the most common complication. Repeat excision of lateral skin wedges with limited skin undermining and superolateral advancement of the lax eyelid/cheek skin usually correct the problem. Direct excision has been performed (once).

Outcome and Prognosis

Palpebral festoons, malar mounds, and palpebral bags occur in a number of configurations and combinations. The patient's appearance can virtually always be helped by a carefully planned and executed surgical procedure. The countenance of some patients can be dramatically improved.

Future and Controversies

The surgeon should never forget that eyelid surgery is orbital surgery and an error in judgment or technique is potentially catastrophic. The photographs of the patient and the diagrams of the proposed operation should be studied again by the surgeon in the operating room, and the photographs should be placed where the surgeon can refer to them during surgery. If the photographs are in view of the anesthesiologist and the surgical staff, extra interest in the conduct of the procedure is generated and additional observers can help judge if the basic orientation is correct.