Lower Lid Festoon Blepharoplasty Treatment & Management

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


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.


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.



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.



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.