Etiology and Treatment of Congenital Festoons.

[BACKGROUND] Festoons and malar bags present a particular challenge to the plastic surgeon and commonly persist after the traditional lower blepharoplasty. They are more common than we think and a trained eye will be able to recognize them. Lower blepharoplasty in these patients requires addressing the lid-cheek junction and midcheek using additional techniques such as orbicularis retaining ligament (ORL) and zygomaticocutaneous ligament (ZCL) release, midface lift, microsuction, or even direct excision (Kpodzo e al. in Aesthet Surg J 34(2):235-248, 2014; Goldberg et al. in Plast Reconstr Surg 115(5):1395-1402, 2005; Mendelson et al. in Plast Reconstr Surg 110(3):885-896, 2002). The goal in these patients is to restore a smooth contour from the lower eyelid to the cheek. The review of literature shows the need for more than one surgery for treatment of the festoons (Furnas in Plast Reconstr Surg 61(4):540-546, 1978). One of the reasons WHY these cases are so challenging is that the festoons tend to persist even after surgical treatment. As Furnas said, "Malar mounds have acquired some notoriety for their persistence in the face of surgical efforts to remove them" (Furnas in Clin Plast Surg 20(2):367-385, 1993). This could be due to different etiology between acquired and congenital festoons. There are currently no cases of congenital festoons described in the literature. In the last 10 years, we have treated a total of 59 patients with festoons or malar mounds. We used the terminology of festoon for acquired cases and malar mound for congenital ones (Kpodzo et al. 2014). We were successful with treating 56 patients who developed acquired festoons later on in life; however, three cases required an additional treatment to improve residual puffiness that they had after the first operation. From the above findings, we hypothesized that there should be something common in patients with congenital festoons or malar mounds which are different from acquired festoons. All of these three patients had one thing in common, and that was a history of puffiness of the prezygomatic space since childhood. Each of these patients expressed that these conditions have been present since a young age but became worse with aging over time. To date, there are no descriptions of the cause or treatment for congenital festoons. Here, we present the first case series of three patients with congenital festoons. We discuss the possible etiology of congenital festoons, the physical exam, and the surgical approaches.

[METHODS] We performed a retrospective review of 59 patients who had surgical correction of festoons in the past 10 years, three of which were presented since childhood. In this paper, we will discuss the pathophysiology and the surgical treatments for congenital festoons. Only patients with festoons present since birth were included. The first two cases were treated with a subciliary blepharoplasty with release of the orbicularis retaining and zygomaticocutaneous ligaments and midface lift with canthopexy and orbicularis muscle suspension. The third case had a subciliary lower blepharoplasty approach, skin, and muscle flap and direct excision of the fat through the orbicularis from the subcutaneous space. In addition, each patient required further treatments to address supra-orbicularis fat by various methods.

[RESULTS] All patients with acquired festoons had successful results with one operation by subciliary skin muscle flap, release of the ORL and ZCL, midface lift, and muscle suspension. All three patients with congenital festoons had residual puffiness that required surgical and non-surgical treatments. There were no complications. Our first case required three surgical treatments for complete correction. The second and third cases required Kybella injections after their initial surgical treatments. The specimen of the first patient, Fig. 10, who had direct excision, showed localized fat collection immediately under the skin and above the orbicularis oculi muscle.

[CONCLUSIONS] Correction of congenital festoons or malar mounds requires a combination of subciliary lower blepharoplasty with skin muscle flap, midface lift, and orbicularis muscle suspension, as well as addressing the supra-orbicularis fat via direct excision, off-label Kybella injection or liposuction.

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