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Outcomes of Surgical Treatment of Malar Mounds and Festoons

  • Original Article
  • Oculoplastic
  • Published:
Aesthetic Plastic Surgery Aims and scope Submit manuscript

Abstract

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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Funding

The authors did not receive any funding for this study. They have no financial disclosures and report no conflicts of interest.

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Authors and Affiliations

  1. Department of Plastic and Reconstructive Surgery, Cooperman Barnabas Medical Center, 101 Old Short Hills Road, Suite 504, West Orange, Livingston, NJ, 07052, USA

    Mokhtar Asaadi

  2. Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA

    Colette B. Gazonas, Christopher James Didzbalis & Anthony Colon

  3. Napa Solano Plastic Surgery, Napa, CA, USA

    Bao Ngoc N. Tran

Authors
  1. Mokhtar Asaadi
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  2. Colette B. Gazonas
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  3. Christopher James Didzbalis
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  4. Anthony Colon
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  5. Bao Ngoc N. Tran
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Correspondence to Mokhtar Asaadi.

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Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file 1: Video 1 Demonstration of anterior septal fat beneath orbital orbicularis of lower eyelid in patient with congenital festoons

Supplementary file 2: Video 2 Direct excision of anterior septal fat from the undersurface of orbital orbicularis

Supplementary file 3: Video 3 Demonstration of orbital orbicularis of lower eyelid in patient without anterior septal fat

Supplementary file 4: Video 4 Demonstration of blunt finger dissection

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Asaadi, M., Gazonas, C.B., Didzbalis, C.J. et al. Outcomes of Surgical Treatment of Malar Mounds and Festoons. Aesth Plast Surg 47, 1418–1429 (2023). https://doi.org/10.1007/s00266-023-03381-4

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