Festoons, edema, and malar bags: is there a consensus on aesthetic treatment?
Festoons, edema e bolsas malares: existe consenso no tratamento estético?

INTRODUCTION

Aesthetic interventions in the face have been increasingly sought after by patients in the context of plastic surgery, improving the facial contour, and returning the harmony and beauty of the face without losing naturalness¹. Data from the American Society for Aesthetic Plastic Surgery (ASAPS) 2017 and the Sociedade Brasileira de Cirurgia Plástica (SBCP) 2016 show that in recent years approximately two hundred thousand surgical procedures have been performed such as blepharoplasty and facelift and more than one million noninvasive procedures on the face as the application of botulinum toxin and hyaluronic acid^1,2.

The periorbital region’s rejuvenation has gained prominence in recent years and ranges from the treatment of the eyebrow area to the transition orbital-malar, where the festoons, edema, and malar bags are found. Periorbital changes are one of the earliest detectable signs of aging, but this region is still very neglected because it manifests pathologies that exhibit complex resolutions.

Besides, the region has a variable terminology that hinders diagnosis and treatment. However, more relevant than knowing nomenclature is to know the region’s anatomy, remembering the three main structures involved in the degeneration that occurs with aging: the orbicularis muscle, the orbital-malar ligament and the cutaneous zygomatic ligament (Figure 1). The malar edema is a fluid accumulation on the malar eminence, the malar bag is represented by chronic edema of permanent soft parts and the festoons are an accumulation of cascading skin³.

Figure 1 - Anatomy of the periorbital region.

Figure 1 - Anatomy of the periorbital region.

In this way, anatomical knowledge and current changes in behavior in the face of festoons, edema and malar bags can help in better management. Thus, surgical treatments associated with new invasive and noninvasive treatments lead to the best proposed aesthetic result, respecting the clinical condition and the will of each patient, with the plastic surgeon’s joint decision.

Thus, this study aims to conduct a systematic literature review on the current types of treatments for festoon, edema, and malar bags correction, dealing with invasive and noninvasive techniques. The objective is also to state the main advantages and disadvantages of each technique, besides proposing a modernized treatment algorithm, since there are few studies on the subject.

METHODS

This is a literature review limited to Pubmed database, Cochrane, and LILACS in English and Portuguese between 2014 and 2019, using the following descriptors: “bolsa malar,” “malar mounds,” festoons” and “malar bags. “ Exclusion criteria were: publications without full access, repeated by overlapping the keywords-key, not directly related to the theme, before 2014 and languages other than Portuguese or English. Two independent reviewers conducted the initial research of articles and subsequent selection.

All research information was tabulated in a spreadsheet for statistical data analysis.

This review is supplemented with photos of patients to illustrate some types of treatment, but they are not identified, and their personal information is also not present. Thus, this work does not require approval in the Research Ethics Committee, although the principles of the Helsinki Declaration of 2013 were followed.

RESULTS

The original research yielded 58 records, of which 23 duplicates were removed, leaving 35 articles for the first phase of screening (Figure 2). After title review and summary to determine relevance on the treatment of festoons, edema, and malar bag, 13 were eligible for full-text revision and listed in Chart 1.

Figure 2 - Organization chart of the articles search.

Figure 2 - Organization chart of the articles search.

Chart 1 - Articles of interest with the main variables.

Most studies were retrospective reviews (76%), three prospective interventionists (23%), and only one systematic review. The types of techniques employed varied among invasive options (46.15%) and noninvasive (53.85%), being represented by the use of Kinesio tape, local injection of antimicrobial, injection of hyaluronic acid, microneedling with radiofrequency, microaspiration, myocutaneous flap, subperiosteal lift of the middle face and direct excision. The findings were as follows:

Invasive treatment

The invasive treatment of malar and festoon bags can range from the myocutaneous flap to the direct excision of excess skin. The choice of a given type of surgical procedure depends on the correct diagnosis, the patient’s age, and the pathologies’ associations, among other variables.

Microsuction

Two articles focused on using this technique to treat patients with edema and malar bag. Superficial liposuction is performed to the orbicularis muscle in the subcutaneous plane. The care required is to avoid skin perforations and irregularities in the facial contour¹¹.

Myocutaneous flap - orbicular muscle skin

The most performed surgical modality in the studies (38.46%) is indicated for patients with malar bag and mild to moderate festoons¹¹-¹³. A subciliary incision is performed, myocutaneous flap dissection to the orbital edge and removal of excess skin (Figures 3 and 4)¹¹. Among the complications observed in the studies, we can have ectropion in up to 4% of cases and hematoma in 3%.

Figure 3 - Muscle-skin flap, subciliary incision.

Figure 3 - Muscle-skin flap, subciliary incision.

Figure 4 - Myocutaneous flap technique: A. Preoperative marking; B. Representing orbicularis muscle (white arrow) and lower orbital edge (blue arrow).

Figure 4 - Myocutaneous flap technique: A. Preoperative marking; B. Representing orbicularis muscle (white arrow) and lower orbital edge (blue arrow).

Middle face subperiosteal lift

In two studies, the indication of this technique was described for patients with festoons. Three routes can perform this: temporal, transpalpebral, or endoscopic assisted video. All techniques aim to make the resuspension of the orbital-malar ligament and suspension of the soft tissue. The difference is that in the first technique, the access is made by the temporal region, in the second by the lower eyelid, and in the third, an incision is made in the temporal region and the oral mucosa. The disadvantage of the video-assisted technique is the fact that it presents a longer learning curve, longer surgical time, besides attending with approximately 25% of oral wound dehiscence. On the other hand, the transpalpebral route may present hematoma more frequently and the temporal access route^3,14.

Direct excision - in canoe

As discussed in three articles, such a procedure is also indicated for patients presenting severe festoons. The incision is made in the festoon’s demarcated area in the form of a canoe or ellipse, and excess skin is removed. As the scar is evident, it is better indicated in older adults. Lagophthalmos and ectropion are the main complication^3,15.

DISCUSSION

Since 1978, when Furnas first described “festoons”, the terms used to describe edema or excess tissue immediately below the infraorbital border within the pre-zygomatic space are variable. As all three anomalies (edema, malar bag, and festoon) cause lumps, we propose the following definitions to describe this broad anatomical problem: malar edema is an accumulation of fluid on the malar eminence that often varies in severity and can worsen after salty meals or in the morning. The malar bag is chronic edema of soft tissues in the pre-zygomatic space, which contains fat or orbicularis muscle due to descent or hypertrophy, and may be congenital. On the other hand, festoons are loose-skin cascade nets and orbicularis muscle below the infra-orbital edge (Figure 5), may also contain herniated or ptotic fat and accumulate edema. They are often found in older adults and represent a progression of the entities described above¹⁶.

Figure 5 - A. Representation of malar bag; B. Malar festoon.

Figure 5 - A. Representation of malar bag; B. Malar festoon.

The treatment of festoons, edema, and the malar bag is complex, involves diverse pathophysiology and inconsistency of terminology. The choice of an erratic approach will leave patients dissatisfied and with poor aesthetic results. Thus, treatment should be individualized, based on size, content (edema, fat, skin, and muscle), patient preference, and knowledge of the plastic surgeon. The choice of only non-surgical procedures should be made cautiously, as it presents limited results if poorly indicated. Kinesio tape was used in the treatment of festoons, but its mechanism of action is based on the improvement of lymphatic drainage, being better applied in malar edema or after surgeries as an adjuvant to minimize postoperative edema and ecchymosis⁴. Similarly, radiofrequency microneedling without association with other techniques would not be the best choice for the treatment of festoons, because despite causing a potential reduction of fat and decreased sagging skin in the lower eyelid, it is not enough to bring the best outcome to the patient¹⁰.

On the other hand, the use of antimicrobials, according to Perry et al., in 2015⁵, seems to produce activity similar to growth factor, stimulating the proliferation of fibroblasts, as well as collagen production and fibrin deposition. Thus, tetracycline 2% or doxycycline 10mg/ml between the orbicularis muscle and deep fascia can improve the repair of the periorbital surface, however, with a poor result in the correction of festoons and severe malar bag because it already contains excess skin^5,6. The use of hyaluronic acid is controversial because, at the same time, it can mask an irregular contour in the periorbital region can also aggravate malar edema in some cases, especially if hydrophilic, with possible involvement of lymphatic drainage⁸.

Besides, periorbital fat atrophy and malar bone resorption contribute to the loss of the lower periorbital area’s structural support. It is believed that medial and lateral resorption of SOOF(suborbicularis oculi fat) and the regeneration of ligaments and orbicularis leads to loosening the ceiling of the pre-zygomatic space, contributing to the pathogenesis of periorbital aging^3,14. Thus, surgical techniques aim to restore the region by acting more anatomically with more predictable and lasting results. The choice of a specific technique over another depends on existing skin excess, patient age, and especially the surgeon’s proximity to the surgical procedure. Microaspiration in the periorbital region acts in such a way as to prevent the malar bag progression to the festoons, besides leading to a local fibrosis and face contour improvement³. The myocutaneous flap, subperiosteal lift, and direct excision rejuvenate the periorbital region by acting on the ligament, muscle regeneration, and excess skin. However, the complications inherent to surgical techniques are more feared and more challenging to treat when compared to less invasive techniques.

Thus, an algorithm is brought in an attempt to minimize doubts, facilitate the interpretation and choice of treatment in the face of a case of periorbital rejuvenation (Figure 6). It is noteworthy that despite the numerous invasive and noninvasive techniques, a single approach is not revolutionary. Thus, most often, repetitive treatments and a combination of techniques are necessary, leading to an increase in the cost and postoperative recovery time¹⁴. Furthermore, studies on the subject are deficient, mainly in Portuguese (found only one in this review), because these are studies at grade IV and V levels, limiting critical analysis and highlighting the need for higher quality studies.

Figure 6 - Algorithm for edema, bag and malar festoon treatment.

Figure 6 - Algorithm for edema, bag and malar festoon treatment.

CONCLUSION

There are numerous techniques for treating festoon and malar bags, but it is up to the plastic surgeon to know its advantages and disadvantages to decide the most appropriate for each type of patient. Therefore, there is no consensus, but it is essential to diagnose correctly and remember that the association of techniques may be the best treatment.