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What are Malar Mounds and Festoons and How to Get Rid of Them

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What are Malar Mounds and Festoons?

There are many theories on the cause of festoons, and several terms are used to describe the puffiness often seen along the lower eyelid.  Festoons are below the lower eyelid, a swollen area appearing as a mound, bump or sagging skin around the cheekbones.

There is a standard definition to describe the fullness under the lower eyelid, and it is important to distinguish the difference in order to increase the chances of correcting the problem.

  • Malar edema is often used to describe a fluid collection over the lid and cheek junction.
  • Malar mound is a term used to describe a chronic soft tissue swelling over the cheek.
  • Festoons are sagging skin or folds of skin at the top of the cheek.  Festoons are caused by lax skin and a weakened lower eyelid muscle and often begin as Malar mounds.

There is much debate regarding the use of this terminology, but the triangular shape seen under the eyes can actually result from a progression of malar edema, causing malar mounds and eventually resulting in festoons.

Causes of Malar Mounds and Festoons

My goal is to correctly diagnose the cause of the malar mounds or festoons so that I can recommend the best treatment option to my patient.

Festoons can be genetic and often get worse with aging, sun exposure, or smoking.  The puffiness under the eyes worsens with age because the skin’s structural support is deteriorating, and the muscles under the eyes weaken.

However, there can be other contributing factors to malar mounds and festoons.

A complete medical history is important to help diagnose the cause.  Medications such as steroids, acetaminophen and nonsteroidal anti-inflammatory drugs, among others, are known to cause swelling from fluid retention.  Allergies, rosacea, blepharitis, thyroid disease, cardiac, renal or liver disease can all contribute to malar edema.

In addition, caution must be exercised when injecting botulinum toxin A to correct deep wrinkles along the lateral eyelid or “crow’s feet.”  I have observed a number of cases where festoons have developed after botulinum toxin injections weakened the orbicularis oculi muscle enough to cause festooning.

A board-certified dermatologist’s knowledge of facial structure and musculature is critical for achieving a good result when injecting toxin or filler.  Putting filler under the eyes is a procedure most likely to be done incorrectly by an inexperienced injector, resulting in unwanted puffiness and palpable lumps.

Hyaluronic acid fillers attract water to the area in which they are injected.  Although fillers were thought to last 6-15 months, we now know that fillers can be seen in the cells and tissue at a microscopic level many years after a single treatment.

Fortunately, hyaluronic acid fillers can be reversed with an injection of an enzyme called hyaluronidase.

Treatments for Malar Mounds and Festoons

When the malar mound or festoon is caused by filler, and hyaluronidase is used to dissolve the filler, there is often an immediate effect of seeing the festoons disappear.  That was the case with the correction I did for the patient below after another injector created Malar mounds under her eyes.

The first photograph shows a case of lower eyelid edema developing as a result of hyaluronic acid gel filler injected into the tear trough or mid-cheek by another practitioner.  Most patients that I see with this type of acquired edema, even many months or years after the filler injections, do have improvement of their swelling with hyaluronidase treatment.

Also, in the before photo, you can see this patient has a post-inflammatory pigmentary change in the same area as the malar mound, which I am treating with Alastin Brightening Serum.

female patient with malar mounds before treatmentFemale patient after malar mounds were treated with hyaluronidase

Several techniques are available to treat festoons and malar bags that were not caused by filler misplacement or migration. Noninvasive techniques include microneedling with radiofrequency, CO2 laser resurfacing, and, when appropriate, injecting hyaluronic acid fillers.

RF Microneedling stimulates the skin to produce more collagen. It rejuvenates and tightens sagging skin like festoons.

Laser resurfacing with a CO2 laser encourages the skin’s natural healing process and revitalizes the area by creating better support in the skin.  It also tightens the skin by “shrinking” tissue.

Surgical treatments with an oculoplastic surgeon may be the best approach in some cases.  However, it is important to correctly diagnose the cause of the festoon in order to direct the patient to the best treatment option.

Refresh your appearance by treating your malar mounds or festoons

Begin your skin rejuvenation journey today with Dr. Cynthia Golomb at Dermatology Boutique.  Dr. Golomb is triple board certified in Dermatology, Mohs Surgery, and Dermatopathology.  She has over 25 years of general and cosmetic dermatology experience.  Patients from Aventura, Sunny Isles Beach, Bal Harbour, North Miami Beach, Pembroke Pines, Hallandale Beach, and Hollywood, FL, regularly travel to her office for cosmetic treatments.  Schedule today by calling or texting 954-251-0367 or schedule your consultation appointment online.

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