The Troublesome Triad: Festoons, Malar Mounds, and Palpebral Bags PDF

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/318042644 The troublesome triad: festoons, malar mounds, and palpebral bags Article in The Journal of Cosmetic Medicine · June 2017 DOI: 10.25056/JCM.2017.1.1.1 CITATIONS...

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/318042644 The troublesome triad: festoons, malar mounds, and palpebral bags Article in The Journal of Cosmetic Medicine · June 2017 DOI: 10.25056/JCM.2017.1.1.1 CITATIONS READS 4 13,535 1 author: kar wai Lam 13 PUBLICATIONS 14 CITATIONS SEE PROFILE All content following this page was uploaded by kar wai Lam on 07 April 2020. The user has requested enhancement of the downloaded file.  Review Article J Cosmet Med 2017;1(1):1-7 https://doi.org/10.25056/JCM.2017.1.1.1 pISSN 2508-8831, eISSN 2586-0585 The troublesome triad: festoons, malar mounds, and palpebral bags Lam Kar Wai Phoebe, MD Dr. Lam's Clinic, Kowloon, Hong Kong The ill-defined lid-cheek junction continues to be one of the most challenging regions for rejuvenation. Malar mounds, festoons or palpebral bags, may occur alone, or in combination, in the infraorbital area. These pathological variants are distinctly different and may contribute to patients’ perception of their eyebags. Traditional lower blepharoplasty (fat repositioning/ removal) with skin adjustment alone may be insufficient in addressing all of these pathologies, and recurrence may occur. This literature review aims to look at current definitions and treatment of festoons, malar mounds, and palpebral bags in Asian blepharoplasty. A Medline literature search for articles with anatomic descriptions of malar mounds, palpebral bags and festoons, particularly in Asian eyelids, was performed. This was supplemented by a manual search of the references of articles obtained. The details of all of the different surgical options for eyelid rejuvenation are beyond the scope of this review article. Thus, only the basic concepts that illustrate the anatomical relationship and the natural progression of malar mounds, festoons, and palpebral bags will be discussed in this article. Some of the treatment options, both invasive and non-invasive, will also be reviewed. There is no singular treatment for malar mounds, festoons, and palpebral bags. Standard lower blepharoplasty with skin excision is ineffective to lift and re-drape malar mounds or festoons. Repositioning of the malar septum, on the other hand, allows for resolution of the edema (malar festoons) above its cutaneous insertion. A number of liposculpturing techniques to volumize deficient areas, such as fat repositioning (cheek, suborbicularis and descended malar fat pad) with lifting of the midface, can be beneficial to restore a smooth lid-cheek junction.Non-invasive techniques like laser resurfacing and Ultherapy® (Ulthera, Inc., Meza, AZ, USA) may be useful in periorbital rejuvenation in selected cases. Keywords: festoon; malar mound; palpebral bag; orbitomalar septum; periorbital rejuvenation Introduction This, however, is insufficient to address all of these anatomical changes and to restore a youthful smooth lid cheek junction. Malar mounds, palpebral bags and/or festoons may appear Furthermore, most elderly Asian patients are not interested in alone or in combination with each other in the infra-orbital a complicated surgical procedure for periorbital rejuvenation, area. Even though these occur within same region, there is a particularly if it is uncomfortable to go through with a long pe- distinct difference between their three pathological variants, riod of recovery time. and all are likely to fall within a continuum of anatomic findings Articles in English with anatomic descriptions of malar (Fig. 1 and Table 1). mounds and festoons, particularly in Asian patients and in Standard lower bleopharoplasty is one of the treatment lower blepharoplasty procedures, as well as details of corrective modalities for what is colloquially termed as “Asian eye bags.” procedures and methods of periorbital rejuvenation were iden- Received August 30 2016, Revised March 9 2017, Accepted March 12 2017 Corresponding author: Lam Kar Wai Phoebe, Dr. Lam's Clinic, 5F Kam Shek Building, Kowloon, Hong Kong Tel: 852-2332-0166, Fax: 852-2300-1699, E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright ⓒ 2017. Korean Society of Korean Cosmetic Surgery and medicine (KSKCS & KCCS).  Lam Kar Wai Phoebe tified from the OVID Medline database (1966–2009). tural differences amongst Asian eyelids have been identified Details of the many different surgical options for eyelid reju- and discussed in recent studies [3-9]. venation are beyond the scope of this review article. However, It was observed that, morphologically, Asians in general have some of the basic concepts that illustrate the relationship be- puffier and fuller lower eyelids than do other races. Anatomi- tween anatomic contribution of malar mounds, festoons and cally, they have high levels of anterior and superior orbital fat palpebral bags and their natural progression, together with and a higher fusional location of the orbital septum with cap- some of the more contemporary procedures, which are gener- sulopalpebral fascia (CPF) as compared with Caucasians, in ally acceptable to patients, will be discussed in this article. which fibers of their CPF are sparse among the subcutaneous tissue. Other anatomical variations identified in a histological Variation in Asian lower eyelids microscopic analysis (e.g. superior extended orbital fat) were found to be attached to the inferior tarsal border in Chinese and There is no article that discusses the overall incidence, Korean eyes, but not in Japanese eyes [4,6,10]. prevalence and management of festoons and malar mounds in Asians that can be found, yet, some intrinsic anatomical struc- Festoons and malar mounds A “mound” is an elevation, and the term “festoon” describes A the hanging of tissues between two points. Festoons and malar mounds are bounded by the insertion of the orbitomalar septum, which extends caudally in the lateral half of the lid-cheek junction, and then curves upward and lat- eral to the outer canthus. This also outlines the caudal margin of an elliptical portion of the superior lateral cheek fat. The orbitomalar septum (Fig. 2) acts as an impermeable membrane. B Tissue edema can accumulate above the cutaneous insertion of this septum, and below the orbital rim, where the facial network originates. This should be distinguished from the protrusion of orbital fat against the weakened orbital septum or orbicularis muscle in the case of palpebral bags, in which the infraorbital fat is instead separated by the arcuate expansion of the inferior oblique later- C ally, and the valley of the inferior oblique medially and eyelid fluid has an even contour that does not respect the orbital com- partments in its distribution. Eyelid fluid does not change much in up-gaze and down- gaze, whereas bulging of the lower lid orbital fat may be at least temporarily reduced by contraction of the orbicularis muscle Fig. 1. The morphological appearance of the three pathological variants, (A) Malar mound, (B) festoon, (C) palpebral bag in the due to its enhanced support. Additionally, eyelid fluid moves infraorbital region. and gathers below the orbital rim as we press on the orbital rim, Table 1. Features and characteristics of the three pathological variants (Malar mound [MM]; orbicularis oculi muscle [OOM]; orbitomalar septum [OrbS]) MM Festoon Palpebral bag Description An "Elevation " Hanging of tissues between 2 points EYE BAG **Compartmentalized fat Composition FAT insinuate within OOM Purely of skin and OOM: Protrusion of orbital FAT accumulation of FAT or FLUID against weakened OrbS or OOM Boundary Insertion of OrbS Inferior orbital rim Relationship with OrbS In FRONT of OrbS BEHIND of OrbS 2 www.jcosmetmed.org  The troublesome triad: festoons, malar mounds, and palpebral bags skin that hang over the fixed line of orbitomalar septal insertion [11,14]. Hoenig et al. observed that malar festoons appear to be correctable only if the malar septum is affected. The authors reported that by vertically elevating the soft tissue of the cheek (i.e. vertical subperiosteal mid-face lift) and repositioning the Orbital fat pad malar septum, the tissue edema (i.e. malar festoons) above its cutaneous insertion resolves. This may be done in combination Orbital retaining ligament with the repositioning of the descended suborbicularis oculi fat (SOOF) and malar fat pad, done by anchoring it to the tempo- Suborbital oculi fat ralis fascia to provide a superotemporal lift in order to restore the natural contours of the eyelid and cheek region [1,14]. The authors identified that the subset of patients with a flat malar Orbitomalar/malar ligament Orbicularis oculi muscle eminence or lack of youthful malar convexity are anatomically predisposed to prolonged postoperative edema and recurrence Fig. 2. The relationship between the orbitomalar septum, lid-cheek. junction, orbital and suborbital oculi fat. Rosenberg et al. proposed the modification of the fatty com- ponent of malar bags with suction lipectomy (i.e. liposuction of whereas infraorbital fat does not move. subdermal fat and edema), but did not give any consideration Festoons are composed purely of skin and the orbicularis of the orbicularis muscle. As such, this approach does not oculi muscle that can accumulate fat or fluid, forming edema- address muscular or ligamentous attenuation and is most likely tous sacks that bulge from the area of malar eminence. They only to benefit a subset of patients with primarily a fat and/or develop from a progressive distribution of the skin and muscle fluid collection [1,16]. secondary to chronic malar edema. Festoons are usually found Caudal to the orbitomalar septum, the malar fat pad is sup- in the following areas: the pre-septal, orbital, and jugal re- ported in its youthful location by multiple fibroelastic fascial gions of the lower lid. It has been reported that orbicularis septa that extend through the fatty cheek mass originating from oculi tonicity may facilitate lymphatic flow, and that the loss of the underlying superficial fascia, which invests the mimetic muscle tone (e.g. after surgery, botox injection) in this area can muscles to insert into the overlying cutaneous dermis. Chronic result in edematous festoons. Other exacerbating factors recurrent tissue expansion of the skin of the lower anterior include a salty meal (due to increased sodium intake), systemic cheek, if combined with stretching of the supporting infraor- edematous state (e.g. chronic renal disease, allergy, or hepatic bital fascial septa, results in downward migration of the malar cirrhosis), or drug use [1,13]. fat pad. With time, the orbicularis muscle attenuates and progres- Restoration of midface volume can improve a saggy appear- sively sags until folds of muscle are suspended across the lower ance secondary to infraorbital and cheek fat atrophy. Addition- lid. If the orbital septum is also lax, the septum may also sag and ally, it effaces folds and depressions, provides support to adja- invaginate into the upper part of skin-muscle, adding a septal cent areas and disguises physical descent of midface structures. pouch to the complex. The festoons typically disappear when Volumizing deficient areas can be achieved via the transposi- the muscle contracts, and reappear as the muscle relaxes [14,15]. tion of orbital fat pedicles or via autologous fat grafting to vol- Malar mounds develop as the fat insinuates into the grooves ume-deficient sites. Alternative options include injectables (e.g. and fenestrations in the orbicularis oculi muscle. This is more non-permanent fillers like hyaluronic acid filler), poly L-lactic common in patients older than 50 years of age [13,15]. Gravity acid, or solid synthetic implants, which allow for augmentation seems to have little effect on the development of malar mounds. of facial framework [17-21]. However, if the swelling in the malar mound region is primarily Older patients may also benefit from procedures directed at subdermal, then the presentation is known as malar festoons skin adjustment (e.g. SMAS lifting and/or tightening and reposi- instead. These “malar bags” may also atrophy with age, result- tioning of the orbicularis oculi muscle). A number of modifica- ing in the appearance of “festoons” of lax infraorbital malar tions in the use of myocutaneous skin flaps in the restoring of a www.jcosmetmed.org 3  Lam Kar Wai Phoebe smooth lid cheek junction have been described [6,15,22-24]. descent. There is still controversy as to whether treatment Fractional laser resurfacing has been demonstrated to im- for the herniation of fat in palpebral bags is best-determined, prove the appearance of malar bags and rejuvenate eyelid skin together with the presence and severity of a tear trough defor- and its use has been reported with some success and without mity or without the consideration of tear-trough deformity. the risks and complications associated with non-fractional de- Whilst over-resection of infra-orbital fat may replace the vices [12,22,25]. However, these techniques do not reposition original bulge deformity to an iatrogenic focal hollow, under-re- the descended structures. It is unclear exactly how they modify section may require an additional surgery to smooth out the lid. local edema and adipose accumulations, but through collagen Therefore, one need to assess the balance between the differ- stimulation and soft tissue tightening, they may correct malar ence between the infra-orbital volume deficit and the native fat skinfolds or reduce malar prominence. Furthermore, scarring available for preservation, the native fat can be either excised, ectropion, and post-inflammatory hyperpigmentation may pos- repositioned, or a combination of the two. sibly occur following these treatments [14,20-24]. There have been a number of modifications made to the “in- tra-SOOF” procedure whereby the fat pads are temporarily se- Palpebral bags cured internally or externally with matrix sutures through cheek skin [2,29]. There are centers which support the use of lower Palpebral bags can develop at an early age. They occur as the eyelid fat repositioning alone; others may combine lower eyelid infra-orbital fat bulges outward against an attenuated or weak orbital septum and oculi muscle of the lower eyelid. Reinforce- ment of both the attenuated orbital septum and oculi muscle appears to be an important aspect not to neglect in the correc- tion of palpebral bags [21,26,27]. Eyelid vector should be taken into consideration when planning surgery. In circumstances in which the tip of the cornea (i.e. globe prominence) is more anterior than the prominence of the lower lid/suborbital area (cheek), a “negative-vector’’ (Fig. 3) is present. Special care must be taken when approaching these cases, as lid over-tightening can bowstring the globe, and excess skin excision may lead to a higher incidence of lower lid malposition. Tear trough (Fig. 4) often relates to the underlying bony struc- ture and is particularly associated with age-related maxillary hy- Positive vector Negative vector poplasia, in combination with the loss of subcutaneous fat with Fig. 3. Anatomical difference between positive and negative vectors, thinning of the skin over the orbital rim ligaments and cheek illustrating the relationship between the tip of the cornea and cheek. Tear trough deformity Malar bag Nasojugal groove Fig. 4. The relationship between (A) Tear trough and underlying orbital bone rim A B and (B) Anatomical appearance of tear trough deformity. 4 www.jcosmetmed.org  The troublesome triad: festoons, malar mounds, and palpebral bags fat repositioning with a mid-face lift, regardless of the condition muscular aponeurotic characteristics, sparing the dermis, and of the tear-trough [2,13,30]. The utilization of fat repositioning the 1.5 mm transducer can coagulate the lower epidermis and (i.e. manipulation of the septal fat pads without septal reset) dermal layer. There is evidence to suggest that the thermal is preferred to fat mobilization (i.e. arcus release and septal effect of Ultherapy® (Ulthera, Inc., Meza, AZ, USA) (HIFU) can release) because in the latter, there is a risk of middle lamellar tighten the orbicularis muscle, orbital septum and intra-orbital contracture with mobilization. fat, which therefore can be beneficial as a non-invasive reju- In circumstances in which the volume deficit is greater than venation technique to restore the shape of the lower palpebral that of the native fat available for preservation, then CPF repair bag in a subset of Asian patients. These are young patients (