Lower Eyelid Festoons:

Features:
Festoons are loose orbicularis oculi muscle hammocks that drape from the medial canthus to the lateral canthus and can be a major cause of baggy lower eyelids and the upper cheek zone.

Causes of Festoons:

1. Genetic’s
2. Accumulated sun damage – actinic exposure primarily in photo skin types I, II, and III.
3. Lifetime of smoking (including 2^nd hand smoke)
4. Natural aging process
5. Inappropriate Botox injections in the periorbital area particularly in the Elderly – those over 60.

Comments:
The orbicularis oculi is a single sheet of muscle with diffuse attachments to the overlying skin and underlying connective tissue.  The orbicularis muscle is subject to a great variation in its appearance.  The bulk/thickness of the muscles is quite variable and primarily a genetic variation.  This unique striated muscle fibers of the orbicularis muscle is constantly active during waking hours.  The muscle action plus gravity, genetics and the features noted above contribute to the appearance of the lower eyelid Festoons.

Examination:
It is important to examine the patient in a vertical position/sitting position and watch the animation features of the eyelids when the patient is relaxed and the squinch test.  The thin pendulous muscle festoons are eliminated as contraction takes place with the orbicularis during the squinch test of the eyelids.  They reappear when the muscle is relaxed.

Treatment of the lower eyelid festoons:

1. The preseptal portion (often associated with genetically determined baggy lower eyelids caused by herniation of the three fat pads – medial, middle, and lateral and extra skin).  Preseptal festoons can be greatly improved with a combination of a lower eyelid transconjunctival laser blepharoplasty and resurfacing the lower eyelid (UltraPulse CO₂ Encore cool scan system and Erbium Yag the same day).
2. Other treatment options for the orbital and jugal variants include:
   -Surgical – muscle plication lower eyelid blepharoplasty
   -ThermaLift – ThermaCool (Thermage company) – an outstanding option for many patients

Complications of surgical treatments:

• Technique dependent
• Uneven – asymmetry of scar tissue with subepidermal fibrosis
• Visible scars
• Hypertrophic and keloid scars
• Vascular scars that may take many years to fade

Unique feature we are seeing more now is patients with lower eyelid festoons created by poor Botox technique in elderly patients.