Updated Anatomy, Pathophysiology and Management of Congenital Festoons
MALAR BAGS are puffiness and swellings in prezygomatic space. Their surgical correction are challenging and difficult with potential risks and complications and sometimes more than one surgery is required to correct them.
We described the congenital festoons or malar mounds for the first time in 2018 in 3 patients.
Malar mounds or congenital festoons are chronic soft tissue swelling within prezygomatic space since childhood.
Acquired festoons are seen later in life due to laxity of orbicularis oculi muscle.
We reported the presence of localized fat under skin and above orbital orbicularis muscle as a pathophysiologic finding in congenital festoons in 2018.
Since 2018 we have operated on additional 5 patients with congenital festoons.
We noticed scattered small fat lobules infiltrated under orbital orbicularis muscles in variable amount and anterior to the orbital septum in these patients, hence, we call them ANTERIOR SEPTAL FAT (ASF), which is different than SOOF.
These fatty deposits (ASF) that are seen in different amounts in patients with congenital festoons depending on the severity of the clinical presentation and are not seen in patients having routine lower blepharoplasty nor patients with acquired festoons.
Methods/Technique:
In the last 13 years, we have seen 200 patients with malar bags. 18 (9%) of them had congenital festoons.
We operated on 3 patients for correction of congenital festoons in 2018 article.
5 new patients with congenital festoons were surgically treated since 2018. All had subciliary lower blepharoplasty with raising skin/muscle flaps and preservation of tarsal orbicularis, release of ORL ( orbicularis retaining ligaments ) and ZCL (zygomaticocutaneous ligaments), supraperiosteal midface lift was done over the lateral SOOF without release of medial origin of orbicularis muscle from maxilla and no release of tear trough ligaments. Postseptal fat excision &/or transposition was done depending on preoperative LATERAL PULL TEST (LPT) findings with septal reset. Canthopexy and orbicularis muscle suspension was done in every patient.
Fat deposits above orbital septum and under septal and orbital orbicularis muscle (ASF) was seen in varying amount in all of these 5 patients. After raising skin /muscle flaps ASF excision was done with electrocautery under loupe magnification. Special attention was paid not traumatizing the nerves which are running horizontally undersurface of the orbicularis muscle.
Conservative triangular skin excision was done only laterally.
The one patient who had direct excision of the malar mounds reported in 2018, had large localized fat immediately under skin and above orbital orbicularis muscle in prezygomatic space, which was different than malar fat usually seen over orbital portion of orbicularis muscle in all patients.
Two patients out of three in the original series reported in 2018, had residual swelling few months after surgery. Both were treated with Kybella injection 0.1 -0.15 ml in two spots, 1 cm apart to the area of swelling. Second Kybella injection were repeated in both of them 4-6weeks later. None of these patients had excision of anterior septal fat (ASF) done at the time of their procedures.
Only one patient out of 5 in our recent series, had minimal residual swelling 5 months post-operatively that was treated with 0.1 ml “off-label“ Kybella injection in two spots one centimeter apart.
Results/Complications: In our original series of 3 patients with congenital festoons reported in 2018, one of them had 3 surgical procedures including direct excision. The other two had Kybella injection for residual swelling after their surgical treatments. At that time we were not aware of ASF (anterior septal fat).
In our recent 5 patients after anterior septal fat (ASF) excision from submuscular area (not SOOF), only one had postoperative Kybella injection for a minimal swelling and the swelling improved after 4 weeks.
No adverse effects were seen after Kybella injection except soreness and tenderness that lasted few days.
Mild upper eyelids swelling and chemosis are seen in all of our patients after surgery, but all resolve after few weeks with conservative treatments with eye ointments and oral steroids.
Bunching of skin in lateral canthal area are expected after muscle suspension, but they go away after few weeks by localized massaging.
No hematoma, no infection, no milia were seen.
No lid retraction, no ectropion, no everted lower lids, no hypertrophic scars, no dysesthesia were seen.
Eventually all patients were pleased with the final results.
Conclusion: Congenital festoons or MALAR MOUNDS are present since childhood and the pathophysiology of them is localized fat over or under orbicularis oculi muscle which is different than SOOF and malar fat.
Successful surgical treatment of congenital festoons requires excision of ASF, located under orbicularis oculi muscles. Persistent subcutaneous fat can be treated with Kybella injection.