Festoons: Why Under-Cheek Swelling Is Hard to Treat

Festoons are soft, puffy bulges that sit on the upper cheek, just below the lower eyelid. In a lecture on new approaches to the problem, a dermatologist from New York University described why they are hard to treat, how filler in the area can sometimes cause or worsen similar swelling, and which newer options look promising but remain unproven.

What are festoons?

Festoons are one of several related conditions that cause swelling over the cheekbone. The presenter suggested grouping them under a broader term, "malar bags", and separating three types:

• Malar edema: fluid collecting over the cheekbone. It is usually soft and squishy, may look worse in the morning or after a salty meal, and can come and go.
• Malar mounds: a more permanent bulge of fat or muscle between the lower eyelid and mid-cheek.
• Festoons: hammock-like folds of loose skin and muscle, sometimes holding fluid or fat. They tend to come with age and often develop from the other two.

The terms are used inconsistently in medical writing, which is part of what makes these conditions confusing for both patients and practitioners.

Why they are hard to treat

Festoons involve several tissues at once: skin, the ring-shaped muscle around the eye, fat and fluid. The lymphatic drainage in this area is also delicate. A treatment that addresses one layer may not help another, and some treatments can make swelling worse.

Swelling in this area also has medical causes that need ruling out first. The lecture listed heart, kidney and liver problems, an underactive thyroid and allergies among the possible contributors. Puffiness that is new, on both sides, or getting worse is worth mentioning to your family doctor.

Why filler can make things worse

Under-eye filler is sometimes used to smooth the hollow between the eye and cheek. In some people, though, filler placed in or near this area can be followed by persistent puffiness that looks like malar edema or festoons. Hyaluronic acid attracts water, and the area's drainage can be easily disrupted, which may help explain this, although the lecture itself did not set out a mechanism. People who already have festoons or fluctuating puffiness are generally considered poor candidates for filler in this area. Our article on who is a good candidate for under-eye filler covers this in more detail.

When filler is thought to be the cause, the presenter recommended considering an enzyme injection to dissolve the hyaluronic acid first. Our article on dissolving filler with hyaluronidase explains how that works.

The options discussed

The lecture reviewed a range of approaches, noting that apart from surgery and liposuction they are off-label for this purpose:

• Surgical removal or lifting by an oculoplastic or facial plastic surgeon
• Laser resurfacing and chemical peels to tighten loose skin
• Radiofrequency and focused ultrasound energy treatments
• Enzyme injection for filler-related swelling
• Injections of a medication meant to scar down fluid-filled tissue, discussed below

The laser and radiofrequency examples were supported only by before-and-after images from earlier reports, not by measured outcomes.

The most promising newer option

The presenter highlighted injecting a diluted solution of doxycycline, an antibiotic that can also cause controlled tissue scarring, directly into the swelling. The idea is to tighten the loose layers and reduce the space where fluid collects. The evidence came from a small retrospective study of 15 patients, who needed one or two treatments on average. Reported side effects included burning during injection, bruising that could last a few weeks and short-lived redness.

Fifteen patients with no comparison group is a very small, early evidence base. This should be seen as research, not an established treatment. Its availability and acceptance vary, and If you are curious about it, ask a physician whether it is authorized in Canada and appropriate for you. Anyone interested should be assessed by an appropriate specialist.

How strong is this evidence?

This source is a lecture slide presentation, not a peer-reviewed study. It summarizes the presenter's view of existing literature. It is a useful overview of how specialists think about the problem, but it does not provide new data, and the treatments it highlights rest on small or image-based reports.

Even so, the lecture is valuable for one reason: it shows that specialists see festoons as a spectrum, with different treatments suited to different parts of that spectrum. That is a helpful way for patients to think about it too.

What it means for you

Festoons are a real, recognized condition, and it is not your imagination if they are stubborn. Realistic steps include:

• Seeing your family doctor if puffiness is new or worsening, to rule out medical causes
• Avoiding under-eye filler if you have festoons or swelling that comes and goes
• Considering referral to an oculoplastic or facial plastic surgeon for significant festoons
• Asking whether skin-tightening treatments might help mild skin laxity, with modest expectations

For some people, the most sensible option is no procedure at all, combined with sun protection and good sleep habits.

Questions to ask at your consultation

• Is my swelling more likely to be fluid, fat, loose skin or a mix?
• Could earlier filler be contributing to it?
• Is there a medical cause I should have checked first?
• Would a surgical opinion be worthwhile in my case?

Frequently asked questions

Are festoons the same as under-eye bags?

Not exactly. Typical under-eye bags sit on the lower eyelid itself. Festoons sit lower, on the upper cheek, and involve different tissues.

Can laser treatment fix festoons?

It may tighten loose skin modestly in some people, but evidence is limited and it does not address fluid or fat. See our article on laser for crepey under-eye skin for what resurfacing can do.

Why does my puffiness change from day to day?

Fluid-related swelling often varies with salt intake, sleep, allergies and position. Persistent or worsening changes should be checked by your doctor.

If you are bothered by swelling under the eyes or on the upper cheek, HealthPark Medical Aesthetics can help assess what may be going on at a consultation and suggest referral where another approach is more appropriate.

Source

Bloom BS. Novel Approaches to the Treatment of Festoons. Lecture presentation, New York University School of Medicine. Read the presentation