Festoons, edema, and malar bags: is there a consensus on aesthetic treatment?

Introduction: Periorbital changes are some of the first detectable signs of aging. The most outstanding currently, refers to the rejuvenation of this region, involving the treatment from the eyebrows to the transition orbital-malar, where are festoons, edemas, and malar bags. However, this management is complex, involving several approaches: invasive or noninvasive techniques. Thus, this review aims to describe the scientific evidence of the most current techniques used in the treatment of festoons, edema, and malar bags and to evaluate the complications related to each modality. Methods: The research was carried out in three databases, PubMed, Cochrane, and LILACS using the descriptors “bolsa malar,” “malar mounds,” “festoons” and “malar bags” in the period from 2014 to 2019, in English and Portuguese. Results: We selected 13 articles; most of the studies were retrospective reviews (76.9%), seven dealt with noninvasive techniques, three about invasive, and three on the association of techniques. Regarding the procedures described, the noninvasive ones were represented by the use of Kinesio tape, tetracycline injection, doxycycline and hyaluronic acid, and the use of microneedling with radiofrequency. The invasive ones were represented by microaspiration, myocutaneous flap, subperiosteal lift of the middle face, and direct excision. Conclusion: There are numerous techniques for treating festoon and malar bags, but it is up to the plastic surgeon to know its advantages and disadvantages to decide the most appropriate in each situation. Thus, there is no consensus, but it is vital to diagnose correctly to indicate the best treatment. ■ ABSTRACT


INTRODUCTION
Aesthetic interventions in the face have been increasingly sought after by patients in the context of plastic surgery, improving the facial contour, and returning the harmony and beauty of the face without losing naturalness 1 . Data from the American Society for Aesthetic Plastic Surgery (ASAPS) 2017 and the Sociedade Brasileira de Cirurgia Plástica (SBCP) 2016 show that in recent years approximately two hundred thousand surgical procedures have been performed such as blepharoplasty and facelift and more than one million noninvasive procedures on the face as the application of botulinum toxin and hyaluronic acid 1,2 .

METHODS
This is a literature review limited to Pubmed database, Cochrane, and LILACS in English and Portuguese between 2014 and 2019, using the following descriptors: "bolsa malar," "malar mounds," festoons" and "malar bags. " Exclusion criteria were: publications without full access, repeated by overlapping the keywords-key, not directly related to the theme, before 2014 and languages other than Portuguese or English. Two independent reviewers conducted the initial research of articles and subsequent selection.
All research information was tabulated in a spreadsheet for statistical data analysis.
This review is supplemented with photos of patients to illustrate some types of treatment, but they are not identified, and their personal information is also not present. Thus, this work does not require approval in the Research Ethics Committee, although the principles of the Helsinki Declaration of 2013 were followed.

RESULTS
The original research yielded 58 records, of which 23 duplicates were removed, leaving 35 articles for the first phase of screening ( Figure 2). After title review and summary to determine relevance on the treatment of festoons, edema, and malar bag, 13 were eligible for full-text revision and listed in Chart 1.
Most studies were retrospective reviews (76%), three prospective interventionists (23%), and only one systematic review. The types of techniques employed varied among invasive options (46.15%) and noninvasive (53.85%), being represented by the use of Kinesio tape, local injection of antimicrobial, injection of hyaluronic acid, microneedling with radiofrequency, microaspiration, myocutaneous flap, subperiosteal lift of the middle face and direct excision. The findings were as follows:

Noninvasive treatment
Noninvasive procedures are more conservative and non-surgical interventions, with variable results, used as primary therapy for mild or moderate malar edema with more restriction of outcome in the treatment of bags and festoons. Although not isolated, the first choice for the most advanced conditions, noninvasive procedures, represent adjunct benefits to surgical therapies.

Kinesio Tape
Only one study described the use of Kinesio tape. The tape was indicated to minimize festoon, through on-site application in an ascending vector, with noticeable improvement after three months, but with limited result in the more advanced festoons 4 .

Tetracycline and doxycycline injection
Two studies focused on the use of antimicrobials in periorbital rejuvenation. In one of them, the application of tetracycline 2% between the orbicularis muscle and deep fascia showed improvement in the contour to correct the festoons 5 . Doxycycline was used in the concentration of 10mg/ml in order to correct festoons and malar edema 6 . Complications such as ischemia, necrosis, nerve paralysis, persistent pain, or edema were not identified 5 . However, the application of these antimicrobials presents limited results, requiring more extensive and more detailed studies to determine the safety and efficiency of this treatment.

Hyaluronic acid injection
In four of the thirteen articles included, there was a description of fillers' use to treat of edema and malar bag. Most studies agree that moderate to severe cases of malar bags or festoons are not adequately treated with filling, the best therapy being the surgical approach 7-9 .

Microneedling with radiofrequency
The use of radiofrequency microneedling devices for the treatment of malar and festoon bag was found in two articles, because they provide energy, similar to microwaves, to induce thermal lesions in adipose and dermal tissue, sparing the epidermis and improving the contour of the periorbital region. Studies generally report mild and temporary side effects such as erythema and edema. The procedure can be repeated in 1-2 months if necessary 10 .

Invasive treatment
The invasive treatment of malar and festoon bags can range from the myocutaneous flap to the direct excision of excess skin. The choice of a given type of surgical procedure depends on the correct diagnosis, the patient's age, and the pathologies' associations, among other variables.

Microsuction
Two articles focused on using this technique to treat patients with edema and malar bag. Superficial liposuction is performed to the orbicularis muscle in the subcutaneous plane. The care required is to avoid skin perforations and irregularities in the facial contour 11 .

Myocutaneous flap -orbicular muscle skin
The most performed surgical modality in the studies (38.46%) is indicated for patients with malar bag and mild to moderate festoons [11][12][13] . A subciliary incision is performed, myocutaneous flap dissection to the orbital edge and removal of excess skin (Figures 3 and 4) 11 . Among the complications observed in the studies, we can have ectropion in up to 4% of cases and hematoma in 3%.

Middle face subperiosteal lift
In two studies, the indication of this technique was described for patients with festoons. Three routes can perform this: temporal, transpalpebral, or endoscopic assisted video. All techniques aim to make the resuspension

Direct excision -in canoe
As discussed in three articles, such a procedure is also indicated for patients presenting severe festoons. The incision is made in the festoon's demarcated area in the form of a canoe or ellipse, and excess skin is removed. As the scar is evident, it is better indicated in older adults. Lagophthalmos and ectropion are the main complication 3,15 .

DISCUSSION
Since 1978, when Furnas first described "festoons", the terms used to describe edema or excess tissue immediately below the infraorbital border within the pre-zygomatic space are variable. As all three anomalies (edema, malar bag, and festoon) cause lumps, we propose the following definitions to describe this broad anatomical problem: malar edema is an accumulation of fluid on the malar eminence that often varies in severity and can worsen after salty meals or in the morning. The malar bag is chronic edema of soft tissues in the pre-zygomatic space, which contains fat or orbicularis muscle due to descent or hypertrophy, and may be congenital. On the other hand, festoons are loose-skin cascade nets and orbicularis muscle below the infra-orbital edge ( Figure 5), may also contain herniated or ptotic fat and accumulate edema. They are often found in older adults and represent a progression of the entities described above 16 .
of the orbital-malar ligament and suspension of the soft tissue. The difference is that in the first technique, the access is made by the temporal region, in the second by the lower eyelid, and in the third, an incision is made in the temporal region and the oral mucosa. The disadvantage of the video-assisted technique is the fact that it presents a longer learning curve, longer surgical time, besides attending with approximately 25% of oral wound dehiscence. On the other hand, the transpalpebral route may present hematoma more frequently and the temporal access route 3,14 .   procedures should be made cautiously, as it presents limited results if poorly indicated. Kinesio tape was used in the treatment of festoons, but its mechanism of action is based on the improvement of lymphatic drainage, being better applied in malar edema or after surgeries as an adjuvant to minimize postoperative edema and ecchymosis 4 . Similarly, radiofrequency microneedling without association with other techniques would not be the best choice for the treatment of festoons, because despite causing a potential reduction of fat and decreased sagging skin in the lower eyelid, it is not enough to bring the best outcome to the patient 10 .
On the other hand, the use of antimicrobials, according to Perry et al., in 2015 5 , seems to produce activity similar to growth factor, stimulating the proliferation of fibroblasts, as well as collagen production and fibrin deposition. Thus, tetracycline 2% or doxycycline 10mg/ml between the orbicularis muscle and deep fascia can improve the repair of the periorbital surface, however, with a poor result in the correction of festoons and severe malar bag because it already contains excess skin 5,6 . The use of hyaluronic acid is controversial because, at the same time, it can mask an irregular contour in the periorbital region can also aggravate malar edema in some cases, especially if hydrophilic, with possible involvement of lymphatic drainage 8 .
Besides, periorbital fat atrophy and malar bone resorption contribute to the loss of the lower periorbital area's structural support. It is believed that medial and lateral resorption of SOOF(suborbicularis oculi fat) and the regeneration of ligaments and orbicularis leads to loosening the ceiling of the pre-zygomatic space, contributing to the pathogenesis of periorbital aging 3,14 . Thus, surgical techniques aim to restore the region by acting more anatomically with more predictable and lasting results. The choice of a specific technique over another depends on existing skin excess, patient age, and especially the surgeon's proximity to the surgical procedure. Microaspiration in the periorbital region acts in such a way as to prevent the malar bag progression to the festoons, besides leading to a local fibrosis and face contour improvement 3 . The myocutaneous flap, subperiosteal lift, and direct excision rejuvenate the periorbital region by acting on the ligament, muscle regeneration, and excess skin. However, the complications inherent to surgical techniques are more feared and more challenging to treat when compared to less invasive techniques.
Thus, an algorithm is brought in an attempt to minimize doubts, facilitate the interpretation and choice of treatment in the face of a case of periorbital rejuvenation ( Figure 6). It is noteworthy that despite the numerous invasive and noninvasive techniques, a single approach is not revolutionary. Thus, most often, repetitive treatments and a combination of techniques are necessary, leading to an increase in the cost and postoperative recovery time 14 . Furthermore, studies on the subject are deficient, mainly in Portuguese (found only one in this review), because these are studies at grade IV and V levels, limiting critical analysis and highlighting the need for higher quality studies.

CONCLUSION
There are numerous techniques for treating festoon and malar bags, but it is up to the plastic surgeon to know its advantages and disadvantages to decide the most appropriate for each type of patient. Therefore, there is no consensus, but it is essential to diagnose correctly and remember that the association of techniques may be the best treatment.