The sometimes baggy area beneath the eyelids overlying the cheek bones are called “festoons”. They represent a difficult problem, which is not solved by standard facelift techniques or a “classical” blepharoplasty. The former pulls and tightens in the wrong direction to have an effect in this area of the midface, the latter usually overresects fat and the subsequent volume loss makes the festoons appear even more prominent.
While the exact cause of festoons is still somewhat controversial, the lack of success of skin oriented procedures with the possible exception of direct excision leaving a very obvious scar, gives evidence that this is not a skin only problem. More successful correction is possible by tightening of the markedly descended round muscle of the eye. This is in accordance with the basic principle of cosmetic surgery, create the structure first and then just drape the skin over it. Even more powerful is a midface lift modified to reposition the round muscle of the eye and the cheek on the underlying skeleton, tighten it and then redrape the skin over the reconstructed structure. This procedure addresses all anatomical structures potentially involved in the causation of festoons. Intrinsic changes of the skin (dark spots, red spots, sun damage) can be addressed with various lasers or peeling agents.
Form follows structure.