Periorbital Aesthetic Surgery: The Evolution of a Multidisciplinary Surgical Subspecialty

Abstract

Festoons are skin folds and ballottable skin edema that occurbetween the transition zone of the thin lower eyelid skin aboveand thick cheek skin below. They can cause a dramatic aestheticdisturbance to the lower lid and are difficult to address. Webelieve that festoons are caused by damage to the skin overlyingthe area where the horizontally contracting orbital orbicularisoculi muscle converges with the vertically contracting elevatorsof the upper lip. Skin/muscle flap surgical procedures tocorrect festoons can be time intensive and yield suboptimalresults. Medical therapy has also typically failed to providesignificant resolution. Lasers used for skin resurfacing havebeen a viable option for the treatment of festoons, with carbondioxide (CO2 ) and Erbium:Yag (Er:Yag) lasers having been usedsuccessfully. The treatment of festoons takes advantage ofresidual thermal energy, which normally accompanies laser tissueablation. This residual heat causes relatively deep collagenfiber devitalization, and most importantly contraction, whichbecomes the framework for new collagen formation. Our clinicalendpoint for treatment is the presence of no further visibletissue shrinkage with the final laser application. Proper use ofthe laser requires following laser safety protocols and blendingthe treated area with the surrounding untreated skin. Frequentfollow-up after the procedure allows for better management ofthe healing process and early recognition of complications. Inour experience, modified laser skin resurfacing is a predictableand effective treatment to reduce festoons, which can greatlyimprove the overall aesthetic outcome in rejuvenation of thelower eyelid--cheek complex.