What Fillers Cause Festoons?

Submited by Kassmd on August 1, 2022

Festoons (also known as malar mounds) are typically swollen mounds or pouches of tissue that may look puffy or filled with fluid; they appear under the eyelid and around the cheek.

They are mainly caused by natural aging, genetics, exposure to the Sun’s ultraviolet rays, years of smoking, sleep apnea, chronic allergies, and sleeping in a face-down position. Fair-skinned people tend to be more susceptible to festoons.

This condition is brought about when this region’s elastic fibers and collagen wear out. The damage allows fluids to fill in this space resulting in swollen skin in the lower eyelid and cheek area. They make a person appear tired, sick, or older than they are.

Festoons are very common and are challenging to treat. These may or may not be caused by a prior filler treatment to the area. Many people seek help from cosmetic surgeons who try to conceal them with injectable fillers. We believe that this is a truly TERRIBLE idea. Unfortunately, having fillers injected into the face can make festoons more noticeable by removing eyelid fullness under the eyes, making them appear worse. Additionally, the festoons can worsen when the surgery is performed to remove fat from the lower eyelid through standard blepharoplasty.

Sometimes, festoon pockets persist longer even when unwanted facial filler product is dissolved with hyaluronidase. Festoon pockets are extraordinarily hard to treat.  Most surgeons don’t know how to treat this condition and what’s worse, is that some surgeons will things which are doomed to make the situation worse. In general, fillers placed on the face can cause swelling; especially those placed underneath the eyes can lead to additional swelling. The swelling can find its way into the festoon area making the condition worse, more noticeable, and more prominent.

The other problem is that fillers are sometimes placed into the lower eyelid region or around the festoon, resulting in disastrous results. This means that when only one of these conditions is corrected, festoons and malar mounds are accentuated and become more pronounced.  We believe that having commercial fillers injected under the eyes is usually not a good idea.

Most experts advise fixing both lower eyelid bags and festoons for the best results. But most surgeons do NOT know how to adequately address festoons as this is a very difficult problem to improve. This combination of procedures provides the most natural rejuvenation of this critical area of the face. However, when only lower eyelid fat is addressed, the swelling dramatically impacts the festoons.

Fillers and Festoons

Many fillers are made from hyaluronic acid but have different calibers; some are more robust than others. Fillers like Volbella and Restylane Silk perform better under the eyes, while Juvederm Voluma fillers are better suited for cheeks and midfacial rejuvenation. Some fillers like Sculptra should not be used under the eye, and some patients react to them and can develop lumps and granulomas.
When the filler is not placed deeper into the skin, the injection site will have a visible blue tint known as The Tyndall effect. This happens when the filler is placed too superficially. Incorrect filler choice can exacerbate festoons and cause under-eye puffing.

While you can easily find physicians who will inject under the eyes to treat a “hollow” appearance, we believe, in general, that this is often not a good idea for the reason given in the next paragraph.

Excess use of facial fillers will lead to an overfill effect or the loss of the normal eye contour, making the pouches under the eyes noticeable. Additionally, Hyaluronic Acid Facial Filler products have a degree of affinity to water molecules making the products used to hydrate and swell when injected into the treatment area. To avoid this, do not overdo it by taking it slow with the injections. Give it some time before going for more additional injections if needed.

Another reason is that the person who performed the treatment is unqualified or inexperienced to perform the facial filler injection. To avoid this, it is highly essential to seek the services of a fellowship-trained Oculofacial Plastic Surgeon for such procedures.

There are various conditions that are known to cause additional under-eye swelling including:

  • Chronic sinus congestion or allergies
  • Rosacea
  • Overconsumption of sodium
  • Inflammatory skin conditions
  • Chronic dry eyes
  • Eyelid muscle laxity
  • Chronic blepharitis or inflammation of the eyelid skin
  • Chronic conjunctivitis (pink eye)
  • Excess alcohol intake
  • Floppy eyelid syndrome
  • Obstructive sleep apnea or other sleep conditions

Managing the underlying cause of the inflammatory condition helps improve your cosmetic results. When the underlying cause is under control, you can achieve long-term results from any lower eyelid cosmetic procedure you may have done.

Treating a Botched Filler Injection

Dermal fillers gradually dissolve over time. If the fillers last longer than expected, corrective action may be taken. Hyaluronidase injections can resolve such situations by dissolving unwanted facial filler products. A routine investigation with a 3D MRI scan can help determine the exact location and the amount or volume of the filler retained in the face. This is to dissolve the filler effectively. Hyaluronic acid fillers can effectively be dissolved using the hyaluronidase enzyme.

After treatment, the skin may appear swollen for a few hours, clearing in a few days. The skin may appear deflated at first, which improves in a few weeks as the skin recovers.

If there are large volumes of fillers present, additional dissolving sessions may be necessary. Once the filler has dissolved, the eye area is examined to check the true contours of the lower eyelid. After this, one can choose not to have additional treatment or have a small amount of filler placed correctly. Use warm compresses, light massage, and sleep with your head elevated to minimize swelling after a filler injection.

The use of the enzyme hyaluronidase sounds like a simple and a great idea. We approve the use of hyaluronidase, injected generously and usually 2-3 times, to try to improve the deleterious appearance of festoons. Sadly, in our experience, we see the patients who have already tried enzymatically dissolving their fillers and in whom the festoons persist unchanged.

Contact Us

Dr. Kass has a variety of dermal fillers that are customizable to deliver the best results effectively. He is highly experienced in filler injection procedures and dealing with previous filler complications. He has successfully treated many patients who had despaired after a botched filler injection leaving them with the desired, long-lasting results. If you have a festoon filler that has gone wrong, contact us today to know how we can help you.

However, please know that often, festoons can only be improved with delicate and not inexpensive surgery. If you have festoons, our advice would be to avoid additional fillers and/or fat injections. If there have been filler injections to the area AT ANY TIME then it makes sense to try hyaluronidase injections. After this, if the festoons are mild, it is ok to try less invasive techniques such as radiofrequency treatments, microneedling, thread lifts, and fractional lasers.  But if the festoons persist and are cosmetically objectionable, we would STRONGLY recommend that you seek out help only from a fully trained oculo-facial plastic surgeon such as Dr. Kass who has extensive experience in treating this difficult problem. The multiple unedited before and after pictures on our website showing actual patients treated at the Kass Center attest to our experience and skill.

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