Among many changes that occur with aging, festoons present a unique challenge to the treating physician. Festoons are composed of lax skin and orbicularis muscle that hang between the medial and lateral canthi, and the pathophysiology is likely multifactorial; some of the proposed mechanisms suggest stretching of the orbitomalar ligament and lymphatic imbalance.1 Many different surgical approaches—including microsuction, flaps, midface lift, and excisions—have been tried with variable success rates. These procedures are often complex, however, and can result in significant complications such as skin perforation, wound dehiscence, chemosis, and ectropion. Botulinum toxin, carbon dioxide lasers, chemical peels, cautery, and tetracycline injections have been used as nonsurgical options, but the results have not been reliable.2 Despite such efforts, treatment of festoons remains difficult and no standard treatment exists.3,4 Here we report a simple, noninvasive, and nonsurgical treatment method using microneedle radiofrequency technology to improve and possibly resolve festoons.
Two patients, a 56-year-old Caucasian woman (patient 1) and a 62-year-old Caucasian woman (patient 2), underwent treatments for their festoons with a fractionated radiofrequency microneedling device. The device (Infini; Lutronic, Inc., Goyang-si, Republic of Korea) consisted of 49 insulated microneedles (7 × 7 needles, 10 × 10 mm), whose tips delivered bipolar radiofrequency transmissions. Each treatment consisted of three passes, in which the depth of microneedles were set at 2.5 mm at 400 msec, 2.0 mm at 200 msec, and 1.5 mm at 100 msec, respectively. A topical anesthetic mixture of lidocaine 2.5% and prilocaine 2.5% was applied 15 minutes before the procedure.
Both patients noted a significant improvement of festoons after one treatment and were highly satisfied with the results. They tolerated the procedure well. The only side effect was erythema in the areas of treatment, which diminished over a few days and could be easily covered with makeup. Both patients opted to receive additional treatments, which resulted in additive benefits. Patient 1 has received two treatments (Fig. 1) over the course of 3 months and patient 2 has received five treatments over the course of 1 year. They have not experienced any scarring, infection, or recurrence from the treatments. As evident in Figure 1, the treatment also resulted in an overall rejuvenation of the lower lid complex.
Bipolar radiofrequency microneedle devices have been reported to improve periorbital wrinkles by increasing collagen and elastic fibers in the areas of treatment.5 Our two patients showed a significant clinical improvement of festoons, likely by means of a similar process of skin rejuvenation. Although we have not treated a large number of festoons with radiofrequency microneedling, this technique has been used many times successfully in our practice for other conditions such as acne scars and neck laxity. The procedure can be repeated 1 to 2 months apart as needed, and the ability to repeat the treatment is helpful given that festoons can recur even after surgical treatments.3 Future studies would be needed to further evaluate the efficacy and safety of the treatment. In summary, the ease of the treatment and the postprocedure recovery process make radiofrequency microneedling a promising treatment option for this challenging condition.
The patient provided written consent for the use of her images.
The authors have no financial interest to declare in relation to the content of this article.
Hana Jeon, M.D.
Laser & Skin Surgery Center of New York
Roy G. Geronemus, M.D.
Laser & Skin Surgery Center of New York
Ronald O. Perelman Department of Dermatology
New York University School of Medicine
New York, N.Y.
1. Kpodzo DS, Nahai F, McCord CDMalar mounds and festoons: Review of current management. Aesthet Surg J. 2014;34:235248.
2. Perry JD, Mehta VJ, Costin BRIntralesional tetracycline injection for treatment of lower eyelid festoons: A preliminary report. Ophthal Plast Reconstr Surg. 2015;31:5052.
3. Endara M, Oh C, Davison SP, Baker SBThe management of festoons. Clin Plast Surg. 2015;42:8794.
4. Einan-Lifshitz A, Hartstein METreatment of festoons by direct excision. Orbit 2012;31:303306.
5. Huang J, Yu W, Zhang Z, Chen X, Biskup EClinical and histological studies of suborbital wrinkles treated with fractional bipolar radiofrequency. Rejuvenation Res. E-published ahead of print 2017.
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