Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Festoons: the baggage you don’t need!

Malar Festoons are the baggy pouches that form under the lower eyelids and on the upper cheek. I have been treating them with laser resurfacing for the last 15 years.

Festoons are a result of numerous causes including sun damage to the skin, fat loss of the cheek area, periorbital changes of skin, muscle and fat. They are also caused by a back up of the lymphatic drainage of this area which causes the tissue to become boggy. The net result is crinkly skin or pouches that make us look old and tired. Before the advent of laser technology, festoons were often treated by surgical excision, which of course left a scar. Other treatments that were supposed to improve festoons have been disappointing.

I have used various types of lasers on this region (CO2, Erbium, Nd:YAG, KTP) and have personally had the best results with the CO2 laser. No other laser has been to shown to produce as much skin tightening or new collagen formation as the ultrapulsed CO2 laser. I believe it remains the gold standard in skin tightening. Although other lasers may claim to produce results with less downtime than the CO2, the result is often less or multiple treatments are required. In reality, the way the procedure is performed and the experience of the surgeon are the most important variables in terms of the best result. Experienced laser surgeons know how aggressive they can be with the skin resurfacing and yet not produce scarring. Good results can be obtained using CO2 and Erbium lasers.



The above patient was treated by Dr. Niamtu with upper and lower blepharoplsty and CO2 laser to the festoons.

Although festoons can be treated as a sole procedure, most patients that are having this area treated also benefit from upper and lower eyelid surgery as well. My most common combination of procedures to rejuvenate this region is transconjunctival blepharoplasty on the lower lids. This procedure does not involve a visible scar and is also safer in terms of not pulling down the lower lids. Instead of cutting skin off of the lower eyelids, the wrinkled skin is treated with the laser and the results are immediate. You can actually see the wrinkles disappearing as the laser contacts the skin. I prefer to treat the lower lids when I treat festoons as the aging process actually represents this entire area. More so, I encourage most patients to perform the laser treatment on their entire face if they desire more comprehensive rejuvenation. By treating the entire face, the patient does not have to worry about the festoon skin being a different color or texture if that is the only area treated.

As most patients that have festoons need their lower lids treated, the same can be said about their upper lids. It is very common to rejuvenate all four lids and the festoons at the same procedure.

In addition to improving malar festoons, the CO2 laser also revolutionized cosmetic blepharoplasty (eyelid tuck) as the surgery can be performed in much less time with no bleeding. That is not a misprint, there is literally no bleeding. During the procedure of operating of 4 eyelids, the total blood loss can be measured in a single Q Tip. Less bleeding means faster healing, less bruising and less pain. Those surgeons who have been using lasers for blepharoplasty can affirm these statements.

This patient was treated by Dr. Niamtu with upper and lower laser assisted blepharoplasty and laser to the lower lid and facial skin

Dr. Niamtu has performed over 5,000 eyelid surgeries with the CO2 laser since 1996 including festoon treatment and full face laser skin resurfacing. In addition, he has written numerous articles and text book chapters on laser treatment.









This patient was treated by Dr. Niamtu with lower transconjunctival blepharoplasty and lower periorbital laser resurfacing.









This patient was treated by Dr. Niamtu with lower transconjunctival blepharoplasty and lower periorbital laser resurfacing.


For more information about Dr. Joe Niamtu, III, cosmetic facial surgery in Richmond, Virginia visit www.lovethatface.com. Joe Niamtu, III DMD Cosmetic Facial Surgery Richmond, Virginia

July 20, 2011 Posted by | Cosmetic Eyelid Surgery, cosmetic facial surgery, Eyelid Surgery, Laser Resurfacing | , , , , | 8 Comments

Eyelid Surgery Vs Browlift: What’s it all about?

One of the most common points of confusion in cosmetic facial surgery is  understanding the diagnosis and treatment options between eyelid surgery and brow and forehead lift surgery.

Put plain and simple, the brow and forehead are intimately related to the eyelids in youth and aging.  If you look at your picture in your 40’s or 50’s and compare them to your high school picture, the chances are that your brow has drooped, your forehead has wrinkled and your eyelids have excessive skin, muscle and fat.

Although cosmetic eyelid surgery is one of the most popular procedures worldwide, many times people have skin removed from their upper eyelids when in fact they should have a brow and forehead lift.  The problem with misdiagnosing the need for browlift surgery is that if a patient has excessive skin removed from his or her eyelids then it may be impossible in the future to have a brow lift as there will not be enough skin left  to close the eye.  Likewise, even if conservative skin removal is performed and then repeated later a brow lift may be impossible.  Finally, if a patient already has low brows and more skin is removed, the brow can be lowered even more. So, what do you do?

Basically, when you seek a consult for upper eyelid rejuvenation, if the doctor does not mention the word “brow” in the first several sentences, you should seek another opinion.  This is because many surgeons do not understand the extreme importance of upper facial aesthetics.  In female patients, the brow normally sits above the upper bony rim of the eye socket (superior orbital rim).  If you ( as a female) reach up and feel your brow and it sits at or below the rim, you may be a candidate for a brow lift.  In males, the brow usually sits at the orbital rim.

Not every patient is a candidate for brow and forehead lifting, but many patients are.  If you look in a mirror and relax your brow and forehead and they gently elevate your brow on the middle and lateral portions regions you can see a preview of what a brow and forehead lift may do.  In the average patient a brow lift of 5-8 millimeters (less than ½ inch) will produce a more youthful, alert, awake and open eyed look.  When I manually elevate a patient’s brow they either love it and say “that is how I used to look years ago” or they feel that it is excessive or unnatural.  Obviously, browlift is not an option unless one likes the look.  In my experience about 60% of patients like the look and the other 40% don’t like the look.  There is no doubt that an excessively elevated brow looks very fake, so conservative surgery is imperative for a natural look.

For those that do like the elevate brow appearance, they will notice that it elevates the most lateral (side) region of the brow.  As this area gets saggy, it causes a “sad puppy” appearance which doctors call lateral hooding.  Elevating this hooding makes most patients look younger.  You will also notice when you elevate the brow that the excess eyelid skin significantly improves.  This is because elevating the brow lifts the saggy tissues and fat and repositions them to a more youthful position.  Many times, patients present to the office asking for blepharoplasty (cosmetic eyelid surgery) and after education them, they opt for brow and forehead lift which corrects the upper eyelid aging as well as the sagging brow and forehead.  Patients with significant excess skin or fat may need eyelid surgery and browlift at the same time.  Another benefit of brow and forehead lift surgery is the ability to improve forehead wrinkles by tightening the forehead skin.

Obviously, not all patients need brow and forehead lift as many patients do not want or need their brows elevated.  In these patients, removal of skin, muscle and fat on the upper eyelids is all that is necessary.  A brow lift is a more comprehensive procedure and is a bigger surgery with a longer recovery when compared to blepharoplasty.  When I perform blepharoplasty I don’t use scissors or scalpels, but rather high tech devices such as CO2 laser and radiowave surgery.  These modalities prohibit bleeding and blood loss is several drops.  Less bleeding means, less bruising, less swelling, less pain and faster healing.  Normally surgery on all four eyelids take about an hour and is usually performed with light sedation.  The recovery is generally one week, although most patients are up and around in less time.

Most old fashioned brow lifts were performed by a very aggressive incision at the top of the head to reflect the entire front scalp during the procedure (coronal brow lift).  Contemporary brow and forehead lift is frequently performed with endoscopic surgery through small, button hole incisions hidden in the hairline.  Another very popular contemporary method of brow and forehead lift is the mini open brow technique.  In this technique, a small incision is made just behind the hairline in a very specialized manner to allow the hair to regrow through the scar, making it extremely cosmetic.  One big advantage of the mini open procedure is that it does not raise the hairline.  All other brow lift procedures will raise the hairline to some extent.  This is not a problem for patients with low hairlines, but many females already have elevated hairlines and would not look good with an even higher hairline.   There are pluses and minuses of both of these procedures and each patient is different.  A competent surgeon will offer multiple means of performing brow and forehead lift to tailor a custom procedure for that specific patient. 

The take home message here is that if you think you need your upper eyelids improved, success may lie in eyelid tuck, brow and forehead lift or both.  If your surgeon does not offer both options or discuss the importance of either, a second opinion may be in order.


Joe Niamtu, III DMD

Cosmetic Facial Surger

Richmond, Virginia


March 6, 2008 Posted by | Brow Lift Surgery, Eyelid Surgery | , , , , | Leave a comment