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There are 3 separate entities lower eyelid bags, festoons and malar bags.
Lower eyelid bags refers to protruding fat or redundant muscle in the lower eyelid itself above the level of the bone rim under the eye.
Festoons refers to redundant folds of skin with or without muscle in the lower eyelid.
Malar pouches, bags or saddlebags are a prominence below the level of the bone rim under the eye due some combination of swelling or edema, drooping eyelid muscle (orbicualris oculi muscle) and fat under the muscle herniating through the muscle. The lower edge of the malar bags is defined or limited by the zygomatico-cutaneous ligament which has also been called the malar septum. This ligament stops the discoloration of a black eye from spreading down into the cheeks. There is a lot of misinformation on the web regarding malar bags, even on online question boards answered by surgeons. Some people call the bags malar crescent.
The presence of malar bags can be related to previous eyelid or nose surgery independent of who your surgeon was, a complication of dermal filler injections that block normal lymphatic flow, the aging process, genetics, allergies, sinus infections, lack of sleep, water retention (related to menses, kidney insufficiency etc.), liver cirrhosis or thyroid conditions (hypo or hyperthyroidism). The chances of them appearing after dermal filler injection is reduced if smaller beads of filler are placed closer to the underlying bone and aggressive massage of the area is avoided. I get them temporarily when my allergies act up and I lose sleep.
The acute onset of malar bags such as those seen after eyelid surgery is best treated with anti-inflammatory steroids with or without diuretics and sleeping with 2 pillows under your head. Those related to allergies should first be treated with antihistamines and avoidance of inciting allergens. The injection of 20 units of Vitrase (hyaluronidase) will quickly resolve malar bags caused by injection of a hyaluronate like Restylane or Juvederm. Chronic malar bags require a medical workup to assess for one of the causes listed. That involves blood tests such as complete blood count with differential, erythrocyte sedimentation rate, serum protein electrophoresis, cryoglobulin and cryofibrinogen testing, rheumatoid factor, antinuclear antibodies, thyroid levels and liver or kidney function blood tests. A history and physical examination will inform your doctor which if any of these tests would be required..
For chronic malar bags where a medical condition is not present or has been controlled through medications surgery can be helpful. Superficial liposuction (with the cannula holes facing away from the skin) of these malar bags via a small incision near the outer corner of the eye was first described in 1984. More recently this same liposuction via an incision at the nostril rim-cheek crease and suture elevation of the muscle to the temple muscles was described.
This is a patient who underwent malar bag liposuction and muscle suture elevation elsewhere.
Nasojugal Crease - Tear Trough Deformity
Blepharoplasty
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter
Hi Dr Stone, I've been getting malar bags on and off for over a year now. I've had them now for weeks they won't go away it seems this time.
ReplyDeleteI have blood work done with regular check ups and nothing out of the ordinary I'm at a loss what's causing them, the right side is more swollen than the left.
Going to see my Dr next week to try to find a cause but not optimistic with previous bloodwork ok while I've been having this problem.
The lady on your photo is a good example of my problem I have no under eye bags just the malar ones.
What kind of price range was her treatment and how long is the recovery time for that procedure?
Also I've read laser therapy may work for this problem, does that last or is that a temporary measure with this?
I have lost a substantial amount of weight over the past twelve months 50lb. could that be a reason?
Given your history of recurrent malar bags I would not recommend surgery as there is more likely something else going on. Surgery should be reserved for those who have consistent constant malar bags because recurrent malar bags are better treated medically i.e. non-surgically. The actual treatment would depend on the cause and your internist not finding the cause does not mean there is no medical reason for the problem. It just means that it has not as yet been found. Never having seen or examined you when the problem is worse and better I cannot say much more.
DeleteDr. Stone,
ReplyDeleteI just noticed that I've developed festoons over the past few months (also coinciding with a pounding headache in between my eyes).
Thanks to your very well written article that includes the wide range of causes for festoons, I suspect allergies or sinus issues.
Thank so much for writing an informative article that is not alarmist - hard to find that on the Internet these days! Very grateful.
Hi Dr. Stone,
ReplyDeleteI developed malar bags a week ago and I suspected they were due to my allergies, but even after my allergies are gone the bags are still persisting. Will these bags eventually go away on their own or should I start looking into surgery? Thanks!
The soft tissue changes that take place due to allergies do not resolve as quickly as the allergies themselves when you begin taking allergy medications. The medications may immediately stop the allergic reactions but it can take weeks or months before the soft tissues return to baseline or reach a new baseline.
DeleteHello is there Ány posibility glicolic ácid caúsed malar bag on my cheek?
ReplyDeleteIf they are truly malar bags it is highly unlikely because the malar bag occurs at a depth well below the effect of the peel.
DeleteI look like I have them and they came on suddenly after I burned my skin using glycolic acid. Did the damage to the skin cause this?
ReplyDeleteIt can from the associated swelling but that should be temporary as deeper damage or allergies are associated with more long term malar bags.
DeleteI had some hiperpigmrntation and Dr Malcolm paul did a section of my cheek w laser . However after the laser my skin turned to charcoal. I used a lot of stem cell, HQ, so thecharcol went away . But now I have malar bags. I really hate them. Not speaking to that doc anymore. I am a pretty girl w the malar bags . What should I do? I have soft Mediterranean skin. 49 year old gained also 10 pounds after surgical menopause
ReplyDeleteNever having seen you I cannot make any specific recommendations but it sounds like you have 2 problems. The first sounds like melasma and the second like malar bags. You have to be careful applying hydroquinone because it can cause permanent darkening with chronic use. Treatment of the bags would depend on whether you have allergies or redundant skin. In the absence of allergies and redundant skin simple liposuction as described above should suffice.
DeleteHi I had juvederm voluma injected in my cheeks I was over filled and i had hyaluronidase and my malar festoon area is puffy i never had malar swelling before the filler. Any advice? I think I may still feel some filler in that area. I had the filler done 3 months ago and hylauronidase a week ago.
ReplyDeleteThe problem could be due to residual filler and you will have to wait until the filler has been completely absorbed before you can make a valid assessment. That is probably a better option than additional injections.
DeleteHello, im 21 years old and i just noticed me having malar festoons ( both the eye bags and the lines across the face ) . They are not obvious unless im under the sun or in certain lightings ( the eye bags mmore obvious than the lines ) I do have hyperthyroidsim but i completed treatment a while ago but i still have them. Im thinking of having my eye bags removed since they are more obvious but im wondering if you know will the eye bags and the lines will go away eventually or if i should have my eye bags removed surgically?
ReplyDeleteWithout photos, a face to face examination and a more detailed history it is impossible to reply specific to your case. In general mild conditions are amenable to filler injections, sever conditions are best treated by surgery and those related to allergies are best treated by antihistamines and avoidance of allergens.
DeleteI had Juvederm injections for malar bags a year and half ago. My bags look worse. It looks like a blister where I was injected. Never saw any improvement after injection,just looked more hollaw around eyes.Could the injection have been placed to much on the surface of the skin? Could I still have Filler there?
ReplyDeleteFrom your description the filler could have been placed too superficially, in the wrong place or both. After a year and a half it should all be gone by now so I do not know why you currently have the "blister" or if the juvederm contributed to the problem. Never having seen you I cannot say whether or not you should have another filler injection but I can say if there is a problem as you describe it should be addressed before even thinking about another filler injection.
DeleteThank you for answering my question above. I have read that misplace Filler can last a long time. I had voluma done. Would it be worth it to have hyaluronidase injected to see about removing the voluma. I had about 2mls injected for malar bag on one side and 1ml on other side. the doctor said I needed more after having 1/2 ml done which didn't show any improvement. So thinking I got over filled and misplaced Filler cause the side I had the 2mls has more of the blister looking. I can't seem to find anyone in Minnesota to help with these malar bags. Thank you for any help.
DeleteThis late in the game I doubt if it will do anything but it certainly will not make things worse or preclude any future treatment of any kind.
DeleteHi doctor! I had juvderm voluma injected in October 2017 and I started swelling months after so I decided to get it dissolved. I am not left with puffy malar fesstoon which I did not have before the filler. I am 29 years old. The last hyaluronidase treatment I had so a little over two weeks ago and I still have puffy malar festoons. Please help! Any advice?
ReplyDeleteI would give it another 2 or 3 months to see if natural dissolving of the injected voluma solves the problem. If it does not your likely only solution is surgery. Never having seen or examined you I cannot be more specific than that.
Deletei, Dr. Stone! I am 27 years old and I have had malar bags/crescent since I was a child which was not obvious until last year. I remember using face cream with retinol and niacinamide for 2 weeks. It was supposed to improve my skin but I noticed that my malar bags/crescent became prominent after using it. It makes me look old and ugly to the point that I lose my self-confidence. My appearance drastically change because of this. Is there any way to remove this naturally? Thank you.
ReplyDeleteAs long as they are not related to allergies I have had good results with liposuction removal of the fat in malar bags, which are distinct from lower eyelid bags.
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