Malar Bags - Festoons. What Do You Recommend? (photo)

You have several things going on here. You appear to have had lower lid surgery at some point in your past. The canthus (lateral attachment to the bony orbit) appears lax as indicated by an increase is scleral (white of the eye) show. You need to have a canthoplasty to tighten and raise the attachment of the lower lid, removal of excess skin and muscle from an open approach. I would also use a bovie electrocautery to induce some slight scar from within the bag to help is seal at the time of surgery. Your picture with the the q-tip tells it all.Dr. JA. Dean Jabs M.D., Ph.D.Board Certified Plastic SurgeonBethesda MD/McLean VA301.493.4334/703.506.0683

There are many causes of eye bags. Some are shadow issues, some are discoloration issues.  From your photos you are a great candidate for lower lid blepharoplasty with or without fat transposition and fat transfer to the periorbital area. This would include a muscle suspension and canthoplasty as you have shown with the q-tip. You would need a good facial analysis by some one who performs a lot of these surgeries prior to a diagnosis but from what I gather from photo this would be helpful. Most people have a multifactorial issue. Failures of treatment for this problem are typically because the surgeon only treats one cause and leaves others out. Below are a list of causes of eye bags, circles, mounds, and festoons. Each cause has a specific treatment. 

1. Prolapsed orbital fat through the orbital septum: treated with lower lid blepharoplasty and fat transpositioning. Can also be helped with fillers or auto fat transfer to the face but the ideal treatment in my hands is surgery for this issue.



2. Eczema: much more common in young people with fair skin. The treatment for this is to hold off on makeup and any manipulation of the lower lid for a few weeks and try some topical anti inflammatory creams. If you have allergies those should be treated also.  A dermatologist is the best person to see for this. We have a multidisciplinary clinic with myself, a plastic surgeon, and my partner, a dermatologist which I think is ideal!



3. Fluid accumulation and/or redundant skin. Could be possible in young patients but would need a good facial analysis and exam to determine. A low salt diet (< 1000mg/day) and a warm compress can help.  I would consider treating with filler/fat transfer, lower lid fractional ablative laser and/or lower lid blepharoplasty.



4. Descent of midface cheek pad. This then causes the nasojugular ligament to become more prominent creating a demarcation and separation of the eye from the cheek subunit. Treated with mid face lift and/or fat transfer.



It is all about the balance of this transition from the orbit to the cheek. There are many ways to treat this and they vary by the underlying cause. I recommend seeing a surgeon who also does a lot of these treatments. This can make a big difference as most people have a combination of the above that lead to the issue.



Hope this helps.



Best of luck,



DrC

Direct excision of the festoon would be a good option with minimal scarring on the eyelid skin because it blends in well with the half-circle contour with the lid-cheek junction.  You already have some scleral show of the eyelid laterally, so any aggressive skin muscle flap technique should be done with extreme caution and must require additional canthal surgery to prevent eyelid malposition.