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 VA

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.

What look like normal under-eye bags to the untrained eye (and sometimes
even to the trained eye) can actually be a condition known as Festoons.
Festoons occur when the skin of the lower eyelid experiences
significant damage, usually by the sun. This causes folds in the lower
eyelids and can lead to swollen mounds on the cheeks known as Malar
Mounds. Festoons often occur with age and are more common in people with
lighter skin types.Lower eyelid bags, in contrast, are caused when age-related fat protrudes through the skin in the lower eyelid region.If lower eyelid bags are addressed by themselves, the festoons often are more noticeable afterwards because they stand out in stark contrast. It’s important to understand the differences between these two conditions so they can be properly treated. The best rejuvenation and most natural results occur when both eyelid bags and Festoons are corrected simultaneously.The first difference is in their cause or etiology;
festoons are a result of sun-damaged skin on the lower eyelid and on the
cheek and are believed to be affected by underlying contrasting muscle
forces over the years of a person’s life.
In contrast, lower eyelid bags are due to age-related fat protruding
through the skin in the lower eyelid region. New research has shown that
fat can grow and atrophy during our lives in asymmetric ways. The
growth of fat in the orbit around the eye along with atrophy of fat in
the facial regions around the eye, as well as weakness in some of the
orbital containing structures, contribute the fullness we see in the
lower eyelid with age. For some individuals, this fat shows up at a very young age and this
is believed to a result of genetic changes in the development of the eye
area in those individuals.
The second difference is the location on the face
where they form. Lower eyelid festoons can be seen primarily on the
cheek with some presence in the lower eyelid region. Lower eyelid bags
are located directly below the lower eyelid lashes and are noticed to
become more prominent when someone with these bags looks upwards.
Conversely, festoons are minimally affected when a person looks upwards.
The third difference is the feel of these conditions
when they are touched. Festoons are squishy and can be made to move
side to side. Lower eyelid bags are firmer, deeper in location beneath
the skin and can’t be moved easily side to side when touched.I have had great success treating festoons and malar  mounds with my Laser Skin Resurfacing RESET treatment for lower eyelid festoons and malar mounds. See the video and link below for more details. 

The treatment of festoons is complex and often not 100% satisfactory to patients. The scar following surgery may be unappealing. For large festoons, direct excision along with canthoplasty and laser skin resurfacing is usually the treatment of choice. You should have an evaluation with a surgeon to discuss your goals and determine the best treatment option. All the best.

Yes, those pesky collections of 'fluid' beneath the lower eyelids can come and go, but never really completely go away. Do salt, hormone levels, stress and aging make them worse?  I agree with Dr Mayer and Kabaker that direct excision offers the most straightforward method of achieving a reduction and improvement in these pesky bags of annoyance.  If surgical healing is routine, the small scars seem like a good tradeoff to the persistent puffiness!

As you can tell by the number of different options presented to you, that this is a difficult problem to address. The more techniques available for a problem, the harder it is to fix!!

 

The best way to remove them completely is to excise them directly which will leave a scar.

All other options [blepharoplasty, laser, etc]  will likely improve to some degree, but not resolve completely.

Your case is mild-moderate, so a blepharoplasty with orbicularis suspension may suffice.

An experienced Oculoplastics or Facial Plastics patient may be your best bet.

Festoons (aka malar bags) are a common annoying problem of the lower eyelid/cheek junction.  They can be mild to severe. There are different types of festoons, namely fluid filled, fat filled, excess skin, or combination of the above.  Treatment options vary for each but complete resolution of festoons are unlikely, especially if fluid component present, and you should expect improvement not complete resolution. In your case, the lower eyelid incision with skin-muscle flap is likely the best method to give the best result.  See an oculoplastic specialist.

In 35 years of facial plastic surgery I have found this to be a less than ideal problem.  Eyelid surgery-blepharoplasty-will not remove these.  Excision directly which leaves a cheek scar is in my opinion the best treatment.  This leaves a scar but done by an experienced plastic surgeon should be worth the trade off. 

Thank you for that question andyour detailed post. I understand where the confusion is coming from. Treatingmalar bag is actually a very challenging procedure, hence, the many possibleoptions given to you by various doctors. The issue with malar bags is that,although direct excision may be used as treatment, the result may only improvethe issue and not totally eradicate it. Moreover, it may leave a noticeablescar on the cheek area. The other treatments you mentioned, arcus marginalisrelease, canthopexy, and transposing of fat is a procedure that leans more toresolve the upper eye bags. It does nothing to the malar bags though. In yourcase, you may need several surgical treatments to resolve the malar bags aswell as the eye bags above it. After the desired result is achieved surgically,you may use non-surgical methods such as fillers to enhance the overall result.
To get a more accurate grasp on this,work only with a board certified plastic surgeon. Your surgeon should properlyassess your case so he or she could devise a specialized treatment plan foryour upper eye bags and your malar bags. Ask questions as well, so everythingwould be clear to you. Hope this answers your question!