Malar bags best solution? (photos)

Question

I am 40 years old have been dealing with malar bags for over a year. My board certified plastic surgeon has injected Kenalog and Restalyne and only very small improvement achieved. He addressed they are difficult to treat. What are the treatment options that can completely solve this problem? Thank you.

Kenneth D. Steinsapir, MD · Answer

He or she may mean well.  However, the steroids will kill your natural cheek fat.  Your festoon is most likely to improperly placed hyaluronic acid filler.  These fillers in the wrong place will create a festoon.  Hyaluronic acid fillers persist much longer than you think.  Will fillers are often described to "last" 6 to 12 months, this does not mean what you think it means.  At 12 months there is still plenty of filler left.  The hyaluronic fillers can and do persist for years.  For most, it is not a problem.  However, for some, the fillers sit in the wrong layers and as the water holding of the filler changes over time, it can create a problem like a festoon.  The answer is not steroids.  The answer is to have an enzyme service to blast out all of the old filler.  You might need a touch up filler service after this but this will be fresh new filler that can be place in just the right places.

Adam Scheiner, MD · Answer

Dear California,It appears that you have evidence of fullness in the lower eyelid region and festoons/malar mounds on the cheek as well. These changes can make a person appear tired, sick and older even when they feel fine inside. 
Many people who undergo one factor which can complicate the results from lower eyelid surgery.
Festoons and Malar mounds are a medical condition in which the skin of the lower eyelid becomes significantly damaged, usually by the sun. This damaged skin can result in folds in the lower eyelids and can lead to swollen mounds on the cheeks. They often occur with age and are more common in people with lighter skin types.
Festoons occur in many people seeking lower eyelid rejuvenation and if not corrected at the time that lower lid surgery is performed, the condition can become exacerbated and make the lower eyelids look worse after surgery.
The reason then why many people are dissatisfied after undergoing lower eyelid surgery to improve the appearance of their lower lids is the result of two main issues:
Swelling that occurs in the face after lower eyelid surgery often accumulates in the lower eyelid region and can take a while to resolve.
The subconscious brain constantly looks for balance in a face, and when lower eyelid fullness and festoons exist they are seen to belong together, as both are usually age-related phenomena. When only one is then corrected (usually the lower eyelid bags), the other is seen in even greater contrast.  The subconscious brain then focuses in on this condition and tells the conscious brain the face is out of balance.
Festoons and malar mounds have been a frustration for surgeons for many years. Thanks to the initial work of Dr. Sterling Baker (a person with whom I trained) and my own improvement and refinement on that work over the last decade, I now have a sophisticated, technically-challenging but effective treatment for festoons and malar mounds.
Many people don’t fully understand or recognize the differences between these two conditions. 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.
 It is important to understand the differences between these two conditions. The best rejuvenation and most natural results occur when both eyelid bags and festoons are corrected simultaneously.
I'll include some links below.
I hope this was helpful.

Sheila S. Nazarian, MD · Answer

Did your surgeon also use filler in the cheek area? This is often one of the easiest ways to improve the appearance of malar bags by smoothing the transition between the upper cheek and lower eyelids. My best,Dr. Sheila Nazarian@drsheilanazarian on Instagram

Jason Emer, MD · Answer

The best treatment for this is lasers and radiofrequency devices.  I often will use fillers but once i get to optimal correction.  Best, Dr. Emer.

Myriam Loyo, MD · Answer

Hi there, Thank you for sharing your photo and questions.From the photo, it looks like you have swelling the junction of the medial and lateral cheek fat pads. This area typically becomes noticeable with aging as the fat pads decent and atrophy. It is also very common location to have puffiness and swelling accumulate. Certainly eating salty food and retaining fluids can exacerbate them. One of the best ways to treat them is to have filler to the cheeks. The filler should be placed in the fat pads to restore the medial and lateral fat pad and not in the cleft in between. Injecting into the cleft may lead to worse puffiness. In very severe cases, the malar bags become what we describe as "festoons" and we can consider excising them. This is not the case for you.I think you can consider cheek filler to decrease the malar bag and improve the overall youthfulness of the faceGood luck!

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