Are these malar bags? If so, what is the best permanent treatment to resolve the issue? (Photo)

Question

Ive had these bags/lines that extend from my dark eye circles onto my cheeks. I liken them to as if I have a second eye bag, double bags almost. Its like a crease that indents on my upper cheek. Ive had them for years and they have slowly worsened. Im 29 and constantly hear “you look so tired”. What is the cause and solution? Do lasers help with this issue? I was hoping to avoid surgical options but will consider all. Thank you

Adam Scheiner, MD · Answer

Dear Boston,It appears that you have evidence of  festoons/malar mounds. These changes can make a person appear tired, sick and older even when they feel fine inside. 
Many people who undergo lower eyelid surgery to improve the appearance of their lower lids are dissatisfied afterwards because of 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.

Thomas Buonassisi, MD · Answer

Malar bags, or nasojugal grooves, are the lines or indentations that can form between the lower eyelid and the upper cheek, often exacerbated by factors like aging, genetics, and lifestyle. These bags can give the appearance of dark circles and may create a tired look, which can be frustrating. At 29, it’s not uncommon to notice these changes as the skin loses collagen and elasticity over time. Non-surgical options, such as dermal fillers, can effectively address volume loss in this area, while laser treatments may help improve skin texture and reduce pigmentation. A consultation with a qualified aesthetic professional can help determine the best approach tailored to your needs, whether that includes lasers, fillers, or other non-invasive treatments.

Raffy Karamanoukian, MD, FACS · Answer

Dark under eye circles can make you look tired and older than you are. I would use a combination protocol that includes topical Melarase creams first, followed by a combination of injectable fillers, fractional laser, and RF to blend out the eyelid hollowness and tighten the skin. 
Recommended Creams: Melarase Brightening Kit
MelaClenz
Melarase AM
Melarase PM
Melapads
Replenish Retinoid Cream
Best, 
Dr. Karamanoukian
Realself100 Surgeon

Jason Emer, MD · Answer

A combination approach will give the most improvement. Fillers like (Belotero, Volbella, Restylane Silk) lasers, and Microneedling/PRP can improve under the eyes. My patients try to get non surgical treatments to avoid surgery. We use PRP and stem cells there often. I suggest consulting with an expert to develop a treatment plan best suited for your short and long term goals. Best, Dr. Emer

Jonathan Kulbersh, MD · Answer

Under eye bags and wrinkles can be permanently corrected with surgery or temporarily camouflaged with fillers (Restylane, Belotero, Volbella).There are great non-surgical options to fill in under eye depressions and hollowness. Using dermal fillers, a liquid eye-lift can be performed. A dermal filler such as Restylane would be placed in the cheek and tear trough to hide the depression or bag underneath your eye.
Surgery would require a fat-repositioning lower lid blepharoplasty. In this surgical procedure, fat from the eye area is moved into the tear trough depression filling the actual depression. 
I hope this helps!

Soheila Rostami, MD, FAAO, FAACS · Answer

the treatment of malar bands are not easy and it should be done over a period of time and it should not be rushed. I do inject with HA products but I also use my needle to subside the attachment of the band to the skin. This may take few trips to the office but after the first treatment it should be lift time of smooth cheeks. I have treated many of these bands successfully for many of my patients with this technique and every time I have rushed to treat them it has been not successful. It need time dedication and patience.

Mitesh Kapadia, MD, PhD · Answer

The line that you are describing is part of an early malar bag. In my opinion, there is no perfect solution to this problem. The malar bag can usually be camoflaged with filler injections, which is what I would recommend in your case.

Onir Spiegel, DDS, PhD · Answer

Hi there,Under eye deflation and volume loss can start in our mid 20s and results in bag like appearance-- exactly as you are showing in your pictures.  The solution is relatively simple with HA fillers.  The Restylane line is particularly good for that and I really like layering soft fillers on top of Restylane Lyft.  Versa is a new HA filler out of Canada that we've been working with for the past 6 months since it's FDA approval in the US. The results have been phonomental. You may just need Versa or in combination with Restylane Lyft which we inject from the malar eminence (cheek area) to the tear trough area (under eyes) to give you a beautiful lift and cheek definition.  I explain more about this in our video below. Best from Boston, Dr. Onir

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