How Do I Reduce the Appearance of the Bags Across my Cheeks?

I don't have eye bags, but bags across the top of my cheeks. From numerous google searches, I think these could be known as Malar Festoons? I am confused about whether they are caused by fluid retention or are simply part of the aging process (although I am only 30 and don't have any other signes of aging). They began appearing a couple of years ago, but would only show when I was stressed or had not slept well, now they are a permanent fixture.

Doctor Answers 10

Malar Festoons: Treatment Options

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At your age and the sudden appearance, I would make sure that there is no underlying condition which could explain the early onset.

You may want to evaluate any thyroid or metabolic disorders which could contribute to localized swelling or fluid retention. Most likely you will be in good health.


From a non-surgical standpoint, you can consider:

    1. options which are purported to tighten the skin such as radiofrequency modalities or chemical peels. But these will not likely provide you with long term solutions
    2. camouflage procedures which enlarge the cheek prominence and mask or blend the junction of the fold with the cheek. Perlane or Radiesse are commonly used for these procedures
    3. I would recommend caution with Botox as this may aggravate the appearance. You will note that if you squint, your bags wll likely improve. IF they worsen, then Botox may be an option.

From a surgical standpoint:

    1. Minimally invasive procedures such as lipoinjection to the cheeks could be of benefit
    2. Suture suspension of the face has not been generally useful for longterm management
    3. Eyelid procedures that use a combination of differentially treating the skin, fat, and muscle and support of the lower eyelid are most likely to achieve the best results.
    4. More aggressive approaches through the lower eyelid such as a cheek lift with repositioning of the malar fat pad or SOOF may produce a satsisfactory outcome.
    5. Other methods of cheek lifts or suspension are available that can be completed through the hairline or the inside the mouth.

Many other options are available and would best be determined after reviewing your goals and evaluating your anatomy.

I hope this helps.

Malar bags

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There is a septum (ligaments) in the cheek that tether the cheeks. Swelling or sagging of skin tethers exactly at that point and, in some patients, results in malar festoons.

Malar festoons are very difficult to eliminate.

They can often be improved by a well-supported superficial cheeklift procedure.

This surgery is technically complex because it essentially involves tightening of the skin below the lower eyelid. This is a risky maneuver because the lower eyelid can pull down, becoming rounded or pulling down in the corner. Therefore, the corner of the eye and possibly the entire lower eyelid must be at least supported, and sometimes slightly shortened if it is loose.

In some patients, adding volume to the cheeks in general or the sub-festoon area in particular can help.

In older patients, direct removal of the festoons is possible; however this leaves a visible scar on the face.

Patients with severe festoons should generally not expect complete removal of the malar festoons. But there are many treatments, depending on the patient's exact anatomy, to improve them.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 188 reviews

Bags Across Cheeks

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There are some medical conditions and lifestyles that also bring about festoons or malar bags but most likely it is inherited. Managing malar pads or bags has been an issue of discussion for many years, however, there are newer treatments which are helpful. Frequently malar bags are accompanied by bulging fat pats from the lower eyelid. Today conservative fat pad removal is more accepted along with more limited incisions of the lower eyelid. Mid face lifts or cheek lifts can help festoons but the problem is not always corrected. Isolated treatment of festoons alone is uncommon so frequently a combination of treatments in the area are needed. Fillers can address the hollow area around the eyelid fat pad removal can be performed from the back side of the eyelid (transconjuctival approach). This allows for less chance of the eyelid changing shape and also allow for a more assertive treatment of the festoon. The festoons can then be treated with micro-needling. micro-needling with radio frequency,  ultrasound or even laser. Remember festoons or malar bags are separate from the eyelid but any treatment in the area can directly affect the eyelid so usually both are dealt with at the same time.

Fat vs. Filler

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You are correct that your description does sound like cheek festoons. We would need a physical exam to determine the tissue plane that is affected. The orbicularis oculi muscle is the sphincter muscle around the eye. This muscle can become thinned and redundant which can lead to this issue. Skin can become redundant and thinned (you are young for this but with enough sun damage it can happen). Fat can also prolapse and fall. This can be orbital fat or mid cheek fat pad. It is important to delineate the cause so that it can be corrected appropriately.

In my opinion you should see a facial plastic surgeon, get a good facial analysis and consider fat grafting vs. filler to transition this area.

Hope this helps.

Best of luck,


Benjamin Caughlin, MD
Chicago Facial Plastic Surgeon
5.0 out of 5 stars 12 reviews

How do I reduce bags across my chhek?

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What you are desribing are called Malar bags which are hereditrary and are caused by scarring due to chronic fluid retention within the upper cheek tissues.  This is a very difficult thing to treat and IMHO, your choices are either:

  1.     a thin filler like Restylane, Juvederm or Perlane to feather in the edges of the malar bags or
  2.     cheek implants, where the cheeks are also flat, to re-shape the cheek area.  This camoflauges the malar bags.  I have used cheek implants to treat malar bags on numerous occassions.  Micro-lipo and local tissue manipulations, including cautery, of the malar bags does not work, IMHO and can cause more tissue irregularity.

Upper cheek bags and swelling.

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Since you are only 30, they are probably not really malar festoons, but may potentially develop into some. Usually they are caused by fluid accumulation in the superficial layers of your skin. If you know what makes them worse, try to minimize these factors. Frequently, the appearance may by much improved by Restylane or Perlane injections. Make sure your doctor does these procedures for this particular indication on a regular basis, as it can be somewhat tricky.

Stella Desyatnikova, MD
Seattle Facial Plastic Surgeon

A Difficult Problem

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You are probably right. By the information you provided, these are most likely malar festoons. These can be very difficult to fully eradicate. I recommend patients try a low salt diet and even antihistamines (Claritin, Zyrtec, etc.) as occasionally this will improve their appearance. I have injected a steroid solution under the skin in this area and have had some patients respond to this treatment. Otherwise, surgery would be indicated.
At your age, direct excision would not be recommended as the resulting scar would be more eye catching than the festoon. My personal recommended treatment technique would be a transblepharoplasty midface lift. Through an incision just under the eyelashes, the underlying muscle is released from the cheek bone, elevated and secured in a higher position, excess skin and muscle is then excised. This usually does an excellent job in creating a smoother cheek, however, the resulting scar to the side of the eyelid can take a few months to become inconspicuous. By the way, an endoscopic midface lift would NOT improve this condition.
I recommend you see a surgeon with extensive experience with this technique as resulting potential complications, such as pulling of the lower eyelid, can be very difficult to correct, and prevention of this is key.
I hope this helps.

Andrew Campbell, MD
Milwaukee Facial Plastic Surgeon
4.7 out of 5 stars 25 reviews

Bags Across Cheeks

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Great question -- but without any photographs its impossible to comment on your specific case. Swelling of the face at the area of the top of the cheeks is most likely early festoon formation. This area can be very challenging to treat. Surgical and non-surgical choices might be available for you. There can be various causes for this condition, and so a full examination by an expert in facial, orbital, and eyelid anatomy is crucial. Please have an in-person consultation with a board-certified, fellowship-trained Oculofacial Plastic Surgeon with specific expertise in cheek and eyelid surgery. Avoid doctors who do this sort of analysis and surgery part-time. Good luck with your search.

Damon B. Chandler, MD

Harvard-Penn Trained Oculofacial Plastic Surgeon


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It sounds like you have more swelling than anything else. Festoons can be from muscle and skin laxity, but yours sounds like fluid. This is edema like people get in their legs. It is very difficult to treat. Sometimes a cheek lift can soften it, also sometimes injectable fillers can camouflage it.

Direct excision versus full cheek lift

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Malar festoons are very difficult to treat. It is a situation similar to having a localized swelling in one area. A good knowledge of the anatomy is very important to be able to get rid of this problem.

Different surgical options:

1-Direct surgical excision: Works well for older patients (males) with large festoons.

2-A full cheek lift with redraping of the orbicularis muscle is a key technical detail in achieving the best possible result.

It is important to discuss expectation with your board certified plastic surgeon. He will be able to choose the best option for you.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.