Does Lower Blepharoplasty Cause Malar Bags?

Malar bags tend to run in families.  Just below the outside portion of the lower eyelid, the tissues are designed to glide when we smile.  Do to various factors, the ligament that supports the lower eyelid at the lid/cheek junction (oribitomalar ligament) can become lax.  The tissue below the ligament will slump or hang into the next ligament system.  This next ligament system is the one that becomes outlined with a black eye.  This arrangement creates the appearance of the festoon or malar bag.  While it is true that lower eyelid generally does not create the bag, it certainly can contribute and bring out the bag.  The biggest cause for festoons after surgery is failure of the surgeon to recognize the existence of the bag before surgery.  Swelling after surgery also is a common cause.  Swelling following surgery does settle so malar bags from swelling typically resolve. However, some surgical procedures can result in damage to lower eyelid lymphatics which can prolong lower eyelid swelling and delay resolution of these bags.  Surgeons can inadvertently damage the nerves that supply the orbicularis oculi of the lower eyelid contributing to an aggravation in the appearance of the malar bags.

Having had to fix these types of problems ( in some cases following surgery by world famous surgeons) I am certain that even a well qualified surgeon cannot avoid these issues is some small percentage of cases.    In other words being well qualified or even very well qualified is not a guarantee that you will never have a malar bag after surgery.  However, a careful preoperative examination by your surgeon to assess if you might be at higher risk for this type of problem and a frank discussion regarding your risks will make it more likely that you will be properly prepared to deal with these issues should they arise after surgery. 

Lower lid surgery can treat lower lid bags and should not cause them to get worse. It depends on the technique used by the particular surgeon.  Experienced eyelid surgeons can avoid or correct malar bags at the same time as the eyelud surgery.

Malar bags are independent of periorbital fat herniation.  If you do not have them, you will not get them from the surgery.  If you do have them to any degree, any surgery or trauma to the face may aggravate them.  You surgeon should warn you.  After all the swelling resolves the malar bags will return to their original size.  Do not complain and goad your surgeon into doing something foolish such as injecting with steroids, or injecting fillers. It may takes months in some cases, but they will go back to original condition with time.  Best wishes.  Knowledge is power.  Luis F. Villar MD FACS

Malar bags can be difficult to correct and do not typically respond well to standard lower blepharoplasty only, nor are they worsened by lower blepharoplasty.  However,  if they are not properly identified before surgery, there may be disappointment as they may become more apparent with relative smoothing of the eyelid above the malar bag.

One approach involves a cheek or midface lift through the eyelid incicion.  More rarely, direct removal of the malar bags can be considered,  however with the risk of a visible scar.

Hi Bowman 929,

Lower eyelid surgery should fix your malar bags, not make them worse!  Having said that, however, the correction of the bags requires that a particular type of lower blepharoplasty is performed.  Discuss your concerns with your surgeon and be sure that he or she knows that the malar bags are a concern of yours.

Good Luck!

A lower blepharoplasty if done correctly, can correct malar bags.  Sometimes there is some loose skin which needs to be removed, but more often, the cause is fat which has descended out of it's original position.  This fat needs to be repositioned-not removed, in order to achieve a youthful lower eyelid/cheek junction.

This can be performed by a board certified plastic surgeon or a board certified ocuoplastic surgeon.

Best wishes,

Dr.Bruno

Malar bags are anatomy related to the cheek, not the lower eyelid.  A ligament which runs through the cheek can collect fluid above it and cause the malar bags.  Just performing a lower blepharoplasty won't cause a malar bag but can "unmask" or worsen the bags if they are present before the surgery,  due to the swelling which occurs after the blepharoplasty.  Typically when the swelling disappears, so do the malar bags.  Malar bags can be very difficult to treat and if severe may require direct excision.  See a board certified plastic surgeon and have a detailed discussion and examination to assess your risk.

Dear Eyelid Surgery Patient,
Lower blepharoplasty or Lower eyelid surgery will not worsen or create malar bags. Lower eyelid surgery will address access skin, muscle, and fatty tissue related to lid structure. Malar bags or festoons are related to cheek structure. You may want to consult with a facial plastic surgeon, oculoplastic surgeon, or a plastic surgeon that is experienced in eyelid surgery.
 

Hi Bowman929,

As other plastic surgeons have stated, there typically isn't a direct correlation with lower eyelid blepharoplasty and malar bags. Lower eyelid surgery typically helps improve skin, fat, and/or muscle. Malar bags are a combination of swelling and ligament structures of the cheek area, and may be difficult to treat. Only after a comprehensive evaluation can a eye plastic surgeon help determine appropriate options for you. Best of luck.

Dr. Chaboki

Typically malar bags are not made worse with lower lid surgery. They may, however, be improved if you and your surgeon identify the problem preoperatively. The same approach can often be used to address those areas of concern. However, they may be difficult to completely correct depending on your anatomy and the source of those bags. I hope this information helps.

I believe malar bags are caused by swelling about a ligament that runs through the cheek.  Even in young patients, a depression starts to develop in the cheek that gets deeper over time as volume is lost and skin becomes looser.

Often, fluid collects above this septum and results in chronic edema, or swelling, leading to malar bags.

Skin tightening does help, in our practice always accompanied by elevation of the cheek tissues, and often augmentation of the cheek volume as well.

It is difficult or impossible to break the cheek ligament completely, and therefore prevent fluid from collecting above it.

When lower blepharoplasty by any technique is done, it is possible for edema to collect above this septum and cause malar bags.  Thankfully, this is usually a temporary condition.  However in patients who have certain anatomical features, the likelihood of this forming is much higher.

Below are several articles and chapters we have written on the topic of cheeklifts and cheek anatomy.