Does Lower Blepharoplasty Cause Malar Bags?

I am considering lower blepharoplasty. Does this cause malar bags or contribute to them? I am assuming a qualified physician would prevent this type of outcome. Which type of physician am I looking for to make sure I have the best results?

Doctor Answers 25

Malar bags are caused by laxity of the soft tissue just below the lower eyelid

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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. 

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Does blepharoplasty cause malar bags?

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Generally lower blepharoplasty does not cause malar bags. Malar bags are often due to allergies or sinus disease. They are essentially fluid trapped inside the muscle at the edge of its compartment.. However if you do have minor malar bags, blepharoplasty can contribute to this because of postoperative swelling. Your best bet is a board-certified plastic surgeon experienced in eyelid surgery or an ocular plastic surgeon.

Andrew Kaczynski, MD (retired)
Sacramento Plastic Surgeon

Lower blepharoplasty and malar bags

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Lower lid blepharoplasties should help correct malar bags not make them worse. You should consult with an experienced plastic surgeon. Be sure to speak with past patients with similar issues.

Gary D. Breslow, MD, FACS
Paramus Plastic Surgeon
5.0 out of 5 stars 44 reviews

Malar bags and lower eyelid blepharoplasty

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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.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 195 reviews

Lower Eyelid Surgery Does Not Cause Malar Bags

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Lower Blepharoplasty will not cause malar bags, though post-op swelling may cause the bags to temporarily look larger.

The two areas (lower eyelids and malar fat pad) are distinct anatomic areas. Blending the contours of the two areas is important, and should need to be addressed as part of the preoperative evaluation and plan.

Seek a Board-Certified Plastic Surgeon with a lot of experience in these procedures.

Paul C. Zwiebel, MD
Denver Plastic Surgeon
4.7 out of 5 stars 46 reviews

Malar bags

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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.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 31 reviews


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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

Luis Villar, MD, FACS
West Palm Beach Plastic Surgeon
4.4 out of 5 stars 11 reviews

Lower Blepharoplasty does not cause malar bags

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Malar bags are unrelated to lower eyelid blepharoplasty. The surgery does not create malar bags, they are fluid retention in the upper portion of the cheek and they are unrelated to fad pads in the lower lids or a lower blepharoplasty.  

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Beware of festoons

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Malar bags or festoons are important to pick up on pre-op exam as they are often a cause of frustration to both the patient and the surgeon post-operatively. The tissues that surround the eyes (malar bags included) will swell and bruise after a lower eyelid blepharoplasty. Most of the swelling will dissipate after 2 weeks but unfortunately, the fluid in the malar bags will often persist much longer than that, sometimes for weeks. It is important that patients be aware of this before signing up for surgery. In patients with malar bags, everything should be done to reduce post-operative swelling as much as possible (head elevation, ice, topical cortisone, even cortisone by mouth...) To answer your question, lower eyelid blepharoplasty can make malar bags worse, but luckily, in most cases, this is temporary. If festoons were to persist permanently, most treatments proposed are quite disappointing. Sometimes, direct excision is the best option, even if it leaves a visible scar. Good luck!

Patrick Boulos, MD
Montreal Oculoplastic Surgeon

Blepharoplasty does not cause malar bags

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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.

David J. Levens, MD
Coral Springs Plastic Surgeon
5.0 out of 5 stars 79 reviews

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.