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