Malar Bags - Festoons. What Do You Recommend? (photo)

I see differing opinions about lower bleph for this. How visible are the scars? One doc recommended a lower bleph w/ an extended incision that runs length of lower lids & about a cm along a smile line in outer corner of eye. Also discussed with another, an arcus marginalis release, fat transposition and canthopexy with a separate skin muscle flap? I have also read about laser tx's. Some say a lower bleph could make problems worse? I've already tried fillers.

Doctor Answers 17

Malar bag, festoon treatment

Thank you for your question. As you may have guessed by the number of different opinions expressed here,  this is a very difficult problem to treat.  Direct excision may improve this problem but many times it only results in an improvement not a complete elimination of the problem.  The down side to doing this is that it leaves you with a significant scar on your cheeks. Arcus marginalis release, fat transposition and canthopexy with a separate skin muscle flap is an excellent operation that will address the "upper" bags of the lower lids but NOT the problem of the malar bags. I also note that your lower eyelids have lateral bowing  (the outside edge of the eyelid appears pulled down). This may be indicative of lower eyelid looseness which also should be addressed.

I have found that the best way to treat malar festoons is very wide undermining of the skin with a tightening of the lower eyelid, tightening of the muscle, re-draping of the skin and possibly cheek fat pad elevation (this would depend on your physical findings).  Best of luck with this difficult problem.


San Francisco Plastic Surgeon
5.0 out of 5 stars 8 reviews

Malar bags

You have several things going on here. You appear to have had lower lid surgery at some point in your past. The canthus (lateral attachment to the bony orbit) appears lax as indicated by an increase is scleral (white of the eye) show. You need to have a canthoplasty to tighten and raise the attachment of the lower lid, removal of excess skin and muscle from an open approach. I would also use a bovie electrocautery to induce some slight scar from within the bag to help is seal at the time of surgery. Your picture with the the q-tip tells it all.

Dr. J

A. Dean Jabs M.D., Ph.D.
Board Certified Plastic Surgeon
Bethesda MD/McLean VA


Put me down as one in agreement with Drs. Meyer and Kabaker; direct excision is safest and surest way to good result. External laser combined with lateral canthopexy (to prevent ectropion or lower lid rounding) could be considered in experienced hands. Conservative approach is safest.

Andrew Pichler, MD
Sacramento Facial Plastic Surgeon
5.0 out of 5 stars 3 reviews

Cheek festoons ("water bags"): what's the solution?

Yes, those pesky collections of 'fluid' beneath the lower eyelids can come and go, but never really completely go away. Do salt, hormone levels, stress and aging make them worse?  I agree with Dr Mayer and Kabaker that direct excision offers the most straightforward method of achieving a reduction and improvement in these pesky bags of annoyance.  If surgical healing is routine, the small scars seem like a good tradeoff to the persistent puffiness!

Donn R. Chatham, MD
Louisville Facial Plastic Surgeon
5.0 out of 5 stars 59 reviews


As you can tell by the number of different options presented to you, that this is a difficult problem to address. The more techniques available for a problem, the harder it is to fix!!


The best way to remove them completely is to excise them directly which will leave a scar.

All other options [blepharoplasty, laser, etc]  will likely improve to some degree, but not resolve completely.

Your case is mild-moderate, so a blepharoplasty with orbicularis suspension may suffice.

An experienced Oculoplastics or Facial Plastics patient may be your best bet.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 30 reviews

Malar bags/festoons per photo

Interesting responses from non-plastic surgeons. 

The key to such problems is identifying what the problem is, what procedure would correct it, and what the trade-offs are. Lower eyelid/malar bagging is a combination of fat pads, stretch and sag of overlying skin, and descent of the upper cheek/malar tissues. A standard lower lid blepharoplasty would address the fat pads but not the stretched and excess skin with an incision in the usual subcilliary location (or transconjunctival). Such a procedure does not address the sag of the upper cheek border and adequate support for the heavier cheek tissues. A direct excision of skin only can also have problems with tension on the lower eyelid border and doesn't lift the upper cheek without separate maneuvers plus the incisional scar is not a favorable tradeoff. 

I would recommend accepting a less than complete correction of the skin (which could be improved by surface treatment separate from the eyelid/cheek lift) and do a standard lower lid blepharoplasty through a subciliary incision and include a release and lift of the upper cheek (part of a midface lift). This is anchored to the fascia lateral to the eyelid margin and much of the excess skin can be removed without tension on the lower lid. I call this an extended lower lid blepharoplasty. It would give you the most improvement for the least visible scar and risk. 


Scott L. Replogle, MD
Boulder Plastic Surgeon
4.0 out of 5 stars 1 review

Festoons (malar bags)

Festoons (aka malar bags) are a common annoying problem of the lower eyelid/cheek junction.  They can be mild to severe. There are different types of festoons, namely fluid filled, fat filled, excess skin, or combination of the above.  Treatment options vary for each but complete resolution of festoons are unlikely, especially if fluid component present, and you should expect improvement not complete resolution. In your case, the lower eyelid incision with skin-muscle flap is likely the best method to give the best result.  See an oculoplastic specialist.

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 58 reviews


Lots of options for FESTOONS:  The standard direct festoonectomy and transconjuntival internal plication approaches will work.  However, don't forget about internal & external laser applications and possible serial adrenocorticosteroid injections, etc.

Robert Shumway, MD
San Diego Facial Plastic Surgeon
5.0 out of 5 stars 11 reviews

Malar festoon surgery

There really only two ways to deal with these and first off, you'd probably want a few consults with Facial plastic or Oculplastic surgeon.  How do you get ride or improve these?

1)  Direct excision.  The scar fades but it looks a lot better than what you had.

2)  Trans-blepharoplasty malar festoon plication.  You'll want to see an experienced Oculoplastic surgeon for this one.


The pexies and other things recommended won't do much for you.  Some fat grafting would be helpful however.


Best of luck


Chase Lay, MD

Chase Lay, MD
Bay Area Facial Plastic Surgeon
4.9 out of 5 stars 72 reviews

Direct Excision of the Festoon

Direct excision of the festoon would be a good option with minimal scarring on the eyelid skin because it blends in well with the half-circle contour with the lid-cheek junction.  You already have some scleral show of the eyelid laterally, so any aggressive skin muscle flap technique should be done with extreme caution and must require additional canthal surgery to prevent eyelid malposition.

Johnny Mao, MD, FACS
Orange Facial Plastic Surgeon
5.0 out of 5 stars 23 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.