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.
Malar Bags - Festoons. What Do You Recommend? (photo)
Doctor Answers 18
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.
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.
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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!
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.
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.
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.
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
Eye bags, circles, and swellings
There are many causes of eye bags. Some are shadow issues, some are discoloration issues. From your photos you are a great candidate for lower lid blepharoplasty with or without fat transposition and fat transfer to the periorbital area. This would include a muscle suspension and canthoplasty as you have shown with the q-tip. You would need a good facial analysis by some one who performs a lot of these surgeries prior to a diagnosis but from what I gather from photo this would be helpful. Most people have a multifactorial issue. Failures of treatment for this problem are typically because the surgeon only treats one cause and leaves others out. Below are a list of causes of eye bags, circles, mounds, and festoons. Each cause has a specific treatment.
1. Prolapsed orbital fat through the orbital septum: treated with lower lid blepharoplasty and fat transpositioning. Can also be helped with fillers or auto fat transfer to the face but the ideal treatment in my hands is surgery for this issue.
2. Eczema: much more common in young people with fair skin. The treatment for this is to hold off on makeup and any manipulation of the lower lid for a few weeks and try some topical anti inflammatory creams. If you have allergies those should be treated also. A dermatologist is the best person to see for this. We have a multidisciplinary clinic with myself, a plastic surgeon, and my partner, a dermatologist which I think is ideal!
3. Fluid accumulation and/or redundant skin. Could be possible in young patients but would need a good facial analysis and exam to determine. A low salt diet (< 1000mg/day) and a warm compress can help. I would consider treating with filler/fat transfer, lower lid fractional ablative laser and/or lower lid blepharoplasty.
4. Descent of midface cheek pad. This then causes the nasojugular ligament to become more prominent creating a demarcation and separation of the eye from the cheek subunit. Treated with mid face lift and/or fat transfer.
It is all about the balance of this transition from the orbit to the cheek. There are many ways to treat this and they vary by the underlying cause. I recommend seeing a surgeon who also does a lot of these treatments. This can make a big difference as most people have a combination of the above that lead to the issue.
Hope this helps.
Best of luck,
Direct Excision of the Festoon
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