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 18

Malar bag, festoon treatment

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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

Malar bags

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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

How to treat malar mounds and eyelid festoons

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What look like normal under-eye bags to the untrained eye (and sometimes even to the trained eye) can actually be a condition known as Festoons. Festoons occur when the skin of the lower eyelid experiences significant damage, usually by the sun. This causes folds in the lower eyelids and can lead to swollen mounds on the cheeks known as Malar Mounds. Festoons often occur with age and are more common in people with lighter skin types.

Lower eyelid bags, in contrast, are caused when age-related fat protrudes through the skin in the lower eyelid region.

If lower eyelid bags are addressed by themselves, the festoons often are more noticeable afterwards because they stand out in stark contrast. 

It’s important to understand the differences between these two conditions so they can be properly treated. The best rejuvenation and most natural results occur when both eyelid bags and Festoons are corrected simultaneously.

The first difference is in their cause or etiology; festoons are a result of sun-damaged skin on the lower eyelid and on the cheek and are believed to be affected by underlying contrasting muscle forces over the years of a person’s life.

In contrast, lower eyelid bags are due to age-related fat protruding through the skin in the lower eyelid region. New research has shown that fat can grow and atrophy during our lives in asymmetric ways. The growth of fat in the orbit around the eye along with atrophy of fat in the facial regions around the eye, as well as weakness in some of the orbital containing structures, contribute the fullness we see in the lower eyelid with age. For some individuals, this fat shows up at a very young age and this is believed to a result of genetic changes in the development of the eye area in those individuals.

The second difference is the location on the face where they form. Lower eyelid festoons can be seen primarily on the cheek with some presence in the lower eyelid region. Lower eyelid bags are located directly below the lower eyelid lashes and are noticed to become more prominent when someone with these bags looks upwards. Conversely, festoons are minimally affected when a person looks upwards.

The third difference is the feel of these conditions when they are touched. Festoons are squishy and can be made to move side to side. Lower eyelid bags are firmer, deeper in location beneath the skin and can’t be moved easily side to side when touched.

I have had great success treating festoons and malar  mounds with my Laser Skin Resurfacing RESET treatment for lower eyelid festoons and malar mounds. See the video and link below for more details. 

Adam Scheiner, MD
Tampa Oculoplastic Surgeon
4.4 out of 5 stars 39 reviews

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

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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 75 reviews

Festoons (malar bags)

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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 91 reviews

Malar festoon surgery

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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 80 reviews

Eye bags, circles, and swellings

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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,


Benjamin Caughlin, MD
Chicago Facial Plastic Surgeon
5.0 out of 5 stars 13 reviews

Direct Excision of the Festoon

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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
4.9 out of 5 stars 59 reviews

Treatment of Festoons

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The treatment of festoons is complex and often not 100% satisfactory to patients. The scar following surgery may be unappealing. For large festoons, direct excision along with canthoplasty and laser skin resurfacing is usually the treatment of choice. You should have an evaluation with a surgeon to discuss your goals and determine the best treatment option. All the best.

Malar Bags - Festoons. What Do You Recommend?

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Festoons are a difficult problem to treat. Sometimes they can worsen after Surgery.
A extended lower blepharoplasty with a mid face lift can help. Canthopexy, arcus release, fat transposition will be performed as a part of the mid face lift. As you have discovered Fillers dont work and occasionally fillers can make festoons and malar bags worse. Lasers don't work either.

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.