I have malar bags (festoons) as well as under eye bags. Can this be treated? Is laser or Blepharoplasty best? (photos)

Doctor Answers 13

Under eye bags can be treated definitively and for the long term, but the fluid that causes malar bags are a challenge

As an oculofacial plastic surgeon for 20 years, the treatment for eyebags is fairly straightforward. However, malar bags have been one of the most challenging things that anyone who works in this area has to deal with.

Under eye bags are caused by something called lower eyelid fat prolapse. Lower eyelid fat prolapse is an anatomic diagnosis where the fat pockets that are around the lower lids, behind the skin and the structure called the septum push forward and create a bulge. This tendency most commonly comes for a genetic pattern. In fact, I have operated on 3 generations in the same family with exactly the same issue.

In order to treat lower eyelid fat prolapse especially in younger people, we would routinely do something called transconjunctival blepharoplasty. Transconjunctival blepharoplasty is an approach of addressing the fat pockets from the inside of the eyelids. With this approach, we are able to avoid an external incision or scar. At the same time, we are able to get the nice natural contour as if you never had eyebags.

On the other hand, malar bags are the result of fluid over the most prominent area of the cheek bones. They are typically associated with allergies, sinuses, smoking and of course genetics. The basis is that fluid tends to back-up into the cheek area and stays there. Since malar festoons or malar edema is due to fluid, surgical procedures are not really effective in making significant improvements. The patients who make the most dramatic improvements are the ones who have the worst festoons that you can directly excise them and they will look better. When they are subtle, we usually don’t do anything. But when they are a little bit more obvious, I do procedures that can soften the transition between the eyebags and the malar edema. We have done things like the use of platelet-rich plasma to try to improve circulation.

There are some doctors that really advocate lasers but these areas are very tricky and when you apply heat in this area, there is no guarantee that the festooning will not get worse. I have not been an advocate of using laser in addressing the festoons alone. That being said, we can consider options such as treating underlying allergies, sinuses or advice the smoker to stop smoking. In addition, we do employ the use of fillers as well as platelet-rich plasma. Platelet-rich plasma briefly is a product of your own blood. We draw your blood, spin it and concentrate the healing factors. This has some improvement in the skin quality as well as the circulation that can make the area look better.

I think that your strategy is to first do the transconjunctival blepharoplasty to reduce the fat pockets and then see how this looks in context with the malar edema. In our practice, we usually find that getting rid of the bags makes a huge difference. At the same time, there’s a percentage of patients particularly those in the advanced facial aging where there’s volume loss, who are happy about the bags being gone but then are concerned about the appearance of the fluid in the cheek area. Many of those patients benefit by adding volume to the cheeks to give them projection and to soften the appearance so that it doesn’t look so obvious.

At this point, I think that you should go and meet with some qualified experienced surgeons and discuss your options then you can move forward with the plan. I hope that was helpful, I wish you the best of luck, and thank you for your question.

New York Oculoplastic Surgeon
4.3 out of 5 stars 61 reviews

Lower eyelid swelling

You have some prolapsed orbital fat which is creating a shadow over the tear trough.  Your tear trough extends pretty fat laterally, just under the malar fat pad.  This is not a festoon, as that would be more over the cheek bone.  If you put some filler into the tear trough you will be able to smooth out this area and improve the appearance for at least at year.  Another option is surgery - but you would need to have the fat repositioned and not removed.  If it is excised you may end up looking worse.   

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 25 reviews

Lower eyelid surgery

I would recommend a lower lid blepharoplasty to remove the herniated fat. Some of the fat can be placed in the groove to efface it.  Laser would not fix this. 

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Options for Under-Eye Bags

From your photos, it looks as though you have only under-eye bags, and lasers would not be an effective option. You are still young, so injectable fillers would probably help reduce the appearance of the bags. That way, based on the results, you could decide whether you wish to continue with them. 

My patients have loved the results achieved with injections, and we find them extremely popular for those not yet ready for blepharoplasty. In the future, you may wish to have blepharoplasty. However, before deciding which option is best for you, consult a qualified facial plastic surgeon in person. And get a second opinion.

Cory Torgerson, MD, PhD, FRCSC
Toronto Facial Plastic Surgeon
4.8 out of 5 stars 112 reviews

I have malar bags (festoons) as well as under eye bags. Can this be treated? Is laser or Blepharoplasty best?

From the photos you posted it appear you have only "eyelid bags" and not festoons.  However an in person consultation would be the best way to determine a correct diagnosis and treatment plan.

However, based on what is seen I would recommend a lower blepharoplasty with the fat re-positioning technique.  The technique will elegantly re-position the eyelid bag (which is fatty tissue) into the deep groove below the bag thereby smoothing the entire area.  (see the link below to see before and after results).

Fillers are a non-surgical option but would not give you the result a lower blepharoplasty would in my opinion.  I would use either Belotero or Restylane and use a cannula to inject.

I hope this helps.

Timothy R. Miller, MD
Orange County Facial Plastic Surgeon
5.0 out of 5 stars 60 reviews

Multi-faceted eye rejuvenation yields the best results

Thank you for your pictures, they help to clarify the situation.   That being said, you need to pursue in person consultation with one or more local facial plastic or oculoplastic surgeons.  This will help you become more educated and get the best recommendations.  

The eye (along with the rest of the face) doesn't age in just one way, so the best rejuvenation will involve different facets as well.  There are 3 main things to consider for rejuvenation around the eye:

First, the skin around the eyes is incredibly thin.  It shows aging changes early but it is also very responsive to treatment.  As far as I can see in your pictures, this area is not a major problem for you.  Therefore, laser treatments and chemical peels won't do much for your concerns.

Next, volume loss in the tear trough and upper cheek helps to bring out and emphasize the appearance of any bagginess of the eyes.  This volume loss can be readily treated with fillers like Restylane or with fat transfer.  The tear trough (area closest to the nose) *can* be improved during blepharoplasty but the depression in your cheek area will not be corrected by blepharoplasty alone.  A more volumizing product is best for the cheek area like Sculptra, Voluma, etc.  

The third aspect to eye rejuvenation  is the bulging of the lower eyelid/orbital septum.  This is corrected by blepharoplasty surgery.  Especially in a younger patient, it is best to want to avoid aggressive surgery as it will leave your eye looking hollow as you get older. One thing you will want to discuss with your surgeon is how much swelling you have on a day to day basis.  If you have major swelling of the lower lid and/or cheek area your recommendations may have to be adjusted.

The volume loss in tear trough and cheek show up first as we get older, and as mentioned above, it very much accentuates the lower eyelid.    Many patients are very surprised at how much improvement they can get from fillers in the cheek and tear trough.

In summary, it appears your major area of concern is the volume loss in the tear trough and cheek.  You should be able to get excellent results with fillers alone to start with.  If necessary, a conservative blepharoplasty could be done later.  

Michael Bowman, MD
Roanoke Facial Plastic Surgeon
5.0 out of 5 stars 9 reviews

Malar bags (festoons) as well as under eye bags?

Most expert experienced artistic plastic surgeons have a variety of procedures at their disposal to produce excellent cosmetic results in the appropriately selected patient: temporary fillers, micro-fat grafts, and blepharoplasties. There is no one best procedure. Each has benefits and potential drawbacks.

A laser treatment would not correct the area that concerns you. The longest lasting procedure that could improve the malar fullness, bulging pat pads, as well address the hollows would be a lower lid blepharoplasty.

Following the advice of anyone who would presume to tell you what to do based on limited 2 dimensional photos without taking a full medical history, examining you, feeling and assessing your tissue tone, discussing your desired outcome and fully informing you about the pros and cons of each option would not be in your best interest. Find a plastic surgeon that you are comfortable with and one that you trust and listen to his or her advice. The surgeon should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS). You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California

Robert Singer, MD
La Jolla Plastic Surgeon
4.6 out of 5 stars 19 reviews

OK, I am going to disagree with Dr. Parsa.

First, there is no substitute for an actual examination.  Remember what we are doing here on Realself.com is entertainment but you won't feel that way reading answers about your question.  

There are many causes for lower eyelid bags.  Doing the wrong surgery will not help you but it will harm you.  The issue you are manifesting in the photos is not actually a lower eyelid bag.  Traditional lower eyelid surgery will not help you.  The feature that is bothering you is called a mid cheek groove.  It is best managed today with carefully performed hyaluronic acid fillers.  Yes it is possible to also perform surgery for this.  The problem is that you need deep buccal fat support and the fillers are the most flexible and efficient method of providing this help.  A treatment for someone your age could last well over a year.

Please be careful what you look for.  If a surgeon spend less than 5 minutes examining and discussing your issue, you are in the wrong office.  Good luck and let us know if you decide to have treatment and how it went.

Kenneth D. Steinsapir, MD
Los Angeles Oculoplastic Surgeon
4.9 out of 5 stars 23 reviews

Malar bags treatment

Dear Christie,
If you are looking for a long term answer to what is bothering you, you should consider lower eyelid blepharoplasty. The newer techniques involve fat repositioning. Any other treatment is only temporary. Lasers don't work for your type of problem. And don't let anyone inject fillers to your lower eyelids. Again this answer is based on what I see from your pictures. Finally make sure you see an oculoplastic surgeon for any thing related to your eyelids. 

Kami K. Parsa, MD
Beverly Hills Physician
4.8 out of 5 stars 35 reviews

Ways to treat under eye bags and festoons/malar mounds

Lower eyelid bags and festoons/malar mounds usually appear as we age. In certain young patients though, the orbital septum is set more forward in the orbital rim allowing this normal orbital fat to be seen in the lower eyelid space. These cases in younger individuals can be seen as early as the early teens.

This can be frustrating because it can cause others to see us as tired appearing.

In your photos, you also appear to have malar mounds/eyelid festoons. As expressed by other doctors, this can be a challenging condition to improve. I myself have had great success using a Dual Pulsed Erbium Laser with my RESET treatment for malar mounds and eyelid festoons.

The lower lid under eye bags can be addressed with a very conservative lower lid blepharoplasty or fat repositioning procedure.

Its best to address both the lower eyelid festoons and bags at the same time for the most natural result.
Its not fair to have to face this issue at such a young age but there are treatment options available for both these conditions.

Adam Scheiner, MD
Tampa Oculoplastic Surgeon
4.3 out of 5 stars 32 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.