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

Doctor Answers 14

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

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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.

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

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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 70 reviews

Lower eyelid swelling

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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.   

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Malar bags treatment

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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 Oculoplastic Surgeon
4.9 out of 5 stars 40 reviews

Eye bags, circles, and swelling

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There are many causes of eye bags. Some are shadow issues, some are discoloration issues.  Most people have a multifactorial problem meaning they have more than one problem causing this demarcation. You are young so you should be conservative with your decision. With your age group we are often able to make a very big difference with laser and fat transfer alone. Some people also require a blepharoplasty but that is more of a fat pad problem. Below is a list of common causes and my treatment protocol.

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

Options for Under-Eye Bags

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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.

Multi-faceted eye rejuvenation yields the best results

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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

Lower eyelid surgery

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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. 

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

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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

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

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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
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 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.