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

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.

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,

DrC

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.