Can Malar bags below the lower eyelid be removed?

Many of the changes we typically encounter in the lower lids with the passage of time--namely tear trough deformities, hollows and bags,  result from shrinkage, shriveling, and a downward descent of the once robust, heart-shaped fat pad that sat immediately under the lower lids and extended out toward the temples, inward toward the root of the nose, and downward about half-way to the angles of the mouth. The loss of this volume and its downward displacement  in the direction of the jaw (due to weakening of the supporting ligaments and the downward pull of gravity) elongates the lower lid to several times its narrow youthful width and leaves it somewhat sunken. In addition, like a balloon having lost its air after being fully inflated for a long while, the skin of the lower eyelid fails to snap back to its youthful smoothness, and instead remains crinkled and baggy.

Today, we can attempt to address these problems nonsurgically with the injection of fillers and volumizing agents to restore the volume to the lower lids and recontour them, mask the bags, and diminish the darkish discoloration.

A variety of have been tried for these purposes.  My personal favorites for dealing with tear troughs--for providing overally smoothness, shape and lift-- are the recently approved Belotero Balance and Restylane L. When more cheek support and buttressing are needed for the lower eyelid, the upper inner cheek immediately below may be supplemented with with Perlane L, known for its lifting capacity. 

In my experience, while more prominent bagging may be improved considerably with this approach, some degree pf bagging typically persists following treatment. On the other hand, for mild to moderate bags, it usually takes about five minutes to treat each lower lid with immediate that typically evoke a "Wow!" response from  patients when they look in the mirror.

While minimal bruising, tenderness, swelling and redness may occur following treatment in this delicate region, these are usually temporary and disappear spontaneously within one to seven days. Most people can return to work or social activities immediately or the following day and coverup may be used if desired.

There are many causes of eye bags. Some are shadow issues, some are discoloration issues.  Most people have a multifactorial issue, meaning that there are a few different issues going on. Successful treatment of eye bags requires recognizing this. A mid facelift can treat certain isolated areas of eye bags and folds but most people require a lower lid blepharoplasty with fat transposition and possible fat grafting.  This can give great results for patients. Below is a list of some of the most common causes of eye bags. I also included some of the treatments that, in my hands, get the best results. There are a few videos attached also explaining my treatment process.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

The treatment of malar bags have dogged the speciality of plastic surgery as it is still one of the most difficult of all facial deformities to correct. Some facelift techniques will improve them and others not so much. Attempts to directly remove them is frought with complications and is not recommended.  I have found that doing a midface lift using the endotine support, possibly with fat grafting during or following the procedure, to provide the best results.Sometimes it is best to be conservative and do the midface lift first before considering adding volume. Sculptra and other volumizers or fillers, will often help to fill out the face following a facelift and improve the malar bag significantly. We now have the tools to add volume in addition to surgical techniques and technologies to tighten the skin. Eyelid surgery alone is not going to treat the malar bag.  It sounds like you have a thin, deflated face and that you need volume. Volume alone is often not the answer and creates a undefined fullness if nothing is done to address the descent of the midface. I would discuss this issue with your plastic surgeon and if not satisfied, see and experienced Board Certified Plastic Surgeon who does these techniques and show you results. I think that you also need to wait before doing anything else. It is still soon to do anything and surgery causes edema that can temporarily worsen a malar bag. 

A standard facelift does not adequately address the malar bags. Your surgeon should know this and should have addressed this with you before your surgery.  Maybe he/she did discuss this with you but there was some miscommunication about it. Correction of these malar bags and hollows usually requries a lower bleharoplasty incision and either a midface cheek lift or redraping of the orbital fat. If your surgeon seems angry with you when you raise this issue, then you certainly should seek another opinion. 

Malar bags can be successfully treated with several options.

A midface lift will elevate tand suspend these bags to the orbital rim and cheekbones.

The Cellulaze sidelaze laser can melt these bags through small incisions.

An extended lower blepharoplasty can also be used to flatten these bags.

Depending on their depth fillers, Perlane, Radiesse, Artefill and Sculptra can diminsh their appearance.

Please consult in person with a Board Certified Plastic Surgeon prior to making treatment decisions.

Malar bags cannot be removed with eyelid surgery or a facelift. Malar bags are best treated with Fraxel laser surgery and when severe enough, a direct surgical excision can be performed.

Malar bags are very hard to deal with. First, let me say that after one month since surgery, you do not yet know the final result of the facelift. You still have some swelling in the malar area.

With that said, if you still have true malar bags, the best way to remove them is to actually excise them. This will leave a scar, but in that region it is hardly perceptable. I learned this by removing various skin cancer in that area through the years and noting that scars were not very visible.

The hollowness that you mention between the malar pad and the mouth is a separate and different problem, but may accentuate the malar pad. This can be treated with a filler first, and if you like the result, fat grafting (transfer) may be indicated. Fat grafting when done according to acceptable methods can be a very gratifyng procedure.

For a temporary filler, Sculptra is a good volumizer for that area and it will last about 1 1/2 to 2 years. Other fillers such as Restylane or Juvederm are good also and have the safety margin of being reversable. Artefill is much more permanent and can work as well. These fillers should be discussed with your plastic surgeon.

Good luck with getting you problem corrected, and thank you for your interesting question.

Malar bags are difficult to treat. It hasn't been that long since your surgery, so please be patient. It may well improve with time as you heal.

There is no one answer that is best. As you can tell from the other answers, there are many options and none are perfect.

Options include more surgery after waiting, fat transfer, fat transposition, and direct excision of the bags.

I hope this helps. Give it a couple of more months first.

Best wishes!

Dr. Chris Saunders

Malar bags are ares of swelling on the cheek that is basically edema fluid.  It is like swollen legs and will not get better.  Sometimes, it can be camouflaged from face lifting.

 Dear Maria, 

Malar bags are difficult to totally correct.  When presented with this particular deformity I usually elect to correct this problem through a lower eyelid blepharoplasty.  Usually the orbital fat can be used to fill in some of the flatness in the central portion and upper malar zone.  In some cases the I separate the skin from the underlying muscle layer essentially creating two separate flaps that can be re-suspended laterally.  In addition the malar fat pad can be elevated in the supraperiosteal plane, just above the cheek bone with a release of the orbito-malar ligament.  These two maneuvers help to suspend the malar bag.  One of the problems is that of edema and swelling that can make the malar bag difficult to totally correct.   Photos of your problem would be useful to help determine your exact concern.  It has only been one month since your surgery and you definitely need more time for things to settle down.  If you do not get significant or satisfactory improvement there are alternatives available.