Significant malar bags at 19 years old, what are the solutions? (Photo)

Since I was a child I have had what I think are malar bags - puffiness on my cheekbones rather than directly under my eyes. They seem to be getting worse as I get older, and often become red at times throughout the day. No one else in my family has this problem, so I was wondering if it may be a medical issue? If so, what are possible causes? If it is a cosmetic issue, why would this occur in someone so young (19 years old) and what are some options to resolve this? Thank you.

Doctor Answers 3

Malar bags and puffiness of the cheeks in a young male present interesting challenges

You present a very interesting case to me, and for the purposes of discussing it, there are a couple of things that come to mind.  We must first think from a standpoint of causation however, and this leads to the development of a list of options for management.  To begin, some people can have inherited conditions which cause cyclical swelling and irritation of their eyelids and orbital regions.  This may also be associated with allergic conditions.  My first approach to treating these kinds of things in younger people, especially males (I'll explain later) is to try and identify any root causes for the condition so that a) those can be addressed first, and thus a lasting, definitive result can be obtained, and 2) we won't sabotage any efforts at cosmetic correction by allowing an underlying functional or physiologic condition to continue unchecked.  You might start with your primary doctor, an ophthalmologist who specializes in eyelid conditions, or an allergist for this purpose.

Having said those things, I can also see from your images that there is a distinct anatomical aspect to your condition too.  That is where we as plastic surgeons come in, because that is essentially what we do:  we analyze your anatomy and come up with ways to change it to hopefully produce a more pleasing aesthetic result.  Thus, all of our treatments as cosmetic surgeons should start there.  If we can't properly identify an anatomical reason for the problem, we probably shouldn't be doing a procedure.  In the images that you have posted I can see a very definite demarcation between the fat pad that encircles the lateral (outside) part of your orbit, or eye socket, and the cheek fat and bony architecture.  This is the oblique line that seems to run right across your cheek.  Part of the reason why it is so prominent in my opinion, is because the fat pad around the orbit, let's call it the "SOOF" (suborbicularis oculi fat) is relatively more prominent than the malar fat (the "cheek" fat) pad.  Additionally, the bony cheek, or maxilla, is relatively underdeveloped in your face, giving you a flatter, broader midface, and providing less of a firm foundation for your cheek soft tissues, including your fat pads.  However, I think your orbital structures, including and especially the SOOF and orbital fat appear normal to me.  Your brows (including the "ROOF" fat pad which is contiguous with the SOOF fat pad), eyelid structure and position, orbital rims, and eyeball positions all appear optimal for a young man your age.  It is the cheeks that are lacking.  Thus, with the orbital structures, including the SOOF, taking precedence, you get the contour irregularity that you are now seeing.  This could be exacerbated by any cyclical swelling or intermittent conditions that overly your anatomy.  

This leads to the question of what to do.  Assuming that we have ruled out any functional causes as I outlined above, or such causes are at least identified and being treated, I will focus purely on options to address the anatomy.  I would personally suggest a plan to augment your cheek soft tissues, and I would suggest a very conservative approach.  The reason for this is, as I alluded to above, one of the most common miscues seen in male facial cosmetic surgery is that the men are feminized by either heavy handed technique on the part of the surgeon or the wrong technique for a male, which creates a feminine appearance.  This is never more true than in the cheeks and midface.  You need more soft tissue volume in your cheeks to camouflage your contours, yet you don't need big, round apple cheeks like most ladies desire.  That would make you appear feminine.  In order to accomplish that goal,  a surgeon might start with some judicious filler injection, or for a more permanent result, transfer of some of your own fat to the cheek would work very nicely.  Again, this can be overdone, so the surgeon has to be on board with the technical nuances of this.  I would not suggest cheek implants because in addition to being fraught with more complications than other methods of augmenting the cheeks, they will primarily augment what is already sufficient upper cheek projection, leaving you appearing bizarre and feminized all at once, and it is really the soft tissues that need the volume and contouring.  I also would not suggest blepharoplasty or anything else on your eyelids themselves, as I don't think that's the problem here.

I know this is a long-winded summary, but it's a fun technical discussion about a very delicate situation in a young man that requires a very nuanced approach.  However, something can certainly be done to improve things.  You should find a board certified plastic surgeon or facial plastic surgeon who has good knowledge of the detailed anatomy of this part of the face and experience with facial soft tissue augmentation approaches.  That way you can get a thorough evaluation and all of your options can be outlined for you.  Best of luck.

Erbium Yag laser treatment

Laser treatment has shown to be very effective in treating the malar bags or fastooning. I don't beleive this is related to blepharochalasis, but this is very much a problem on its own. and it is anatomical and genetic in origin. Lower eyelid blepharoplasty can help as well but it takes for ever for the edema to resolve. injection of filler in this area can worsen the problem unless the person knows how to use the fillers in this condition. I have been able to resolve some of these fastoons with just injection of little filler and laser treatment.   

Significant malar bags at 19 years old, what are the solutions?

In a patient with your inherited anatomy, fillers or non-surgical procedures may produce a small temporary improvement but will not achieve a good long-term cosmetic result.

The best correction would be achieved with a lower lid blepharoplasty: conservatively removing the excess skin, tightening the loose lower lid muscles, contouring any bulging fat pads if they are present, smoothing the depressed tear troughs with micro-fat graphs and tightening the malar area.

Keep in mind that following advice from a surgeon on this or any other website who proposes to tell you exactly what to do based on two dimensional photos without examining you, physically feeling your tissue, assessing your desired outcome, taking a full medical history and discussing the pros and cons of each operative procedure would not be in your best interest. I would suggest that you find a surgeon certified by the American Board of American Plastic Surgery and one who is ideally a member of The American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with.

If you live outside of the United States, the surgeon should ideally be a member of the International Society of Aesthetic Plastic Surgery (ISAPS).You should discuss your concerns with that surgeon in person.

Robert Singer, M.D., FACS

La Jolla,California

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

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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.