What Causes Water Retention Under my Eyes?

I am 47 years old and I have developed malar edema. It sits right above my cheekbones and will not go away. Should I find out if there is an underlying health condition before I go to a plastic surgeon and if so, what type of tests should be done? Thanks

Doctor Answers 13

"Water Retention" Myth

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What people usually (mistakenly) refer to as "water retention under the eyes" is actually fat prolapse. The fat can become more prominent for different reasons. The bags look larger in the morning because they become more swollen as we sleep on our backs. Allergies may also increase the swelling as can some medical conditions. It is best to seek an in-person consultation with your Oculoplatic Surgeon to determine an appropriate treatment plan. I hope you find this helpful.

Fluid retention under eyes

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Hi Lisa

I know how frustrating your condition can be.  As stated by the other doctors checking for a familial predisposition should shed some light as to the cause.  However, I have found this problem to be what we as doctors call, multifactorial (many things can lead to it).  You should check with your primary doctor if any medical condition can be adding to the problem (something that would cause you to retain salt). 

As far as treatment options.  Surgery can aggravate the condition and cause more or new fluid retention.  Mechanical compression with tape at night, etc. is very unpredictable if at all helpful.  Some of the more aggressive lasers which remodel the skin and deeper tissue have shown some success - but with prolonged recovery.  I and some colleagues have attempted inserting a metal probe (insulated) to the area and applying heat to shrink and tighten the tissue and reduce fluid.  This is generally benign and has had variable success.

I think a consultation with a specialist is worthwhile so the tissue can be seen and felt.

Best of luck

Guy Massry, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 54 reviews

Eye bags, circles and demarcation

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There are many causes of eye bags. Some are shadow issues, some are discoloration issues.  If anything you could have your thyroid levels and a hemoglobin check. Fortunately this is likely just the result of living life!  Below are some common causes and treatments.

1. Prolapsed orbital fat through the orbital septum: treated with lower lid blepharoplasty and fat re-positioning. 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. Ezcema: 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 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

Water Retention and Eye Bags

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Hi Lisa Bone,

Eye bags have multiple causes, with each having various contributions to facial appearance. Bags are commonly due to eye fat which protrudes a little from the eye socket, in addition to sagging eyelid skin & muscle or edema. One also looses facial fat in the skin & cheeks from age. Weight fluctuations will affect eye bag appearance. Allergies and hormonal conditions will affect eye & cheek bags too. Lastly, water retention will affect the face from such factors as diet, medication, heart, or kidney conditions.

You may start with a visit with your primary care physician, or seek the opinion from a plastic surgeon. After a comprehensive evaluation can a specialist help determine the cause of your specific eye bags and provide some treatment options. Best of luck.

Dr. Chaboki

Houtan Chaboki, MD
Washington DC Facial Plastic Surgeon
4.9 out of 5 stars 89 reviews

Under eye bags

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Under eye swelling can be contributed to by allergies, alcohol consumption as well as herniation (or bulging) of orbital fat deposits.  Making sure all allergies and external causes of swelling (alcohol intake, etc) are addressed prior to any interventions you elect is really important. It's totally reasonable to start with your PCP prior to seeing a plastic surgeon.
Best of luck in reaching your goals

Fluid retention lower eyelids and cheeks "malar bags"

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Malar bags are small sacks of edema that accumulate over the cheek bones in people who are genetically predisposed to have it occur.  You can try and cut down on your salt intake and see if they improve.  There are no surgical ways to reliably decrease malar bags...but I have been successful in people who are also candidates for Cheek Augmentation, by improvong the Cheek Shape with Cheek Implants that camouflage the malar bags.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Consider seeing an oculoplastic surgeon.

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Dear Lisa

There is what doctors call a differential diagnosis for malar swelling.  However, for many this change is associated with aging and family genetics.  So if all the women of your family have a similar issue as they age, that is most likely the answer.  Yet there are other possible causes so if the malar festoon is newly acquired and not a feature of your family, a consultation to address possible medical causes is reasonable.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Malar Edema

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Hi Lisa,

That can be a frustrating problem.  To date, I have never uncovered a health condition that directly correlates with malar edema, and I do not recommend routine testing of any sort to look for an undiagnosed problem for the average patient.  I can imagine there are exceptions to this, but I personally do not encounter them in my practice, with the exception of patients who have undergone complex reconstructive surgeries.

My own mental schema of the lower lid and midface likens the complex to a sponge.  Sponges suck up water, and the movements of the face wring that water out and help move it along into the lymphatic drainage system.  The only approach that I have that works is to tighten every layer of the lower lid / midface complex to improve the effectiveness of the "wringing" of the sponge. I tighten the midface, then the lateral canthal tendon, then the muscles that encircle the eyelid, and finally, the skin.  This does not work all the time, but it does a significant percentage of the time.

The fact that there are so many "solutions" to this problem suggests to me that there are no true high percentage fixes with any of the techniques.

Best regards, 


Joseph Walrath, MD
Atlanta Oculoplastic Surgeon

Lower eyelid / cheek puffiness

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Hello, I believe that your edema may be due to three reasons: 1) the connective tissue sheath surrounding the three fat pads within the lower eyelids thins with age, leading to fat herniation and puffy lower eyelids; and 2) the lower eyelid skin becomes less elastic and descends, causing a crepe-y lower eyelid skin appearance and tired look; and 3) it may be due to malar festoons, which look like thickened mounds sitting atop the cheek bones. I would recommend a consultation with an oculoplastic surgeon to help distinguish these three conditions and plan your treatment accordingly. 

Tanya Khan, MD
Austin Physician

Festoons-Difficult to Fix

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In reading the answers below I see that many focus on lower eyelid fat pseudoherniation and blepharoplasty. In reading your question, I think you are actually referring to malar edema caused by festoons. If you read about festoons you will see that they are difficult to treat, and many possible solutions exist.

Festoons are the result of a spongy tissue that lives between a triangle of ligaments in the malar area. This spongy tissue collects fluid and is troubling to many patients. 

Minimally invasive treatments include decreasing salt intake and sleeping with your head elevated may be helpful. In some situations, oral diuretics can be prescribed. More invasive treatments are also available including deep laser resurfacing and surgery. There are many surgical options and they must be individualized. Direct excision is an option, as well as transconjunctival manipulation. Orbicularis elevation with compression of the area can also be helpful in some situations.

I recommend seeking care with a surgeon who has extensive experience in this area.

Best of luck!

Ivan Vrcek, MD
Dallas Oculoplastic Surgeon

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.