Malar bags and festoons:
not eye bags, not tear troughs

What causes malar bags and festoons?

Malar bags and festoons are caused by changes in the tissue over the cheekbone, in the triangle bounded above by the orbicularis retaining ligament, which runs along the rim of the eye socket, and below by the ligament that anchors skin to the cheekbone. That triangle is a natural pocket. With age and sun exposure the orbicularis muscle and the skin over it lose tone and begin to hang, the ligaments stretch, and the lymphatic channels that drain the pocket work less well, so fluid collects. Inheritance matters: some families show a malar mound from their twenties, and some faces have a cheekbone shape that makes the pocket prominent.

Fluid is the second ingredient, and it is why the swelling changes through the day. Anything that increases fluid in the face or slows its drainage makes malar oedema worse: lying flat overnight, salt, alcohol, allergies and sinus congestion, thyroid eye disease, some blood pressure medicines, and inflammation after procedures around the eye. Hyaluronic acid filler placed in or near the pocket is a recognised cause, because the gel draws water into itself and adds bulk to tissue that already drains poorly. The eye bag treatment page describes the four causes of under-eye fullness, and malar swelling is the one that sits outside the eyelid altogether.

What do they look like, and how are they told apart from eye bags?

A malar bag looks like a soft, rounded fullness on the upper cheek, sitting on or just below the cheekbone, separated from the lower eyelid by a visible groove. A festoon is the more advanced form: a loose fold or hammock of skin and muscle that hangs over the cheekbone and can be lifted with a fingertip. Malar oedema is the same area swollen with fluid, worse in the morning and after salty meals or alcohol, better by evening. All three sit below the line where a true eye bag ends.

The examination separates them from the two conditions they are confused with. A true eye bag is fat pushing forward from behind the lower eyelid; it sits directly under the lashes, is unchanged by smiling and becomes more prominent when the closed upper lid is pressed gently. A tear trough is a hollow along the bony rim, not a swelling at all. Malar swelling, by contrast, sits lower, often becomes more prominent on smiling as the cheek pushes up into the lax pocket, pits or shifts under gentle pressure when fluid is present, and fluctuates through the day. Photographs taken in the morning and evening are a useful part of the history. The under-eye filler guide describes the tilt and pressure tests used to separate a hollow from a bag at the same visit.

“Filler helps one under-eye problem, worsens another, and does nothing for the third.”

Dr Sin YongOn deciding whether filler belongs in the under-eye

Why does filler make malar bags worse?

Filler makes malar bags worse for two reasons that follow from the anatomy. Hyaluronic acid is hydrophilic: it binds water, and in a pocket that already drains poorly that water has nowhere to go, so a mound becomes a larger mound. And filler is a volume treatment, suited to concavities; a malar bag is a convexity, so adding gel beside it tends to blend the bag, the groove and the cheek into one heavier shape rather than smoothing them. This is why a visible malar mound or any fluctuating swelling over the cheekbone is one of the findings that rule tear trough filler out, as the tear trough filler guide sets out.

When the swelling has appeared or worsened after filler elsewhere, the first question is what product was used and where it sits. Ultrasound can show hyaluronic acid in the pocket, and dissolving it with hyaluronidase may be the right first step; non-hyaluronic acid products cannot be dissolved and are managed differently. A second opinion visit is the usual route for this, and it proceeds whether or not you have the records.

In what order is treatment planned, and what are the limits?

Treatment begins with the causes that can be removed. Allergies and sinus disease are treated, salt and alcohol are reduced, sleeping with the head raised is tried, thyroid function is checked where the history suggests it, and medicines that cause fluid retention are reviewed with the prescriber. Filler in the pocket is identified and, if it is hyaluronic acid, dissolved. For many people with malar oedema this medical review is the whole plan, and it is the step that is skipped when the swelling is treated as an eye bag.

The next layer is the skin and muscle envelope. Where the problem is early laxity rather than established folds, energy-based tightening can firm the skin over the cheekbone: monopolar radiofrequency, including the Thermage eye tip over the periorbital skin, and laser directed at skin quality. These are conditioning treatments with honest limits: they do not remove a fold of redundant skin, they do not re-route lymphatic drainage, and heat applied carelessly to a fluid-prone pocket can swell it temporarily, so settings are conservative. Skin boosters are not placed into the pocket itself for the same reason that filler is avoided there. Botulinum toxin and surface treatments are sometimes described for this area elsewhere; they are not part of the plan here because the evidence is limited and the mechanism does not address the cause.

Established festoons, with loose skin and muscle hanging over the cheekbone, are a surgical problem. Options described in the surgical literature include direct excision of the festoon, lower eyelid surgery with release and resuspension of the retaining ligaments, and midface lifting, and they are performed by a plastic surgery or oculoplastic specialist. Dr Sin Yong refers rather than offering a non-surgical substitute when the examination shows that the envelope itself has to be repositioned or removed. Fees for anything done here depend on what the assessment finds and are quoted in writing after the consultation, as the fee page explains.

What are the risks, and when should you call?

The risks differ by step. Dissolving hyaluronic acid filler carries a small chance of allergic reaction, which is screened for, and it also acts on the body's own hyaluronic acid in the area, which is why it is used after examination rather than on request. Energy-based tightening over the cheekbone can cause temporary redness, warmth and swelling, and in a fluid-prone pocket the swelling can be more noticeable for a time; less commonly there can be a blister, a crust or pigment change in darker skin. Treating the wrong diagnosis is the main risk of all, because filler, or heat, or surgery aimed at an eye bag that is really malar swelling leaves the person worse off.

Call the clinic for swelling that is increasing rather than settling after any treatment near the eye, for pain, redness or warmth that suggests infection, and after any filler for white, dusky or mottled skin or worsening pain, which need same-day assessment. Any change in vision is an emergency: go to a hospital emergency department. The complication care page explains what to do if something feels wrong after a treatment, wherever it was done.

When should you see a doctor about malar swelling?

See a doctor when swelling over the cheekbone fluctuates through the day, when it appeared or worsened after filler, when it is one-sided or came on quickly, which needs medical review for causes such as infection or a blocked tear duct, or when it comes with itchy eyes, congestion, weight change or changes in heart rate that point to allergy or thyroid disease. Established folds that bother you are worth assessing so that the surgical route can be explained rather than guessed at. Singapore's rules prevent prices from being advertised, so fees follow assessment. The consultation process page describes what the visit involves and what to bring, including morning and evening photographs.