Malar bags, also known as festoons, are a common aesthetic concern appearing on the mid-face. These chronic swellings can make an individual look perpetually tired or unwell. Unlike typical under-eye puffiness caused by bulging orbital fat, malar bags involve a complex issue of the skin, muscle, and fluid dynamics of the cheekbone area. Finding a lasting solution ranges from simple daily habits to specialized surgical procedures.
Defining Malar Bags and Their Causes
Malar bags are chronic, puffy mounds of skin and tissue that appear on the cheekbone, or malar mound, just below the lower eyelid-cheek junction. They are often classified as a form of chronic swelling that can worsen into festoons, which are more severe, drooping folds of tissue.
The development of these mounds is multifactorial, involving age-related tissue changes, fluid retention, and environmental damage. As the skin loses collagen and elastin, the delicate supporting structures weaken, including the orbicularis oculi muscle that encircles the eye. This laxity allows fluid, sometimes called malar edema, to collect and become trapped in the area, often appearing more prominent in the morning. Sun damage, or elastosis, further degrades the skin’s structure and is a primary contributing factor to the severity of the condition.
Lifestyle Adjustments and Topical Approaches
Initial management involves simple adjustments to daily habits aimed at reducing fluid retention and supporting skin health. Reducing the intake of salty foods and alcohol can minimize systemic fluid buildup, which exacerbates puffiness, especially overnight. Elevating the head while sleeping can also assist in encouraging lymphatic drainage, preventing fluid from pooling in the cheek area.
While lifestyle changes offer minor symptomatic relief, topical products have a limited role due to the condition’s deep, structural causes. Retinoids (like Tretinoin) may help marginally by promoting new collagen formation and improving skin texture over a long period. Caffeine-based creams are sometimes used to temporarily constrict blood vessels, offering a slight reduction in swelling, but they are not curative for the underlying tissue laxity or chronic fluid accumulation.
In-Office Non-Surgical Treatments
For individuals seeking professional intervention without surgery, a variety of in-office, minimally invasive procedures are available to address the components of malar bags. These treatments primarily focus on tightening the compromised skin and reducing the chronic inflammation and fluid volume within the mound. The mechanism of energy-based devices, such as radiofrequency (RF) and laser treatments, is to deliver controlled thermal energy to the skin and underlying tissue. This heat stimulates the production of new collagen and elastin, leading to a noticeable tightening and improved skin density over several months.
Ablative laser resurfacing, such as with CO2 lasers, can be highly effective in tightening skin and improving texture damaged by elastosis, but these procedures come with significant downtime. The process involves removing the outermost layers of skin to trigger deep healing and tissue contraction. Radiofrequency microneedling combines the collagen-boosting effects of microneedling with deep thermal energy to target laxity in the deeper layers of the skin, offering a less aggressive tightening option.
Injectable Treatments
Injectable treatments are utilized to target the fluid and inflammation components of the malar bag, but they require careful application. Steroid injections, typically with a low-dose corticosteroid like Kenalog, are used to shrink the inflamed tissue and reduce fluid retention. This approach carries a risk of tissue atrophy, or thinning, if the medication is administered incorrectly or too frequently.
The role of dermal fillers is controversial, as adding volume to an already swollen area can often worsen the appearance of the mound. Fillers are sometimes strategically placed around the festoon, such as in the tear trough or mid-cheek, to camouflage the transition and smooth the contour, but they do not treat the bag itself. If misplaced filler is contributing to the swelling, dissolving the existing filler with hyaluronidase is a necessary first step.
Deep chemical peels are another option to address significant sun damage and skin laxity. However, they are limited to improving the superficial skin quality and cannot resolve the deep structural issues.
Surgical Options for Permanent Reduction
When malar bags are severe or have not responded to non-surgical methods, surgical intervention offers the most definitive and long-lasting correction. The choice of procedure depends on the extent of tissue laxity, fluid accumulation, and the patient’s overall facial anatomy.
Direct excision involves physically removing the festoon or malar mound, along with the excess skin and underlying tissue. This technique is typically reserved for the most pronounced cases, as it involves an incision often placed along a natural skin crease, requiring careful scar management.
More comprehensive surgical approaches often combine a midface lift with a lower blepharoplasty. This combination allows the surgeon to address excess skin and fat in the lower eyelid while lifting and repositioning the sagging midface tissues. During a midface lift, the underlying orbicularis oculi muscle is often tightened and suspended (muscle plication), which provides crucial structural support to prevent future sagging and fluid accumulation. A transconjunctival approach (an incision on the inside of the eyelid) may be used to address associated fat pockets or access deeper layers of the midface for repositioning. These surgical options require a longer recovery period than non-invasive treatments, but they offer the most significant and permanent improvement by correcting the underlying structural causes.