There are a lot of different things that can contribute to an overall aged look, but malar bags are one area that can especially age your profile. Once the natural fatty deposits and bone tissue beneath the eyes begin to recede, your face can look worn out and tired, no matter how well-rested and youthful you really feel.
What are Malar Bags & Creases?
Malar bags (malar mounds or malar edema) are bumps that occur just below the outside corner of the eye, on the top of the cheekbone. Malar bags do not form from tissue growth or from something raising up the tissue in that location. Malar bags are relative elevations in that they only appear like a bulge because the cheek below is sinking. An analogy is that of a rock at the beach. When the tide is high, the rock looks small. As the tide goes out, the rock looks bigger. The malar bag is the rock, and as we get older, the tide goes out with the loss of excess fat and bone from the cheek directly below the bulge. This creates the appearance of a malar mound. Usually, at the bottom of the malar bag is a sharp crease that runs diagonally from the inside corner of the eye down laterally. Malar bags occur equally in both men and women, becoming more pronounced as we age. Leaving the condition untreated will not necessarily make malar bags permanent, but it can worsen the condition substantially.
They are often caused by fluid retention, aging, or a genetic predisposition.
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Malar Bags vs. Festoons
Malar bags are different from festoons. Festoons have the appearance of a “swag” in the skin texture on the cheek directly below the eye. Festoons and malar are both caused by thinning skin of the lower eyelid and skeletonization of the orbicularis oculi muscle (the muscle that wraps around the eye and closes the eyelid). Festoon treatment will improve appearance when the patient squints and tightens up the muscles around the eye; however, malar bags do not improve with squinting and tightening the orbicularis oculi muscle.
How Do You Treat Malar Bags?
There are a couple of different approaches to treating malar bags. The right one for you might depend on the severity of the issue and your candidacy for each option.
Non-Surgical Dermal Fillers
The best treatment for malar bags is the injection of hyaluronic acid fillers such as Restylane, Juvederm, or Voluma into the upper cheeks below the malar bag to hide the shadows and restore the gentle convexities of youthful cheeks. If there is a very sharp, embedded malar crease, the filler needs to be injected directly below the crease and into the skin of the crease to change the concavity to a gentle convexity.
Following the injection, you may experience some bruising, but this is much less common because we use cannulas (blunt-tipped needles that are less likely to cause bruising). Occasionally, we will prescribe medication to take before and after these non-surgical treatments to decrease the amount of swelling that can occur after an injection. For the first twenty-four hours after a malar bag treatment, you should apply cold compresses to your cheeks and limit your bending. You can shower and wash your face that day, and resume using makeup in the area the next day. You will follow up with Dr. Stanislaw seven to ten days after the injection, when the injectable filler can still be molded and sculpted if needed.
Also, if you use retinol or Retin-A, you should stop using these creams in the areas to be injected one week before and one week after the injection.
Facelift
Depending on the causes of the malar bags and the patient’s facial anatomy, a facelift can sometimes help improve the appearance of the malar eye bags themselves. This cosmetic surgery can free the malar crease skin from the ligaments anchoring it to the bone, allowing the excess skin and fat to be repositioned to create a better cheek contour and, therefore, hide the malar bags. At the same time, a facelift will restore a youthful appearance by removing excess skin and tightening areas of significant skin laxity. Although this is a more invasive option that comes with downtime, it can produce long-term results without the need for multiple injections.
Non-Surgical vs. Surgical Treatments
There are both non-surgical and surgical options for treating malar bags and festoons, depending on their severity and the patient’s anatomy. Dr. Stanislaw will discuss both surgical and non-surgical solutions during your consultation to determine which method best fits your goals and lifestyle.
Non-surgical treatments can be effective for mild to moderate malar mounds. By adding subtle volume to the upper cheek and under-eye area, hyaluronic acid fillers help smooth transitions between the eyelid and cheek and conceal the shadowing that makes eye bags appear more pronounced.
Surgical options may be better suited for patients with excessive skin, excess fat, or significant sagging in the cheek area. These cosmetic surgery approaches often yield more long-lasting results compared to injectables and are performed by a board-certified plastic surgeon for optimal precision and safety.
Who is a Candidate for Treatment?
Ideal candidates for malar bag treatment are healthy individuals bothered by puffiness or eye bags that make them look tired or older than they feel. You may be a good candidate if you:
- Have visible malar mounds or festoons along the upper cheek or under-eye area
- Experience skin laxity, excessive skin, or volume loss between the eyelid and cheek
- Have realistic expectations and are in good overall health
- Are not currently pregnant or nursing and have no active skin infections
Lifestyle and environmental factors, such as sun exposure and smoking, can worsen the appearance of malar bags and festoons over time. Therefore, Dr. Stanislaw will also review your skin health and habits to ensure the best treatment outcome.
What to Expect During Treatment
For non-surgical approaches such as filler injections, the procedure is typically completed in under an hour. After cleansing the area, Dr. Stanislaw uses a fine cannula to precisely place small amounts of filler in the cheek area below the malar mound, restoring smoothness and contour.
If you undergo a surgical treatment, it will be performed in a controlled setting under local or general anesthesia. These procedures address deeper structural concerns by lifting the eyelid and cheek region and removing excess skin or fat that contribute to visible bulging.
Results & Longevity
Both surgical and non-surgical treatments can produce noticeable improvements in the appearance of malar bags and festoons. Non-surgical results from filler injections are visible almost immediately and can last 6–18 months, depending on the product used and the patient’s unique anatomy. Surgical results typically offer long-lasting results, often enduring for several years before any maintenance may be needed.
Side Effects & Safety
Both surgical and non-surgical malar bag treatments are considered safe when performed by an experienced plastic surgeon. However, as with any medical procedure, there are some potential risks.
After filler injections, temporary side effects such as mild swelling, redness, or bruising can occur in the upper cheek or under-eye area. These typically resolve within a few days. Avoiding smoking, limiting sun exposure, and following all aftercare guidelines will help ensure a smooth recovery and the most natural-looking, rejuvenated results.
What Causes Malar Bags?
Malar bags are caused by thinning skin of the lower eyelid and skeletonization of the orbicularis oculi muscle (the muscle that wraps around the eye and closes the eyelid). However, the etiology of malar bags is multifactorial. Even in one person, there can be several different components or factors causing the appearance of a malar bag. The malar mound can be caused by the formation of a malar crease at the lower border of the lump. The following are possible causes of malar bags:
- The loss of cheek fat in the area below the eye causes a hollowing of the cheek, which can make the malar bag look more pronounced. The loss of cheek fat can be age-related, but it can also occur in people who are in good physical shape with very little body fat.
- An osteocutaneous ligament attaches the skin to the underlying bone of the lower eyelids. Think of it as an anchor that keeps your skin from sliding off your cheekbone. As we age, our facial bones resorb and change shape. The facial bones are essentially involuted in all directions: front to back, up and down, and side to side. The osteocutaneous ligaments pull the skin in as the bone sinks inwards, causing the crease.
- The crease below the malar bag can be an actual embedded crease in the skin. The skin has taken on a cupped shape. If you look closely at the crease below the malar bag, you’ll notice many enlarged pores. If you look at the skin of lower eyelid bags, there are no pores, and the skin is smooth. These pores in this crease cause inflammation in the skin’s deeper layers. This inflammation in the deep layers of the skin causes a differential in skin growth between the top and bottom layers. This differential in growth is similar to a plant bending towards the light. The side of the plant exposed to the light grows more slowly than the side not exposed to the light. This change in growth causes the plant to bend towards the light (essentially causing an arch in the plant stalk) causing trough in the skin.
- The osteocutaneous ligament anchors the sagging skin to the underlying bone. When you smile, you will notice that the cheek bulges up to the point of the malar crease, but because it is securely anchored to the bone, the bulge stops right at the crease. From years of smiling, the fold has become embedded in your cheek.
- In rare instances, people can have swelling of the malar bag from fluid accumulation. In this situation, instead of gravity draining the fluid out of the malar bag, the fluid gets trapped above the malar crease and causes the malar bag to become more prominent.
Schedule a Consultation
The best way to learn more about your options for facial rejuvenation is by meeting with an expert board-certified in aesthetic plastic surgery. To schedule a consultation with Dr. Paul Stanislaw at our Avon, CT office, we invite you to contact Stanislaw Facial Plastic Surgery Center by calling or filling out our online form.
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