What Are Malar Bags?
Malar bags — sometimes called festoons — are pockets of swelling that sit on the cheekbone, just below the lower eyelid. They're different from eye bags: while eye bags are caused by bulging fat at the eyelid margin, malar bags sit lower, on the malar (cheek) area.
I see them in patients of all ages. They can be genetic, appearing relatively early in life, or they can develop with age as the ligaments and tissues of the midface weaken. Fluid tends to accumulate in this area, creating a puffy, tired appearance that doesn't respond to rest or lifestyle changes.
Why Malar Bags Are Difficult to Treat
I'm always honest with patients: malar bags are notoriously difficult to treat. The aim is improvement — often significant improvement — but complete elimination isn't always possible.
The reason is their location and structure. They sit in an area with complex anatomy: close to the eyelid, involving the midface tissues, and affected by the natural descent of facial structures over time. Simple removal isn't straightforward because aggressive treatment risks damaging the nearby eyelid.
This is why we often "throw everything at it" — using multiple treatments together, each targeting a different aspect of the problem.
Treatment Option 1: Mid-Face Lift
A mid-face lift addresses the descent of midface tissues. Through an incision inside the lower eyelid, I can lift all the lower tissues upward, restoring them to a more youthful position. This lifts the malar area and reduces the puffiness that accumulates there.
The mid-face lift doesn't remove the malar bag directly — it repositions the tissues so the bag is less prominent. It's particularly effective when the malar bags are partly caused by descent and sagging of the cheek tissues.
Recovery: Relatively straightforward. Mainly bruising and swelling for 1-2 weeks.
Treatment Option 2: Fat Grafting
Fat grafting can be combined with a mid-face lift. The principle is to add volume strategically around the malar area to smooth the transition between the lower eyelid and cheek, reducing the appearance of the bag.
Fat is harvested from another part of your body (typically the abdomen or thighs), processed, and carefully injected into the under-eye and cheek area. About 50% of transferred fat cells establish a blood supply and become permanent; the rest are gradually absorbed by the body over several months.
Recovery: Puffiness and swelling that gradually resolves. The final result is seen once the fat has settled, typically after several months.
Treatment Option 3: Laser Skin Tightening
Laser can tighten the skin overlying the malar bag. If there's loose, crepey skin contributing to the appearance, laser resurfacing contracts this skin and improves its texture.
When combining laser with mid-face lift and fat grafting, I typically include it because I'm already working in the area and it adds skin tightening without significant additional cost. The laser works by drilling tiny holes in the skin, causing the surrounding tissue to contract as it heals.
Recovery: This is the most demanding recovery component. The skin will be red for several weeks and pink for several months (typically 6-9 months). If you have a history of rosacea, this is worth discussing as laser can temporarily increase redness before ultimately improving it.
What About Direct Excision?
Some surgeons do cut malar bags away directly. However, I'm cautious about this approach for a specific reason: the proximity to the eyelid.
When you cut tissue close to the eyelid, scar tissue forms as it heals. This scar tissue can contract over time, pulling the eyelid downward. Even a millimeter of pull can cause problems — the eyelid can turn outward (ectropion) or pull away from the eyeball, disrupting the tear film.
Tears are produced at the outer aspect of the eyelid and pumped inward toward the drainage ducts at the inner corner. If the eyelid doesn't sit flush against the eyeball, this pump mechanism doesn't work properly, leading to dry eyes, watering, and discomfort.
If direct excision is being considered, I would typically plan to include a protective stitch that supports the eyelid position while scar tissue matures, reducing the risk of downward pull.
Why Combination Treatment Often Works Best
For most patients with significant malar bags, I recommend a combination approach:
- Mid-face lift — to lift descended tissues
- Fat grafting — to restore volume and smooth contours
- Laser — to tighten overlying skin
Each treatment has an incremental effect, and together they produce better results than any single approach alone. The procedure typically takes about an hour and a half and is performed as a day case under general anaesthesia.
Setting Realistic Expectations
I'm always clear with patients: the goal is improvement, not perfection. Malar bags may look significantly better after treatment, but they may not disappear completely. Understanding this from the outset helps ensure you're satisfied with realistic results.
If you're considering treatment for malar bags, a thorough consultation will assess your specific anatomy and help determine which combination of approaches will work best for you.
Frequently Asked Questions
Malar bags form when fluid and fat accumulate in the malar (cheek) area, just below the lower eyelid. They're related to the natural ageing process, genetics, and the way ligaments in the midface weaken over time. Unlike eye bags, they sit lower on the cheek.
No. Standard lower blepharoplasty treats eye bags (bulging fat at the eyelid), not malar bags (swelling on the cheek below the eye). Malar bags require a different approach, typically involving a mid-face lift.
Malar bags are notoriously difficult to treat, and complete elimination isn't always possible. The goal is significant improvement. A combination of mid-face lift, fat grafting, and laser typically produces the best results, but some residual appearance may remain.
Direct excision risks pulling down the lower eyelid because the scar tissue that forms can contract. This can cause the eyelid to turn outward (ectropion) or pull away from the eyeball, leading to dry eyes and tear problems. If direct excision is considered, protective measures like a lid-supporting stitch may be needed.
Mid-face lift and fat grafting have relatively straightforward recoveries — mainly bruising and swelling for 1-2 weeks. Laser recovery is more prolonged, with redness lasting weeks and pinkness lasting several months. Combined treatments require accounting for the most demanding recovery component.