Festoons and Malar Bags

Treatment Summary

Dr. Sabrina Shah-Desai has a vast experience, spanning 2 decades, and is considered the “go to” UK Oculoplastic surgeon for treating this challenging multifactorial condition.

Although surgical treatment seem to be the classic option, with possible improved long-term stability, revisions are not uncommon and postoperative results often need to be further enhanced by tailored non-surgical procedures

Non-surgical options offer an exciting alternative for mild to moderate malar bags,
but require repeated treatments, due to temporary improvements or insufficient rejuvenation.

Thus the role of a single optimal treatment remains unclear, but it seems likely that malar bags are best managed by using a multifaceted approach with a variety of individualized interventions.

Unlike eye bags (fat bulges above the bony eye socket rim), up-gaze and down-gaze do not significantly affect the appearance of “malar bags”. “Malar bags” is a broad anatomical umbrella term used to describe malar edema, malar mounds and festoons that clinically appear as water-logged swollen “saddle bags” at the junction of the lower eyelid-and upper cheek.

Malar Edema

Malar edema is fluid accumulation over the eminence of the cheek. It can vary in severity often worsening after salty meals or in the morning. The consistency is usually soft and compressible. There is occasionally pitting with a slight bluish or purple discoloration. Cardiac, renal, or hepatic insufficiency, hypothyroidism, surgical or under eye filler injections, as well as allergies may be causative.

Malar Mounds

Malar mounds are chronic soft tissue swelling within upper cheek. This permanent soft tissue bulge usually contains hypertrophic fat or muscle which has descended. Often there is a familial history of mounds and can be seen from childhood.

Festoons

Fluid or fat filled hammocks of lax skin and orbicularis muscle below the infraorbital rim are referred to as malar festoons. Festoons are typically senile and have progressed from malar mounds and edema to become evident in the elderly, often seen in severely sun damaged skin or in smokers

Before & After Pictures

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What Are Your Treatment Options?

Malar bags are more challenging to treat than the common herniated under-eye fat bags.
It is important to understand and try to tackle the causative factors and choose an Oculoplastic Surgeon with multi modal experience in managing this condition.
Frequently Asked Questions

Minimally invasive treatments – Suitable for Mild to Moderate Malar Bags

Hyaluronidase – A dissolving enzyme. Often one quick and painless injection is highly effective in resolving the malar bag, specially if it is present due to contributing under eye filler. This is accepted as a first line treatment for malar swelling post tear trough / cheek hyaluronic filler injection.

Cost from £300 per session

Injection with 2% tetracycline, within the malar bag has been reported to modestly reduce malar bags.

The mechanism is thought to be a sclerosis that is triggered by Tetracycline along with stimulation of collagen and fibrin. Maximal effect is expected around 3 months, after which repeat injections can be considered.

Although further research is required, this offers an non-invasive alternative for mild malar edema and mounds as well as a complementary intervention for more significant or persistent bags.

Cost £300 per injection

Dermal Filler injected in the cheek – Dr. Sabrina Shah-Desai prefers to use Ellanse or a hyaluronic acid gel filler with less water binding capacity. High Water binding fillers may worsen malar edema in patients who have had previous eyelid surgery or trauma and may have disrupted lymphatics. The aim of this treatment is to camouflage mild swelling and support the ptotic malar muscle & fat.

Cost from £450 per syringe.

Radiofrequency Micro-needling. Dr. Sabrina Shah-Desai has extensive experience with this energy based treatment since 2016 and finds a course of 3 treatments every 4-6 weeks is highly effective in reducing excessive skin laxity & tightening the “ptotic” malar fat by 30-75%. Animal studies indicate encouraging possibility of lymphatic reorganisation. Side effects are generally mild and temporary (redness, swelling & bruising) with most newer studies showing no significant complications. Furthermore, there are no limitations to the skin types that can be treated with radiofrequency as opposed to lasers. The long term effectiveness is variable and currently Dr. Shah-Desai recommends an annual maintenance treatment.

Cost from £1800 per course of 3

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Minimally invasive treatments – Suitable for Moderate to severe Malar Bags

Endolift laser is a relatively newer procedure for treating malar bags.
Dr. Shah-Desai uses this technology to deliver laser energy into the malar fat compartment under the skin. Long term effectiveness is not clear, however early results are very encouraging.

Dr. Sabrina advises to consider this prior to invasive surgical treatments, as the downtime is generally only 2 weeks (swelling, bruising) and the malar bags improve by 50% within 3-6 months after one treatment.

Cost from £2000

Invasive treatments – suitable for Severe or Persistent Malar bags

Surgical Management

Apart from being invasive, surgery is associated with an increased potential for complications and can leave a high percentage of persistent malar bags postoperatively.

There is no single surgical procedure that is “gold-standard” for all patients.

Direct excision

An option for select elderly patients who either have excessive skin redundant festoons that are persistent & severe or patients that worry less about potential scarring in place of the malar bags.

  • Advantages: Quick, performed under local anesthesia & minimal downtime (1-2 weeks).
  • Disadvantages: Not suitable for patients with extensive orbicularis hypertrophy or attenuation or ptotic midface
    Will leave a visible scar over the area of the festoon.

Cost from £4000

Extended Lower lid Blepharoplasty with Midface Lift

An option for select patients who either have severe malar edema, malar mounds or festoons, that are persistent or recurrent, following minimally invasive non-surgical treatments.

  • Advantages: Allows eye bags and saddle bags to be tackled simultaneously
  • Disadvantages:
    Performed under general or twilight anesthesia
    Longer downtime (2-12 weeks).
    Will leave a small scar at the outer corner of the eye

Cost from £6000

About Dr Sabrina Shah-Desai MS, FRCS

Dr Sabrina Shah-Desai is an extremely distinguished oculoplastic surgeon and is one of London’s leading eye specialists. She has over two decades of surgical experience and is renowned for her ability to create a natural look.

She has a deep anatomical knowledge of the periorbital area and appreciation for the differences in raising the brows and eyelids of men vs women. For example, in men it’s important to preserve the t-shaped brow in order not to feminise their appearance with a blepharoplasty.

Festoons and Malar Bags Reviews

Treatment Cost

Hyalase for festoons from £300
Tetracycline injections for festoons from £300
Filler for mid-face – from £450/ml
Morpheus8 course of 3 treatments £1,800
Endolift® for Festoons £2,000
Surgery – Direct Excision from £4,000
Extended lower lid blepharoplasty from £6,000

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