What are festoons and malar bags?
Festoons are persistent, soft mounds of skin and subcutaneous tissue that develop on the mid-cheek, just below the lower eyelid. Unlike simple under-eye bags, which involve prolapsed orbital fat, festoons involve changes in the skin, orbicularis oculi muscle and underlying fat pads of the mid-face, often combined with lymphatic insufficiency causing fluid accumulation.
Three terms are often used interchangeably but describe a spectrum: malar oedema (fluid over the malar eminence), malar mounds (soft tissue prominence over the malar area), and festoons (the most pronounced form — baggy swellings drooping from the lower eyelid into the cheek). Festoons often worsen in the morning and improve when the face is upright, reflecting their fluid component.
The causes are multiple: age-related weakening of the mid-face retaining ligaments, descent of the malar fat pad, skin laxity and sun damage. In some patients, previous hyaluronic acid filler in the tear trough has contributed to fluid accumulation in the festoon zone — a recognised complication.
Treatment is inherently more complex than lower eyelid surgery because no single technique works for all festoons. An accurate assessment of the underlying anatomy is essential before any treatment is chosen.
Been told your festoons are untreatable? Get a specialist assessment from Dr. Alia Issa.
How are festoons and malar bags treated?
Dr. Issa tailors treatment to the specific findings at assessment. A personalised approach may include one or more of the following:
- Hyaluronidase (filler dissolving) — if previous tear trough filler is contributing, dissolving it is often an important first step
- Lower blepharoplasty with orbicularis tightening — repositioning and tightening of the lower eyelid and upper cheek structures
- Direct excision — surgical removal of festoon tissue, reserved for the most prominent or refractory cases
- Midface lift — elevation of descended mid-face structures to reduce festoon prominence
- Intralesional sclerotherapy — to reduce the fluid component of festoons
- CO2 laser resurfacing — skin tightening of the lower eyelid and upper cheek to improve skin quality
A combination approach typically produces the most durable improvement. Dr. Issa is candid about what each technique can and cannot achieve, and will not recommend surgery unless it is likely to provide a meaningful benefit for your specific anatomy.
What to expect at consultation
Festoon assessment is detailed and takes time. Dr. Issa will:
Photograph the festoons in the morning (when most prominent) and later in the day, and assess the fluid versus tissue component, since these require different treatments.
Review any previous filler treatment and assess the malar area for retained hyaluronic acid, which can contribute to fluid accumulation.
Evaluate the lower eyelid support, skin laxity and lid-cheek junction, and discuss the realistic range of improvement achievable with each option.
Provide a frank opinion about which approach is most likely to help — and which is most likely to disappoint or cause problems in your case.
Why choose an oculoplastic surgeon for festoons and malar bags?
Festoons involve several tissue layers and may have more than one cause, so treatment that helps one type can worsen another. An oculoplastic surgeon who assesses the fluid-versus-tissue balance and any prior filler is well placed to plan a combination approach — rather than applying a single technique to a complex problem.
Patients who have been told their festoons are untreatable, or who have had worsening after lower eyelid surgery elsewhere, are welcome to seek Dr. Issa's assessment.
Related reading in the Journal: because festoons are often confused with under-eye bags, our guide comparing eye bag removal in Dubai: surgery vs non-surgical options explains the difference.
Frequently asked questions
What are festoons and malar bags?
Festoons are soft, fluid-filled or tissue mounds on the mid-cheek, just below the lower eyelid. They are caused by laxity of the skin and orbicularis muscle, often combined with lymphatic stasis and fluid accumulation. They are distinct from simple under-eye bags, which involve orbital fat prolapse.
What causes festoons?
A combination of factors: weakening of mid-face retaining ligaments, descent of the malar fat pad, skin laxity, lymphatic insufficiency, and sometimes previous hyaluronic acid filler in the tear trough area.
How are festoons treated?
Treatment is individualised and usually involves a combination of approaches — lower blepharoplasty with orbicularis tightening, direct excision, midface lift, hyaluronidase (if filler-related), intralesional sclerotherapy and CO2 laser resurfacing. No single treatment addresses all festoons.
Can filler injections cause festoons?
Yes. Hyaluronic acid filler in the tear trough can migrate or swell in the malar region, exacerbating fluid accumulation. Dr. Issa assesses for filler-related changes at consultation and may recommend dissolving prior filler as a first step.
Why are festoons so difficult to treat?
Festoons involve multiple tissue layers and may have more than one contributing cause. Treatment that works for one type can worsen another, so accurate assessment by an experienced oculoplastic specialist is essential before any treatment is chosen.
What results can I expect?
Meaningful improvement is achievable for many patients with a well-planned, combination approach, though complete elimination may not always be possible. Dr. Issa will be honest about what your anatomy allows before recommending any treatment.
Book your festoons and malar bags assessment in Dubai with Dr. Alia Issa.