Oculoplastic Surgery

Aesthetic Surgery Journal

Special Topic 2020, Vol 40(3) 246–258
© 2019 The Aesthetic Society.
Reprints and permission:
Updated Management of Malar Edema, journals.permissions@oup.com
DOI: 10.1093/asj/sjz137
Mounds, and Festoons: A Systematic Review www.aestheticsurgeryjournal.com

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C. Ian Newberry, MD; Hilary McCrary, MPH, MD; J. Regan Thomas, MD;
and Eric W. Cerrati, MD

Abstract
To deliver a natural, aesthetically pleasing periorbital rejuvenation, restoration of the youthful lid-cheek junction and malar
eminence is often essential. However, the management of malar bags is complex secondary to the diverse pathophysi-
ology and varying severity of malar edema, mounds, and festoons. Treatment must be individualized based on extent
and content. This scoping review updates the audience on the anatomy, pathophysiology, and evaluation of malar bags
in addition to the latest literature regarding minimally invasive intervention and surgical refinements. A modernized treat-
ment algorithm is proposed.

Level of Evidence: 4

Editorial Decision date: April 23, 2019; online publish-ahead-of-print May 3, 2019.

With periorbital changes being one of the earliest detect-
able signs of aging, periorbital rejuvenation is vital in the
pursuit to restore a graceful appearance.1 The goal should
be to reestablish youthful proportions with delicate tran-
sitions from brow to cheek. Blepharoplasty has been the
classic procedure to revitalize this region; however, there is
no “cookie-cutter” approach, and additional techniques as
well as alternative procedures are frequently required for
optimal results. To deliver a natural, aesthetically pleasing
lower eyelid, restoration of the youthful lid-cheek junction
and malar eminence is often essential. Yet the spectrum
from malar edema to festoons represents a persistent chal-
lenge when addressing these ambiguous “malar bags.”
The management of malar bags remains problematic sec-
ondary to the diverse pathophysiology, inconsistent ter-
minology, and variable severity of patients’ malar edema,
mounds, and festoons. Furthermore, the management of
these complex entities has been rapidly changing as more
minimally invasive techniques are being utilized to pro-
duce natural results without surgical intervention. In this
review, we briefly discuss the anatomy, pathophysiology,
and ­evaluation of malar bags in addition to updating the
plastic surgeon on the latest literature r­ egarding ­minimally
invasive intervention and surgical refinements. A modern-
ized treatment algorithm is proposed based on patient
and surgeon preferences as well as ­ specific a
­natomic
considerations.
Drs Newberry and McCrary are Residents, and Dr Cerrati is an
Assistant Clinical Professor, Facial Plastic and Reconstructive Surgery
Division, Otolaryngology-Head and Neck Surgery, University of
Utah School of Medicine, Salt Lake City, UT. Dr Thomas is a Clinical
Professor, Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Northwestern University,
Chicago, IL.
Corresponding Author:
Dr Christopher Ian Newberry, Department of Otolaryngology-Head
and Neck Surgery, University of Utah, 50 North Medical Drive, SOM
3C120, Salt Lake City, UT 84132, USA.
E-mail: ian.newberry@hsc.utah.edu; Twitter: @IanNewberryMD
Newberry et al247
Figure 1. Flowchart. Preferred Reporting Items for Systematic Review and Meta-Analysis algorithm.
METHODS
The study and search methods were reported utilizing rele-
vant items of the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis checklist (Figure 1).2 A meta-
analysis was not conducted due to inconsistent or nonex-
istent outcome measures. With the assistance of a medical
librarian, we searched all indexed years through March 3,
2018 of the PubMed, Embase, Cochrane Library, and Elsevier
Scopus databases to identify relevant studies. Major med-
ical subject headings terms utilized for the systematic re-
view included malar edema, malar mounds, festoons, saddle
bags, eyelid bags, cheek bags, palpebral bags, secondary
bags, triangular cheek festoon, and fluid bags. Two authors
(C.I.N. and H.C.M.) independently reviewed titles, abstracts,
and full-text articles to determine if they met inclusion criteria.
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If disagreements occurred, a senior author (E.W.C.) would
independently review for inclusion or exclusion. Phase 1
­included screening of titles and abstracts. Phase 2 included
evaluation of the full text. Studies were included if they
­contained direct or indirect findings related the treatment
of festoons. Exclusion criteria included the following: incom-
plete manuscripts, review articles, non-English language, or
lack of focus on treatment or management of festoons.
RESULTS
The original search yielded 2204 records, of which 633
duplicates were removed, leaving a total of 1571 records
available for the first phase of screening. After title and ab-
stract review for determination of relevance to treatment
248 Aesthetic Surgery Journal 40(3)

Table 1. Summarized Interventions and Complications of Included Studies

Study Intervention Type of MIP Extended Midface lift Direct Lid anchoring Complications Level of
category blepharoplasty Excision (E or O) evidence

Adamson et al Surgical — X O±E Chemosis, scleral show IV

Anastassov and Surgical — X E Temporary ectropion, edema, tran- IV

Hilaire sient infraorbital nerve paresis

Bellinvia et al Surgical — X — Temporary edema IV

Branham Both Laser resurfacing, X X O None noted V

radiofrequency

Byrd Surgical — X O±E Temporary facial nerve paresis, tem- IV

poral fat atrophy

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Carriquiry et a Surgical — X O Lateral orbital bulge IV

Choucair et al Surgical — X O None noted IV

Einan-Lifshitz and Surgical — X O or E Temporary edema IV

Hartstein

Endara et al Surgical — X X O or E Festoon reoccurrence, facial numb- V

ness

Farrior and Kassir Surgical — X O None noted IV

Fernandes Surgical — X — None noted IV

Furnas Surgical — Xa O Scar, lateral orbital bulge IV

Furnas Surgical — X O±E None noted IV

Hashem et al Both Laser resurfacing X O or E None noted V

Hilton et al MIP Hyaluronidase — Reoccurrence of edema IV

Hoenig et al Surgical — X O Edema, oral wound dehiscence IV

Klatsky and Surgical — X O Ectropion, hematoma V

Manson

Krakauer et al Surgical — X E None noted IV

Liapakis and Both Liposuction X O No complications observed V

Paschalis

McCann and Both Chemical peel X O±E Bruising, edema, chemosis V

Pariseau

Papageorgiou MIP Filler — None noted IV

et al

Perry et al MIP Tetracycline — Transient pain, bruising IV

Roberts Both Laser resurfacing Xa ±E Lowered lid margin, scleral show IV

Roberts and Both Laser resurfacing Xa ±E Lowered lid margin, erythema, IV

Yokoo milia, transient hyperpigmentation,
synechia

Small Surgical — X O±E Ectropion, edema V

Stevens et al Surgical — X O±E Scleral show IV

of festoons, 98 were identified for full-text review for eligi- Terminology

bility; 26 unique studies were included with an additional 7
articles added through secondary references and manual Since Furnas first described “festoons” in 1978, variable
search of the literature (Table 1). terminology has been employed to describe swelling or
Newberry et al249

Table 1. Continued

Study Intervention Type of MIP Extended Midface lift Direct Lid anchoring Complications Level of
category blepharoplasty Excision (E or O) evidence

Rosenburg MIP Liposuction — Skin perforation IV

Chang et al MIP Intense focused ul- — None noted IV

trasound

Sullivan and Surgical — Xa E Lowered lid margin, chemosis, IV

Drolet edema

Hunzeker MIP Laser resurfacing — Transient edema, erythema IV

Scheiner and MIP Laser resurfacing — Herpes infection, cellulitis, milia, er- V
Baker ythema

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Jeon MIP Radiofrequency — Erythema IV

Asaddi Both Kybella X X O and E Lid retraction, lateral orbital bulge, IV

chemosis

E, eyelid tightening/shortening; MIP, minimally invasive procedure; O, orbicularis suspension. aBlepharoplasty without muscular suspension.

excess tissue immediately below the infraorbital rim within
the prezygomatic space.3,4 Because all 3 anomalies cause
malar bulges or bags, we propose that “malar bags” be
used to describe the broad anatomical problem that en-
compasses malar edema, mounds, and festoons.5 Although
not always distinct and isolated, this article will use the fol-
lowing definitions to delineate the continuum.
Malar Edema
Malar edema is fluid accumulation over the malar emi-
nence. It often varies in severity and can worsen after
salty meals or in the morning.6 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
periorbital cosmetic injections, as well as allergies may
be causative.
Malar Mounds
Malar mounds are chronic soft tissue swelling within the
prezygomatic space (Figure 2). This permanent soft tissue
bulge usually contains fat or orbicularis, due to either des-
cent or hypertrophy. Mounds can be congenital and may
be suspected when the patient notes the puffiness since
childhood as well as a possible family history.7
Malar Festoons
Cascading hammocks of lax skin and orbicularis muscle
below the infraorbital rim are referred to as malar festoons
(Figure 2). They may also accumulate edema or herniated
or ptotic fat. Festoons are typically senile and have pro-
gressed from the above entities to become evident in the
elderly.
Anatomy and Pathophysiology
Malar bags show excess volume within the prezygomatic
space that is bounded by the orbicularis retaining ligament
(ORL) superiorly and zygomaticocutaneous ligament (ZCL)
as well as the malar septum (MS) inferiorly (Figure 3).4,5,8
The ZCL takes its course along the malar origins of the
facial expression muscles (zygomaticus major and minor,
levator labii superioris) then invests into the mid-cheek
dermis, defining the midface groove, and the MS arises
from the orbital rim and courses inferiorly to insert into
the mid-cheek.4,9 The ORL originates from the bony or-
bital rim, traversing the orbicularis oculi muscle to insert
into the dermis of the lid-cheek junction, defining the
palpebromalar groove. This ORL provides an indirect at-
tachment of the orbicularis to the rim.
The ORL can attenuate, either with aging or hered-
itary laxity, allowing the orbicularis and overlying lax
skin to sag. However, festoons may also arise from
chronic malar edema superficial to the impermeable MS
stretching the orbicularis and skin as well as from skin
elasticity changes. Cephalad attenuated orbicularis,
lax skin, accumulated edema, and ptotic fat can all
hang over the stronger inferior attachments (ZCL, MS)
to form malar bags.9 Notably, the subcutaneous supra-
orbicularis fat will be characteristically excessive in con-
genital mounds, whereas the suborbicularis fat (SOOF)
and/or subcutaneous fat or edema may be contributory
in acquired bags.7
250
A B
Figure 2. Eyelid bags. (A) This 69-year-old man presented with palpebral bags (P) and malar mounds (M). (B) This 61-year-old
man presented with cascading festoons (F).
Clinical Evaluation
Malar bags show excessive tissue in the prezygomatic
space, which forms a triangle under the infraorbital rim
with the apex medially.9 Unlike palpebral bags above the
infraorbital rim, up-gaze and down-gaze should not signifi-
cantly affect their appearance. The surgeon should have
the patient squeeze their eyelids together to contract the
orbicularis oculi. This tightening should improve the ap-
pearance of the festoon if there is a significant orbicularis
laxity component to the festoon.3 If orbital fat or edema
is suspended within the festoon, it will not be effaced but
rather pulled superiorly during muscle contraction. This in-
dicates to the surgeon that fat excision or suspension may
need to be part of the surgical plan. The surgeon should
pinch the bags at rest and while the patients makes ex-
pressions to help determine the composition of the bags,
whether it be skin, muscle, skin-muscle, and/or fat.3,5
Minimally Invasive Management
Minimally invasive procedures (MIPs) are potential con-
servative interventions based on the known or suspected
components. Although results are variable, these proced-
ures may permit primary therapy for some mild-moderate
malar edema or mounds and mild festoons; however,
these less invasive procedures are typically inadequate for
prominent festoons, edema, and mounds. Nevertheless,
these alternatives likely represent beneficial adjuvants to
surgical therapies.
Injections
If a mild edematous or ptotic component is noted on exam or
ultrasound, viscous fillers, such as calcium hydroxylapatite
Aesthetic Surgery Journal 40(3)
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or thicker hyaluronic acid (HA) formulations, can be in-
jected to create a “posterior-girdle” compression effect
and lift ptotic malar components.4,10 Less viscous HA fillers
can provide volume around mild malar edema or mounds
to deliver a camouflage effect. Filler to camouflage is in-
jected intradermally around the bulge with particular atten-
tion in placing along the ZCL at the inferior aspect of the
bags to conceal and soften the midface groove. Notably, if
the malar mound or edema is too prominent, fillers will not
be able to efface the bulge. Occasionally filler, especially
those with higher water-binding capacity, may prompt or
worsen malar edema in some, such as those who have had
previous periorbital surgery or trauma and may have dis-
rupted lymphatics.11,12
Intralesional injection of 0.24 to 0.75mL 2% tetracy-
cline has been reported for treatment of malar bags.13,14
Tetracycline not only triggers sclerosis but stimulates fi-
broblast proliferation as well as collagen and fibrin deposi-
tion.13 Injections are able to modestly improve malar edema
and mounds. Tetracycline may be best concentrated within
the subcutaneous and suborbicularis planes to sclerosis
the subcutaneous edema/fat and SOOF in addition to stim-
ulating fibrosis between the orbicularis and deep fascia.
Maximal effect is expected around 3 months, after which
repeat injections can be considered.13,14 Complications
such as ischemia, necrosis, nerve palsy, persistent pain,
or edema were not identified (0%).13,14 Because the SOOF
is most prominent inferolaterally to the orbital rim, in a
hockey stick configuration, care should be taken to not in-
ject within the immediate vicinity of the infraorbital nerve
located along the mid-pupillary line approximately 1 cm
below the orbital rim. Although further research is required,
this presumably offers a safe noninvasive option for mild
malar edema and mounds as well as a complementary in-
tervention for more significant or persistent bags.
Newberry et al251

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Figure 3. Artwork depiction of the prezygomatic space bordered superiorly by the orbicularis retaining ligament (ORL) and
inferiorly by the malar septum and zygomaticocutaneous ligament (ZCL). The malar septum courses inferiorly to a point just
distal the inferior border of the orbicularis. Sagittal section of the prezygomatic space, reprinted with permission from artist
Warren Noel, MD (plastic surgeon, Paris, France). SOOF, suborbicularis fat.

Kybella (deoxycholic acid, Allergan, Irvine, CA) may
be used “off-label” in certain forms of malar bags.7 In pa-
tients with congenital mounds, or bags where sizeable
supra-orbicularis fat is suspected, Kybella can be offered
as primary or adjuvant therapy. Kybella (20 mg/2 mL) can
be injected subcutaneously in 2 spots within the malar full-
ness, typically utilizing 0.1 to 0.15 cc per side, and may re-
quire 1 to 2 repeat injections separated by 4 weeks. The
study demonstrated only temporary soreness without any
local reactions, bruising, or swelling.7
Hyaluronidase injections are effective in the manage-
ment of malar edema following periorbital HA-filler injec-
tion, but its effect on idiopathic malar edema is limited with
edema reaccumulating usually within 2 to 3 weeks.11 About
20 to 75 IU of hyaluronidase per side can be injected di-
rectly into the edema. Significant improvement or resolu-
tion was noted after 1 injection in most patients, but some
may require an additional 1 to 2 injections at weekly inter-
vals.11 No adverse effects were observed except for occa-
sional needle-related bruising.
Laser Resurfacing, Ultrasound, and
Radiofrequency Technology
Excessive skin laxity may play a crucial role in the ap-
pearance of malar bags, in particular festoons. Both CO2
and Er:Yag ablative lasers can be used in the treatment of
malar bags when redundant skin is evident.15-17 Aggressive
protocols specific for the prezygomatic region with mul-
tiple passes (2-10) have been developed.15,18 Scarring and
ectropion, although possible, were not observed over a
15-year period with these protocols; however, ablative frac-
tional lasers (CO2, Er:Yag) may provide a further decreased
risk of scarring, ectropion, and dyspigmentation with su-
perior end-results due to deeper thermal injury, though
more than 1 fractional treatment may be necessary to op-
timize results.15,16,19 Laser resurfacing may also be used to
improve the hyperpigmentation of malar bags that is some-
times present.18 Laser resurfacing, however, cannot repos-
ition ptotic muscle or fat or significantly modify edema or
fat accumulation. Therefore, laser resurfacing will be best
used for mild festoons or edema or mounds with mild skin
excess as well as adjuvant therapy during and following
surgery. If frank or latent ectropion exists, postoperative
ectropion is a risk, and either the patient should have a
lid-anchoring procedure with the laser treatment, or an al-
ternative surgical intervention that includes a lid-anchoring
technique should be performed.15
Furthermore, there are limitations in the patient pop-
ulation that can be treated with lasers. Because pa-
tients with Fitzpatrick Class skin types IV-VI have an
increased risk of postoperative dyspigmentation, especially
252
hyperpigmentation, the skin type should be evaluated ini-
tially and lasers should be reconsidered in darker patients,
especially because laser protocols for malar bags are
more aggressive.15,20 However, should lasers in moderate
skin-toned patients (III-IV) be considered, the surgeon may
want to use ablative fractional lasers and consider pre- and
posttreatment utilizing topical hydroquinones and retin-
oids.21,22 Similarly, previous facial radiation or use of oral
retinoids within the last year should prompt the surgeon to
avoid laser therapy in these patients, because the density
of pilosebaceous appendages needed for healing may be
reduced.15
Intense focused ultrasound (IFUS), such as Ulthera
(Ulthera Inc., Mesa, AZ), uses acoustic energy waves to
induce directed thermal injury.19,23 Small, micro-thermal
lesions from the dermis down to the fibro-muscular
layers are produced with subsequent tissue coagula-
tion and neocollagenesis and neoelastogenesis. Using
1.5-, 3.0-, and 4.5-mm transducer probes, IFUS could po-
tentially improve malar bags by tightening the dermis,
orbicularis, orbital septum, ORL, superficial-musculo-
aponeurotic-system, and subcutaneous fat without
a significant epidermal effect.23,24 Unlike lasers and
radiofrequency, IFUS targets all potential aspects of the
continuum—skin, retaining ligaments, fat, muscle, and
subcutaneous edema. Therefore, IFUS could be con-
sidered in all minor malar bags or if adjuvant therapy is
required; however, malar edema will not be significantly
improved.24 In clinical trials and postmarketing surveil-
lance, generally mild and transient side effects have
been noted such as initial tenderness or soreness (1.6%),
bruising (0.4%), temporary pain (0.2%), transient nerve
irritation (0.2%), edema (0.2%), and transient erythema
(0.1%).23-25
Microneedle radiofrequency devices deliver energy,
similar to microwaves, to induce thermal injury within the
dermal and adipose tissue, sparing the epidermis. The po-
tential fat reduction and skin tightening allow this to be
a potential option for mild mounds and festoons as well
as adjuvant therapy in these cases.26,27 Similar to IFUS,
side effects are generally mild and temporary (erythema,
edema) with most newer studies showing no (0%) signifi-
cant complications.27,28 The procedure can be repeated in
1 to 2 months, if needed.27,29
Furthermore, an inexpensive method using electrocau-
tery can be trialed. A stab incision can be made within a
rhytid at the lateral canthus or pre-auricularly with sub-
sequent subcutaneous dissection to the prezygomatic
space.30 Once into the prezygomatic space, an insulated
monopolar Bovie can be employed to induce thermal in-
jury while palpating to ensure the overlying epidermis is
not overheated. Although this may treat subcutaneous
malar edema and fat (mounds), redundant skin will need to
be addressed, such as through laser resurfacing.
Aesthetic Surgery Journal 40(3)
Microsuction
If there is a significant edematous or adipose component,
liposuction in the subcutaneous plane can be an important
tool for addressing malar bags. Studies have hypothesized
that malar edema mostly exists in the subcutaneous supra-
orbicularis plane, superficial to the impermeable MS, and
mounds may have excessive adipose in this same area.31
Mild-moderate malar edema as well as mild-moderate
mounds with suspected bulky subdermal fat component
may be amenable to treatment with liposuction, knowing
that adjuvant treatment may be required to obtain com-
plete results. Excess fat and edema in the subdermal plane
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is suctioned utilizing a small-caliber liposuction cannula
(2.3 or 3.0 mm) until the bulge is no longer palpable or vis-
ible.5,31 This approach does not address muscular or liga-
mentous attenuation. With muscular or ligamentous laxity,
liposuction can be combined with midface lift or orbicularis
muscle suspension.32 If excess skin exists before or after
removal, adjuvant treatment with lasers, radiofrequency,
IFUS, or surgical excision can be performed. Transient
bruising and swelling were noted in all patients (100%), but
no infections, hematoma or seromas, or lower eyelid weak-
nesses were noted.31,32
Surgical Management
Surgical interventions have long been the preeminent
therapy for the malar bag continuum but also have in-
creased potential for complications, are more invasive, and
leave a high percentage of persistent malar bags postop
eratively.5,7,26,33,34 Despite their relative weaknesses, sur-
gical interventions remain the gold-standard for severe or
persistent malar bags; however, there is no gold-standard
surgery for all patients.3,33,35,36 Operative management
has not significantly transformed in the recent years, and
focus remains on direct excision of affected components,
redraping of tissues, and/or release of retaining ligaments.
Extended Blepharoplasty
The extended blepharoplasty can be employed for mild-
severe malar mounds and edema as well as mild festoons,
knowing that this technique may not correct extensive
ptosis, fully release and suspend the MS/ZCL, or remove
extensive cutaneous redundancy. In particular, patients
who have malar mounds, edema, or festoons and only
some midface ptosis but do not meet severity for compre-
hensive midface lifting, or who want to avoid the extended
recovery associated with such techniques, could benefit
from extended blepharoplasty (Supplemental Figure 1).37
Extended blepharoplasty involves extending the dis-
section to a level below the infraorbital rim to release to
retaining ligaments.35,36 The technique typically utilized
Newberry et al253
a skin-muscle flap with a variable segment of skin-only
flap to allow individualized redraping and excision of
­tissues.5,26,33,35 A subciliary incision is made 2 mm below
the lash line extending inferior-lateral from the lateral
canthus for 5 to 10 mm. At least 3 to 5 mm of skin only
is raised to preserve pretarsal orbicularis, but this skin-
only flap may be elevated to mid-cheek if separate skin
and muscle flaps are needed.33,38 An orbicularis incision
3 to 5 mm below the margin allows entrance into the
preseptal plane, then elevation is bluntly extended to
the rim. Once at the infraorbital rim, cautery is employed
to fully release the ORL with further blunt dissection in
only the preperiosteal/suborbicularis plane over the an-
terior maxilla to release the MS and ZCL by cutting their
fibrous-cutaneous extensions. This dissection is carried
just distal to the inferior border of the orbicularis into the
area of the malar fat pad. Careful attention must be paid
to the infraorbital and facial nerves. Because the goal
of this technique is to lysis the midface retaining liga-
ments and not to fully mobilize the malar soft tissues, the
midface is not suspended here.
Depending on the extent of fat hypertrophy or ptosis,
subcutaneous fat and SOOF can be removed and or-
bital fat can be transposed over the rim (Figure 4).7,38
If separate skin and muscle flaps are created, fat can
be debulked above and below the orbicularis. If a
skin-muscle flap is created, an incision through the
orbicularis at the superior aspect of the malar bag can
be created for subcutaneous fat excision and skin eleva-
tion to stimulate subcutaneous fibrosis to improve malar
edema.33,35
The myocutaneous flap is then redraped in a superior-
lateral direction. The segment of orbicularis excised is ei-
ther perpendicular to its fibers along its lateral-oblique axis
or a thin parallel strip along the original orbicularis incision
to the mid-pupillary line. The lateral portion of orbicularis
is then either suspended to the lateral orbital periosteum
or a primary myorrhaphy is performed without suspension.
A lateral-based triangular skin flap is excised and the skin
is gently redraped. If orbicularis suspension is performed, a
concomitant eyelid-shortening or -tightening procedure is
not always required to prevent ectropion.39–41 However, if
significant preoperative laxity is noted or if orbicularis sus-
pension is not performed, an eyelid-tightening procedure
is recommended with canthopexy for mild eyelid laxity (lid
distraction <6 mm) and canthoplasty for more severe cases
(>6 mm).39,42
Extended blepharoplasty complications (eg, dry eyes,
infection, hematoma, scleral show, ectropion) and its rates
are typically considered similar to those of the standard
lower blepharoplasty.26,36,37,43,44 In a series of 532 patients,
transient ectropion (4%) and hematoma (3%) were noted;
however, no facial paresis or paralysis, infections, or per-
sistent dry eyes were documented.38
Midface Lift
If extensive orbicularis or fat ptosis is present, midface
lifting may be necessary. Lifting not only resuspends the
midface but also ensures proper release of the retaining
ligaments. These procedures can be employed for mild-
severe edema, mounds, or festoons; however, suspension
may fail to fully eliminate festoons if there is tremendous
skin redundancy. If there is only extensive malar edema
and fat with severe orbicularis ptosis, then a trans-temporal
lift with microsuction can be trialed.32 Typically, excessive
skin redundancy exists in moderate-severe festoons and
solely midface lifts will not suffice. Instead, a subperiosteal
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vertical upper-midface lift (SUM-lift) or transblepharoplasty
midface lift may be required.45
SUM-lift allows for subperiosteal midface elevation
utilizing both temporal and buccal sulcus incisions. Once
freed, 2 sutures are placed within midface soft tissues and
passed subperiosteally up to the temporal incision to sus-
pend the midface to the deep temporal fascia.46 Next, util-
izing a subciliary incision, an orbicularis transposition flap
is sutured to the lateral rim, or the temporal fascia, and a
conservative skin-only blepharoplasty is performed.5,41,46,47
However, the SUM-lift does not address fat hypertrophy
or cause fibrosis of subcutaneous malar tissues where
edema can accumulate. Although recovery time is longer,
the transblepharoplasty midface lift is less time consuming
and may yield better results.48 Employing an approach
initially similar to the extended blepharoplasty, the skin-
muscle flap is elevated to the rim, then the arcus marginalis
and ORL are incised and wide subperiosteal dissection is
performed to the inferior aspect of the festoon to release
MS and ZCL.5,49 The periosteum may need to be incised
at its most inferior extent to fully release the midface. The
released midface, containing SOOF, malar fat, and subcu-
taneous tissues, is now suspended to the orbital rim perios-
teum.5,42,50 Ptotic orbicularis and skin can then be excised
and suspended to redrape in a superior-lateral direction.50
Of note, for patients with only mild-moderate midface
ptosis, the same transblepharoplasty midface lift steps can
be executed, but instead of a subperiosteal dissection, a
supraperiosteal elevation is performed with solely a SOOF
lift and suspension to orbital rim periosteum.44,50
With midface suspension allowing some eyelid ten-
sion to be removed, some have argued, on the basis
of low ectropion rate, that if an orbicularis transposi-
tion flap is also utilized then canthal tightening is not
required, which can help to avoid the distorted eye ap-
pearance sometimes noted after canthopexy or canthop
lasty.39,40,46,50,51 Nevertheless, if extensive preoperative
eyelid laxity exists or if no separate orbicularis suspen-
sion is performed, we believe a canthopexy is indicated
for mild eyelid laxity, whereas a canthoplasty is con-
sidered in more severe cases. However, there are no
254 Aesthetic Surgery Journal 40(3)

A B

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C D

Figure 4. (A, C) Preoperative views of this 69-year-old man who presented following Moh’s resection of temple squamous cell
carcinoma with worsening of his premorbid malar fullness and was found to have upper eyelid dermatochalasis and ptosis with
malar bags having both a malar edema and mound (adipose in etiology) component. No significant midface ptosis was noted.
(B, D) Postoperative views 12 months after upper blepharoplasty, muller muscle ressection, canthopexy, and extended lower
blepharoplasty with malar and palpebral adipose excision without midface lifting.

high-level data comparing with or without concomitant temporary or permanent injury to sensory and facial nerve
canthal procedures in midface lift. branches, hematoma formation, lateral canthal distortion,
Midface lifting adds complexity and increased poten- lower lid malposition, and, in particular, prolonged post-
tial for complications.37 Potential complications include operative edema.26,37,42,50 Specific to the SUM-lift, 25%
Newberry et al255

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Figure 5. Adaptable modernized algorithm. If persistence despite initial intervention, determine persistence etiology:
redundant skin, excessive/ptotic fat, attenuated orbicularis. Targeted minimally invasive procedure (MIP) (Table 2), revision
surgery, or direct excision may be indicated. AIf on the more severe side of moderate, may want to consider surgical
intervention as first option, Bparticularly for primarily skin redundancy without significant midface ptosis. CTargeted minimally
invasive procedure based on primary component(s) of malar bags. IFUS, intense focused ultrasound; RF, radiofrequency.

of patients were noted to have an intraoral wound dehis-
cence, but no alopecia, hematoma or seroma, infections,
or persistent pain were documented.46 In a series of 757
patients who underwent midface lifting, the overall com-
plication and revision rate was 19%.51 Furthermore, in an-
other series of 512 patients who underwent midface lift,
15% of patients experienced complications. In particular,
9% had “major complications” (eg, scleral show, ectropion)
requiring surgical correction and 6% had minor complica-
tions including mild scleral show, infection, chemosis, or
persistent edema.50
Direct Excision
Direct excision presents another treatment option in select
patients who either have persistent, severe bags or worry
less about potential scarring in place of the malar bags.
Because the amount of skin excised utilizing subciliary
incisions is limited by potential eyelid tension, direct exci-
sion is particularly useful for elderly patients with extensive
skin-redundant festoons. However, those with extensive
orbicularis hypertrophy or attenuation or ptotic midface
may be better served by other alternatives or could require
adjuvant therapy with or after direct excision.
The procedure can be performed under local anes-
thesia. Employing a “skin-pinch” technique with the pa-
tient in an upward gaze, the greatest amount of skin is
drawn up for excision while ensuring the absence of trac-
tion on the lower-lid margin.34,52 Subcutaneous under-
mining is then performed to further allow closure without
lower eyelid tension. Skin and subcutaneous tissue are
typically excised, but if hypertrophic subcutaneous fat
or SOOF is present, it could be removed directly or after
delicately spreading apart the orbicularis fibers, respect-
ably.52 Presumably, if there is attenuated orbicularis, exci-
sion, until a thin layer of muscle is left to protect the facial
256 Aesthetic Surgery Journal 40(3)

Table 2. Individualized Application of Minimally Invasive Postsurgical Management

­Procedures
Minimally invasive procedure Application
Intralesional tetracycline injections Sclerosis subcutaneous fat and edema
Sclerosis suborbicularis fat
Fibrosis lax orbicularis to deep fascia
Mildly tighten excessive skin
Hyaluronidase injection Reduce subcutaneous edema
First line if edema post hyaluronic filler
injection
Many patients with malar bags will have profound postop-
erative edemaor lymphedema following surgery. Because
prolonged edema may diminish results, we typically rec-
ommend cold compresses, Arnica montana, and oral ster-
oids (Medrol dosepak) for 5 to 7 days, especially if edema
was a major initial component. Compressive dressings
have been described utilizing Mastisol and long Steri-
Strips to compress the malar region.53 If any significant
edema is noted in the early postoperative period, diuresis
(furosemide 20-40 mg/d with potassium replacement) for
approximately 7 days could be considered.54 Two weeks

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postoperatively, massage and hyaluronidase injections
Filler injections Camouflage and compress mild subcuta-
neous edema
may help until lymphatic drainage improves. Sunscreen
and topical retinoids should be utilized daily. If there is a
Camouflage and lift ptotic malar muscle strong history of allergies with frequent periorbital swelling,
and fat
montelukast and second-generation antihistamines can be
Kybella Dissolve prominent subcutaneous fat recommended.7
Microsuction Evacuate subcutaneous fat and edema

Laser resurfacing Tighten excessive skin DISCUSSION

Improve malar hyperpigmentation/
dyspigmentation
Intense focus ultrasound Tighten excessive skin without ablating
epidermis
Tighten attenuated orbicularis, SMAS,
and retaining ligaments
Ablate fat
Radiofrequency Tighten excessive skin without ablating
epidermis
Ablate fat
SMAS, superficial-musculo-aponeurotic-system.
nerve, followed by muscle plication could improve results.
However, with more extensive excisions, postoperative
scarring may be more evident. Of note, a lid-anchoring
procedure should be considered in all patients previous
to excision, especially in those with preoperative lid laxity
signs or symptoms (foreign body sensation, reoccurring
conjunctivitis).34,52 Because this technique does not signif-
icantly address orbicularis attenuation or ptosis, concom-
itant orbicularis suspension could be particularly useful
here.34,40
In 2 studies including more than 60 patients, no tem-
porary or permanent ectropions and minimal to no visible
scarring were noted.34,52 Yet to minimize potential scarring,
the incision should remain within the thinner upper malar
skin, and patients with darker eyelid pigmentation should
be excluded.34 Scar revision or prophylactic prevention or
reduction could be performed with laser treatment in the
delicate eyelid region.22
The management of malar bags is complex secondary to
the diverse pathophysiology and varying severity of malar
edema, mounds, and festoons. A one-size-fits-all approach
is likely to leave many patients with unsatisfactory results.
Instead, treatment must be individualized based on extent
and content (edema, fat, skin, muscle) as well as patient
preference, considering that severe bags are not antici-
pated to completely resolve solely with MIPs (Figure 5).
Nevertheless, this algorithm serves to simply provide con-
densed, compact advice rather than definitive steps, and
interpretation as well as personalization will evolve with
surgeon experience and preference.
Although sometimes asserted as revolutionary treat-
ment options with minimal recovery time, it should be noted
that noninvasive options often require repeated treat-
ments due to temporary improvement or insufficient reju-
venation. These options may lead to eventual increased
cost or prolonged downtime, especially if trialed on more
severe cases.55 However, although surgical intervention is
the classic therapy and may have improved long-term sta-
bility, revisions are not uncommon and postoperative re-
sults may be enhanced by tailored nonsurgical procedures
(Table 2). Thus, the optimal treatment remains unclear, but
seems to be a multifaceted approach employing various
individualized interventions described in this review.
Finally, although the literature regarding malar bags
is mounting, inconsistency remains in the terminology
employed and lack of description in regard to the spe-
cific severity and component of the target abnormality.
Consequently, this makes comparison between studies
difficult and outcome measures and data are particularly
deficient. Furthermore, like many aesthetic problems, the
Newberry et al257
current publications regarding malar bags are level IV and
V evidence, which limits critical analysis but importantly
highlights the crucial need for higher quality studies. Still,
this study provides a summarized basic guidance in the
anatomy and pathophysiology, terminology, evaluation,
and evolving management of a difficult-to-treat topic that
is often of interest to many surgeons.
CONCLUSIONS
The spectrum from malar edema to festoons represents
a persistent challenge for the plastic surgeon. A thor-
ough understanding of the anatomy, pathophysiology,
and evaluation of malar bags in addition to maintaining
an up-to-date knowledge on evolving minimally invasive
intervention and surgical refinements is required. As tech-
nology and research progress, incorporating MIPs as pri-
mary therapy for less severe abnormalities or as adjuvant
therapy for persistent malar bags will continue to become
an important skillset for surgeons. However, continued re-
search and evaluation is needed and, in particular, higher
quality studies are necessary going forward.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with re-
spect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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