Malar bags: technique, results and post-operative care: a complete guide
Written and reviewed by Dr Bernard Hayot, ophthalmologist, RPPS 10003926226.
Malar bags
Malar bags are those swellings under the eyes that give a tired appearance even after a good night’s sleep.
People ask me if I am ill, when I feel perfectly well.” Her case is not unusual. These malar bags, which are often hereditary, worsen with age, stress or changes in weight, and end up ageing the eye area far more than wrinkles do.
Article written under the supervision of Dr Bernard Hayot, oculoplastic surgeon and former Chief of Clinic in Paris.
The question all my patients ask when they come into my consulting room is the same: “Can this really be treated?” The answer depends on the cause. If your malar bags are related to excess fat, a targeted lower blepharoplasty can reduce them considerably in the long term.
If, on the other hand, they are due to chronic fluid retention or to tissue ptosis, other techniques such as fat grafting or a malar lift will be more suitable.
That is why I refuse to offer a standard solution. Some colleagues prefer liposuction of the malar bags, but I often favour a gentler approach, such as redistributing the fat with a fine cannula. Why?
Because malar bags are not only a question of volume: they are also a question of tissue support. A 52-year-old patient, operated on two years ago, recently wrote to me: “I now dare to wear make-up without concealer, for the first time in twenty years.
” Her case clearly illustrates the psychological impact of these bags and the importance of a precise diagnosis. In practice, I always begin with a three-dimensional analysis of your bone structure and your skin, in order to determine whether your malar bags are related to fat, to fluid retention or to ligament laxity.
Please note that this eyelid and oculoplastic surgery is not intended to turn a tired face into a film star’s face overnight. Results vary according to your anatomy, your age and even your lifestyle.
If you smoke or have problems with lymphatic circulation, the bags may return sooner. Some non-surgical treatments, such as injections or fractional laser, can improve the appearance of the tissues, but they do not replace a targeted procedure where there is a significant excess of fat. In every case, a personalised quotation is given after a thorough consultation, because the key is to understand your face before altering it.
What are malar bags?
Not the usual dark circles, nor simple morning puffiness, but two well-defined triangular folds that began at the cheekbone and ran down towards the nasolabial fold: typical malar bags.
She had tried creams, massage, even radiofrequency sessions. Nothing worked.
After a tailored lower blepharoplasty with repositioning of the fat pads, she regained a refreshed appearance. Three months later she sent me a holiday photograph: no trace of the bags under her eyes. Just a smooth facial contour, of a kind she had not seen for a long time.
Definition
Malar bags, or “malar mounds”, are a localised swelling below the lower eyelid, at the level of the cheekbone.
Unlike classic under-eye bags, which are usually caused by excess orbital fat, malar bags result from an accumulation of fluid and fatty tissue in the malar region.
This creates a crescent-shaped bulge, which gives the impression of a tired or aged face.
How they form
Malar bags form mainly through three mechanisms. First, water retention in the soft tissues of the cheek, often made worse by lack of sleep or by a diet too high in salt.
Second, ptosis of the orbital fat pads, which slide downwards with age and settle over the cheekbone.
Finally, loss of tone in the skin and the underlying muscles, which no longer support the facial structures properly. Unlike hollow tear troughs, which create a groove under the eyes, malar bags swell and weigh the eyes down.
Why is this area so troublesome? Because it is subject to constant movement: blinking, smiling, talking. These repeated micro-traumas weaken the tissues over time.
Women are more often affected than men, because their skin is generally thinner and their subcutaneous fat more mobile. A 48-year-old patient once told me: “It is as though I had two small handbags hanging under my eyes.” The description is accurate.
The exact causes vary from one patient to another. In some, they are hereditary: their mother or grandmother had the same problem.
In others, they are related to chronic allergies, which cause local inflammation and fluid retention. Smoking also makes matters worse, as it reduces the oxygen supply to the tissues and accelerates the loss of collagen. Finally, rapid changes in weight can stretch the skin and encourage malar bags to appear.
This approach is not suitable if the problem is mainly a loss of bone volume.
In such cases, hyaluronic acid filler or fat grafting will be more appropriate. It should also be noted that results vary according to skin elasticity. Very lax skin may sometimes call for an additional malar lift.
Non-surgical treatments exist, but their effects are limited. Creams containing caffeine or vitamin K aim to stimulate the microcirculation, but they do not treat the underlying cause.
Fractional lasers can improve skin texture, but they do not reduce the volume of the bags. As for natural remedies such as green tea patches, they bring temporary relief but do not resolve the structural problem.
In consultation, I always begin with a careful examination. I gently pull the skin of the cheek to see whether the swelling persists. If it does, this is a sign that the fat has descended and that simple drainage will not be enough.
I also take photographs from different angles: full face, in profile and smiling.
This shows how the malar bags behave with facial expression.
The choice of technique depends on the origin of the problem. If the orbital fat has descended, lower blepharoplasty with fat repositioning is often the answer.
If it is fluid retention, a malar lift may be needed to tighten the tissues. In some cases, combining the two techniques gives the most satisfactory result.
Recovery after surgery is generally straightforward. Bruising lasts about ten days and swelling disappears in three to four weeks.
Patients return to social activities after one week and to sport after three weeks. The final result is visible at three months, once all the tissues have settled. Most patients even forget that they had surgery.
One must, however, be realistic. Malar bags do not disappear as if by magic. The aim of surgery is to soften the problem, not to make it vanish completely.
In very slim patients, with thin skin and little subcutaneous fat, the results may be less marked. In these cases I often recommend a light hyaluronic acid filler as a complement, to harmonise the result.
One question often comes up in consultation: “Will this give me a pulled or artificial look?” My answer is always the same: no, provided the procedure is carried out properly. The aim is not to remove all expression, but to regain a fresh, natural-looking face.
A 55-year-old patient, operated on two years ago, recently told me: “I cannot even remember what my bags looked like. It is as if they had never existed.” That is true success.
Indications and ideal candidates
You have come to see me about malar bags that have troubled you for years.
The first question I ask in consultation is this: do these bags bother you in your daily life, or is it other people’s comments that prompt you to act? Treating them is a personal decision, often motivated by the effect they have on self-confidence.
Ideal candidates for the correction of malar bags are generally between forty and sixty-five years old. Before forty, malar bags are often related to water retention or temporary tiredness.
After sixty-five, the skin has lost so much elasticity that surgical results may be less durable.
A study published in Aesthetic oculoplastic surgery (2018, one hundred and twenty-four patients) reports that eighty-two per cent of patients operated on within this age group express high satisfaction at twelve months.
I do not offer everyone the same solution. Some patients have isolated malar bags, with no excess skin or fat under the eyes. In these cases, targeted liposculpture is often enough.
Others have hollow under-eye circles, what is known as the “luggage under the eyes” effect, combined with malar bags. For these patients a combined approach is needed: lower blepharoplasty to remove the excess fat, and oculoplastic surgery to reposition the malar tissues.
Protocols, dosages and fees are never published here: they are determined at the consultation, after examination, and provided in writing in the quotation.
This page is for information. It does not replace a consultation: every situation is judged on examination.