Under-Eye Bags, Festoons, and Malar Edema: What Is the Difference?
These conditions look similar but have different anatomy — and different treatments.
| Condition | Location | Fluctuates? | Treatment |
|---|---|---|---|
| Orbital fat bags | Just below the lower lash line | Slightly (worse mornings, salt, fatigue) | Lower blepharoplasty ✓ |
| Festoons | Lower eyelid/upper cheek junction | Significantly — varies day to day | Direct excision or laser — not bleph |
| Malar edema | Cheekbone (malar) area | Greatly — may be absent some days | Treat underlying cause first |
| Tear trough hollow | Depression below lower lid | No | Hyaluronic acid filler |
Orbital Fat Prolapse (“Under-Eye Bags”)
The eye sits within the bony orbit surrounded by orbital fat, which cushions the globe. A fibrous layer called the orbital septum holds this fat in position. With age — and sometimes beginning in young adults — the septum weakens and fat pushes forward, creating a rounded, persistent bulge beneath the lower eyelid.
Characteristics
- Located immediately below the lower lash line, in medial, central, and lateral fat pockets
- Present consistently — slightly worse in the morning or after sodium, alcohol, or fatigue
- Firm to the touch; gently pressing the lower eyelid increases the bulge
- Strongly hereditary — can be prominent in patients in their 20s and 30s
Treatment: Lower Blepharoplasty
Lower eyelid blepharoplasty approaches fat through either a transconjunctival incision (inside the eyelid — no visible scar, ideal when skin is not excessive) or a transcutaneous incision (below the lash line — allows concurrent skin removal). Fat is either removed or repositioned into the tear trough depression, producing a smoother lower eyelid-cheek junction.
Festoons (Malar Mounds)
Festoons are redundant folds of skin and orbicularis muscle that drape in a hammock-like fashion at the junction of the lower eyelid and upper cheek — along the inferior orbital rim. They are anatomically distinct from orbital fat and represent one of the most challenging periorbital problems to correct effectively.
Characteristics
- Located below the orbital fat — further down on the cheek (malar area), not just under the lash line
- Soft, fluid-filled folds that fluctuate significantly — often much worse in the morning, after alcohol, sodium, or allergen exposure
- “Hammock” appearance: loose skin suspended between fixed anchor points on the lateral and medial cheek
- The fold persists even when lying down — unlike pure edema
Why Lower Blepharoplasty Does Not Fix Festoons
Orbital fat removal addresses the upper portion of the lower eyelid — a completely separate anatomic compartment from the malar fold. Removing fat or tightening the lower eyelid does not reduce the festoon, and the change in tissue tension may actually accentuate the appearance of the malar fold postoperatively.
Treatment Options
- Direct festoonectomy: surgical excision of the redundant skin fold — most reliable result but leaves a visible (though well-concealed) scar
- Ablative laser resurfacing: CO₂ or erbium laser to tighten and resurface the skin; multiple treatments usually required; results variable
- Allergy management: for cases with significant fluid fluctuation driven by an allergic or inflammatory component
Malar Edema, Tear Trough, and Dark Circles
Malar Edema
Fluid accumulation in the cheek tissue — often from lymphatic dysfunction, allergic or inflammatory conditions, or medication side effects (including certain glaucoma drops and prostaglandin analogs). It fluctuates dramatically. Treatment targets the underlying cause rather than the eyelid itself.
The Tear Trough (Nasojugal Groove)
The tear trough is the depression that runs from the inner corner of the eye diagonally down the cheek. Volume loss in this area creates a shadow that patients interpret as “dark circles” or looking chronically tired. Hyaluronic acid filler placed precisely in this groove can significantly reduce the shadowed appearance without any surgery.
Dark Circles: Three Distinct Causes
- Structural (shadowing): the tear trough hollow casts a shadow — responds well to hyaluronic acid filler
- Pigmentation: excess melanin in the lower eyelid skin, often hereditary — responds partially to laser resurfacing, chemical peels, or topical agents
- Vascular: dilated vessels visible through thin eyelid skin — responds to laser treatment targeting hemoglobin
Many patients have a combination of all three. Treatment must address each component.
A physical examination is required to distinguish orbital fat prolapse, festoons, and malar edema — many patients present with a combination. Dr. Sakol will evaluate your specific anatomy and explain which treatment — surgical or non-surgical — applies to your situation.
Accurate Diagnosis Is the First Step
Schedule an evaluation with Peter J. Sakol, MD to find out whether you have orbital fat bags, festoons, malar edema — or a combination — and the right treatment for each.