Malar edema and festoons: differences, causes, and modern treatment

• April 12, 2026
• By Fernando Amato

Malar edema and festoons are aesthetic changes in the area below the eyes that often cause doubt in both patients and professionals. Although they may seem similar at first glance, they have different origins and often coexist in the same patient. This overlap thus makes diagnosis and treatment more challenging — and requires a careful, individualized approach based on multiple anatomical levels.

In this article, you will understand what these conditions are, why they arise, how to differentiate one from the other, and what the most modern treatment options are, including surgical and non-surgical approaches.

What is malar edema

Malar edema, also called “malar mound,” is an accumulation of fluid and/or tissue in the cheekbone area, just below the lower eyelid. It can give the impression of persistent swelling, even in young people.

Therefore, from a technical point of view, it is an alteration in lymphatic drainage and fluid retention in a specific compartment of the face. In simple terms, it is as if there is a difficulty for the body to “drain” liquids from that region.

Among the main associated factors are:

• Aging of the skin and deep tissues
• Muscle laxity
• Changes in lymphatic drainage
• Previous use of facial fillers
• Genetics

What are festoons

Festoons are more evident and structured folds in the area below the eyes, generally appearing as more marked and heavy bags. Unlike malar edema, they involve not only fluid but also lax skin and muscle.

In technical terms, however, there is redundancy (excess) of skin and relaxation of the orbicularis oculi muscle — the muscle that surrounds the eyelid.

In practice, festoons tend to:

• Be more visible when smiling
• Appear as “sagging bags”
• Persist even with rest

Why it is difficult to differentiate malar edema and festoons

In most patients, there is no clear separation between these two conditions. It is common to have a combination of:

• Fluid accumulation (edema)
• Muscle laxity
• Excess skin

For this reason, many specialists choose to treat both integrally, instead of trying to classify them rigidly. This modern view avoids incomplete treatments and improves results.

Main causes — with emphasis on fillers

One of the most relevant changes in recent years has been the increase in cases related to the use of hyaluronic acid fillers.

Although widely used and safe when properly indicated, these products can cause:

• Fluid retention in the malar region
• Compression of lymphatic channels
• Irregularities in facial contour

Today, many specialists consider fillers to be the most common cause of acquired malar edema.

When this occurs, the approach may thus include the application of hyaluronidase — an enzyme that dissolves the product — before any surgical approach.

Evaluation before treatment

Before defining the treatment, a complete evaluation is essential, which may include:

• Skin quality analysis
• Degree of muscle laxity
• History of aesthetic procedures
• Presence of fillers or fat grafts

This step is as important as the treatment itself. In fact, detailed pre-operative exams are fundamental, as explained in pre-operative exams

Non-surgical treatments

Not all cases require surgery. In mild or initial situations, some options can help:

• Lymphatic drainage
• CO₂ laser for skin improvement
• Dissolution of fillers with hyaluronidase
• Specific adjustments with deep filling (in specific cases)

However, these methods have limitations. When there is structural laxity, the result tends to be partial.

Modern surgical treatment of malar edema and festoons

In moderate to advanced cases, surgical approach usually offers more consistent results.

One of the most complete techniques involves the combination of procedures that act on different layers of the face.

Deep-plane rhytidectomy (deep-plane facelift)

Modern rhytidectomy does not only treat the skin. It also acts on the SMAS (Superficial Musculoaponeurotic System), a deep layer responsible for facial support.

By repositioning this structure, it is possible to:

• Improve the transition between eyelid and cheek
• Reduce the “heavy” appearance of the face
• Soften festoons and malar edema

This concept also appears in other facial contouring procedures, such as mammoplasty and mastopexy, where structural support is essential for lasting results.

Sling of the orbicularis oculi muscle

One of the most important techniques is the so-called “orbicularis sling”.

It consists of suspending the muscle around the eyes, which is pulled and fixed in a higher position.

Benefits include:

• Improved lower eyelid support
• Reduction of muscle laxity
• More harmonious contour of the region

This technique can be performed during blepharoplasty or even alone in selected cases.

Canthopexy and eyelid support

Canthopexy is a procedure that reinforces the lateral corner of the eye (outer region of the eyelid).

It is especially important to prevent complications such as:

• Ectropion (eyelid turned outwards)
• “Scleral show” (excessive exposure of the white part of the eye)

In higher-risk patients, additional measures may be used, such as:

• Temporary tarsorrhaphy
• Frost suture

These techniques help protect the eyelid in the post-operative period.

Importance of anesthesia and surgical environment

The safety of the procedure also depends on factors such as adequate anesthesia and hospital structure.

Learn more about these aspects in anesthesia and day hospital

Possible complications

Like any surgery, there are risks that must be considered:

• Prolonged edema
• Asymmetry
• Ectropion
• Visible scars (rare in modern techniques)

Therefore, choosing a qualified professional and proper follow-up are fundamental.

Care before and after surgery

Adequate preparation significantly improves results.

Before surgery:

• Avoid smoking, as advised in smoking risks
• Follow dietary guidelines, as in diet
• Perform all requested exams

After surgery:

• Maintain relative rest
• Avoid sun exposure
• Correctly follow medical instructions

See general guidelines in tips for preparing.

What about fat grafting?

Fat grafting can be useful in some cases, but must be done with caution.

When performed in excess, it can cause:

• Irregularities
• Nodules
• Increased malar edema

The current trend is to be conservative, avoiding “overcorrection”.

Direct excision of festoons

In selected cases, especially when festoons are well defined, direct removal may be considered.

This approach is more direct, but requires experience to avoid visible scars.

What medical literature says

Studies show that the most effective treatment usually involves a combined approach — skin, muscle, and deep structures.

A review available on PubMed highlights that techniques that reposition the SMAS and thus reinforce muscle support tend to present more lasting and natural results.

Conclusion

In summary, malar edema and festoons are complex conditions that often coexist and require an individualized approach.

However, modern treatment goes beyond the skin, acting on multiple levels of the face to restore support and natural contour.

Thus, the choice of technique depends on several factors, and evaluation with an experienced plastic surgeon is indispensable to define the best strategy.

FAQ

What is malar edema?

It is an accumulation of fluid in the cheekbone area, below the eyes.

Are festoons the same as eye bags?

Not exactly. Festoons involve lax skin and muscle, while bags can be just fat.

Can filler cause malar edema?

Yes. Hyaluronic acid can interfere with lymphatic drainage and cause persistent swelling.

Does all malar edema require surgery?

No. Mild cases can be treated with non-surgical measures.

What is the orbicularis muscle sling?

It is a technique that repositions the muscle around the eyes to improve eyelid support.

Does surgery leave a scar?

Scars are generally discreet and well-positioned.

How long do the results last?

It depends on the technique and the patient, but structural procedures tend to last longer.

Is it possible to treat with laser alone?

Laser helps with skin, but does not resolve significant muscle laxity.

What is ectropion?

It is when the lower eyelid turns outwards.

How to know which treatment is ideal?

Evaluation with a specialist is essential to define the best approach.

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