Malar Mounds and Festoons: Causes and Treatments

The area behind the eyes may show signs of aging and fluid retention. Malar mounds, festoons, and eye bags are sometimes used interchangeably, although each has unique characteristics, causes, and treatment options. In this article, we shall discuss malar mounds and festoons. 

What Are Malar Mounds and Festoons? A Scientific Overview

There are numerous ideas on the cause of festoons, and various labels are used to characterize the puffiness that is frequently found along the lower eyelid.  Festoons are swelling areas beneath the lower eyelids that appear as mounds, bumps, or sagging skin around the cheekbones. There is a conventional definition for fullness under the lower eyelid, and it is critical to discern the difference to improve the possibilities of resolving the issue.

• Malar edema is a term used to describe a fluid collection around the lid and cheek junction.

• Malar mound refers to a chronic soft tissue swelling on the cheek.

• Festoons are sagging skin or folds on the top of the cheek.  Festoons are caused by lax skin and a weakened lower eyelid muscle, and they frequently start as malar mounds.

There is great controversy about the use of this phrase, although the triangle form observed behind the eyes can be caused by malar edema progressing to malar mounds and then festoons.

Defining the Difference Between Eye Bags, Malar Mounds, and Festoons

The area under your eyes can develop numerous types of puffiness or swelling, but not all are the same. Understanding the anatomical variations between eye bags, malar mounds, and festoons is critical for determining the appropriate treatment and setting reasonable expectations.

• Eye bags: Directly behind the lower eyelid, at the lash line. Protruding fat pads caused by aging, heredity, or fluid retention. Primary reasons include fat herniation through the orbital septum, loss of skin elasticity, and fluid accumulation (temporary puffiness). The best treatments include lower blepharoplasty (surgical fat repositioning/removal). In mild cases, apply topical caffeine, lymphatic massage, and cold compresses.

• Malar Mounds (or Malar Edema): Just behind the lower eyelid, on top of the cheekbone (malar prominence). Muscle laxity and lymphatic fluid retention resulted in firm, localized swelling over the malar region. The primary causes include weakening in the orbicularis oculi muscle, inadequate lymphatic drainage, and often heredity, which are exacerbated by sleep posture, alcohol, or salt. The best treatments are lymphatic drainage procedures, CO₂ laser resurfacing, or RF microneedling, and fillers (with caution) to smooth transition zones. Persistent cases may require surgery.

• Festoons: Below the malar mounds, usually at the middle of the cheek, where the lower lid meets the cheek. Skin laxity and chronic swelling generate sagging, fluid-filled pouches, which are commonly exacerbated by UV damage and aging. Primary causes include skin and muscle layer laxity, persistent sun exposure, lymphatic stagnation, and, in certain cases, genetic predisposition. The most effective treatments include CO₂ laser or radiofrequency skin tightening, surgical excision for severe cases, subcision + laser for scarred or tethered festoons, and blepharoplasty (only for festoons that extend into the lower lid area).

Anatomical Insights: Where and Why They Occur

Understanding the anatomy of the lower eyelids and midface is essential for determining the cause of cosmetic issues such as eye bags, malar mounds, and festoons. Each disease arises in a specific anatomical layer and has separate physiological origins.

• Eye bags: They appear beneath the lower eyelid, slightly below the orbital rim. The orbital fat pads are located behind the orbital septum. With aging, the orbital septum (a thin membrane that maintains fat in place) weakens. The fat herniates forward, causing noticeable bulging. exacerbated by genetics, lack of sleep, and fluid retention.

• Malar mounds: Directly above the zygomatic (cheekbone). Lies above the malar eminence but beneath the lower eyelid. Laxity or weakness of the orbicularis oculi muscle. Impaired lymphatic drainage in the midface. Fluid accumulates between the skin and muscles. It is frequently congenital or inherited but deteriorates with age, posture, and lifestyle.

• Festoons: They are located below the malar hump and extend into the mid-cheek region. Frequently lateral and inferior to the lower eyelid. Loss of ligaments and skin elasticity. Chronic lymphatic stasis and drooping of the soft tissues. Sun exposure causes skin thinning and photodamage. Linked to long-term UV exposure, aging, and fluid imbalance.
  

The Role of Skin Aging, Genetics, and Lifestyle Triggers

Visible puffiness or drooping under the eyes, often known as eye bags, malar mounds, or festoons, does not occur overnight. These issues stem from the intricate interaction of three key influences: intrinsic aging, genetic predisposition, and environmental factors. Understanding the underlying reasons helps to guide preventative, management, and treatment approaches.

• Genetics: It determines facial architecture, including bone shape, fat pad positioning, and ligament strength. affects skin thickness, elasticity, and collagen levels. Affects lymphatic function and fluid retention tendencies. Early warning signs of genetic predisposition include eye bags, puffiness, and malar edema. Close cousins exhibit similar under-eye or cheek puffiness. Swelling worsens with sleep, allergies, or fluid consumption, even with regular skincare. Genetic malar mounds can emerge in youth and remain despite a healthy lifestyle.

• Skin aging: It is the gradual weakening of the skin, muscle, fat, and connective tissue that hold the midface together. Key age-related changes include loss of skin elasticity (collagen and elastin breakdown), fat pad descent, and volume loss, particularly in the cheeks, as well as weakening of the orbital septum, which causes fat herniation (eye bags). Muscle laxity (particularly orbicularis oculi), resulting in fluid buildup (malar mounds and festoons). Maintaining ligament laxity, permitting sag and fluid migration (festoons).

• Lifestyle and environmental factors: While genetics and age are important, certain lifestyle choices can exacerbate or accelerate under-eye puffiness and sagging. UV exposure, smoking, alcohol, salt intake, allergies/sinus, poor sleep, sleeping flat, and lack of SPF are major triggers. UV exposure breaks down collagen, causing lax skin and festoons. Smoking reduces circulation and damages skin and lymphatics. Alcohol dehydrates skin and promotes water retention. Salt intake increases fluid retention and worsens swelling.

Diagnosing the Condition: Identifying Festoons Correctly

Festoons, also known as eye bags or malar mounds, are drooping skin and fluid-filled pouches that form near the lower eyelid-cheek junction. Proper diagnosis is required to avoid unsuccessful therapies and provide a suitable remedial approach.

• Visual Inspection: Look for soft, sinking folds beneath the malar prominence. It frequently manifests as bilateral "bags" that move with expression.

• Palpation: Festoons feel soft and fluid-filled, rather than stiff like fat herniation. The size may vary during the day (worst in the morning).

• Patient history: Long-term swelling or "tired" appearance. History of sunburn, smoking, or face puffiness. It is usually resistant to fillings or topical treatments.

Clinical Evaluation vs. At-Home Observation

Distinguishing between eye bags, malar mounds, and festoons can be difficult, especially since they frequently occur simultaneously. While at-home observation can provide insights, a clinical examination is required for an accurate diagnosis and appropriate treatment plan.

• Clinical evaluation: A clinical exam by a dermatologist, plastic surgeon, or oculoplastic specialist includes detailed facial analysis under optimal lighting and magnification; palpation to distinguish between fat, fluid, and loose skin; dynamic assessment (how swelling moves with facial expression or smiling); evaluation of lymphatic congestion, skin laxity, and muscle tone; medical history review (genetics, allergies, sun exposure, prior procedures); and optional use of high-resolution images. Advantages include accurate distinction of eye bags, malar mounds, and festoons; detection of comorbid disorders (e.g., tear trough hollows, cheek volume loss); and an informed treatment approach (non-surgical vs. surgical).

• At-home observation: While not diagnostic, at-home examinations can help you identify patterns and initiate a conversation with your clinician. Observations at home include a mirror check (puffiness under the eyes vs. over the cheekbones), a smile test (do folds or swelling become more prominent?), a morning vs. evening comparison (swelling worse in the morning = fluid-based), a head tilt (gravity accentuates festoons more than bags), and a touch test.

Common Misdiagnoses and Why Precision Matters

The periorbital region is one of the most complicated and misunderstood locations in aesthetic treatment. Without correct identification, eye bags, malar mounds, and festoons are frequently misdiagnosed, resulting in inefficient or even hazardous therapies.

• Malar mounds are mistaken for eye bags: Lower blepharoplasty (eye bag surgery) was a mistake. The issue is either muscular laxity or fluid buildup on the cheekbone, not fat herniation. Surgery eliminates fat; however, the mound remains the same or grows more prominent due to hollowing.

• Festoons that were misdiagnosed as under-eye hollows or wrinkles: They were treated with filler or topical treatments. Festoons are associated with skin and lymphatic laxity rather than volume loss. Fillers compress the region, exacerbating puffiness and festoon drooping.

• Eye bags treated with skin tightening only: Assume that all puffiness is attributable to skin laxity. Fat protrusion, rather than loose skin, is often the cause of eye bags. Lasers and radiofrequency may tighten the skin, but they do not treat the underlying fat.

When to Seek Professional Dermatologic Care

The under-eye and mid-cheek area is one of the most visually sensitive and medically difficult parts of the face. While slight puffiness or tired-looking eyes can be treated at home, persistent or increasing symptoms may suggest deeper structural abnormalities requiring the knowledge of a specialist.

• Swelling that does not go away: Puffiness lingers beyond the morning hours, does not respond to diet, sleep, or lymphatic massage, and worsens over time or occurs unexpectedly. It could imply malar mounds or festoons, rather than simple fluid retention.

• Puffiness or drooping that moves with expression: Bulging or sagging is more visible when you smile or squint. Indicates involvement of the orbicularis oculi muscle or skin laxity. Common with malar mounds and festoons, which require professional evaluation.

• Home treatments and topicals aren't effective: I tried lotions containing caffeine, retinol, and peptides  and cooling tools, but there was still no significant change. These are frequently ineffectual in treating structural issues such as fat herniation or festoon sagging.

• Under-eye filler worsened the area: Puffiness increased or shifted following dermal filler, and the area appears lumpy, heavy, or unduly bloated. Festoons and malar mounds do not respond well to filler and may need to be reversed.

• Visible skin laxity or draping beneath the eyes: Wrinkles, folds, or loose skin hanging below the lower eyelids, which may appear worse while lying down or at the end of the day. Suggests extensive skin laxity or festoons that require laser or surgical treatment.

• Considering in-office procedures: When considering in-office procedures such as CO₂ laser, fillers, RF microneedling, or blepharoplasty, it's important to get an appropriate diagnosis before treatment. A skilled dermatologist or oculoplastic surgeon can advise you on the safest and most effective treatment option.

Effective Treatments for Malar Mounds and Festoons

Malar mounds and festoons are among the most difficult facial conditions to cure because they include numerous layers of skin, muscle, fat, and lymphatic processes. A precise diagnosis, layer-specific intervention, and, in many cases, a multimodal strategy are all required for effective treatment.

Treatments for malar mounds

• Radiofrequency microneedling: It is most suited for early to moderate mounds. It promotes collagen formation and tightens the muscle-skin interface. Gradual enhancement of shape and puffiness

• Fractional CO₂ or erbium lasers:Ideal for skin tightening and edema control. Controlled thermal injury remodels the dermis and increases suppleness.  Also helps fine lines and texture.

• Lymphatic drainage therapy: It is ideal for mild, fluid-based lumps. Manual massage, lymphatic facial instruments, and compression. Temporary; works best in conjunction with other modalities.

• Targeted neuromodulators: It weaken the orbicularis oculi muscle. A subtle rise or softening of the mound area. An experienced injector to avoid harming grin or eye function.

Treatments for festoons

• Direct surgical excision: Direct surgical excision is most suited for mild to severe festoons. Removes excess skin and tissue. Definitive and immediate contour improvement. An oculoplastic or facial plastic surgeon will perform the procedure.

• CO₂ laser resurfacing: It is ideal for mild to moderate festoons with skin crepiness. Tightens skin and decreases fluid retention.

• Subcision + laser combination: Ideal for festoons with tethered or scar-like bands. Releases fibrotic tissue beneath the skin and encourages rebuilding. It's typically used with fractional CO₂ or RF energy.

• Radiofrequency skin tightening: Effects of collagen contraction and dermis tightness. Ideal for those who aren't ready for surgery.

Laser Therapies: CO2 and Beyond

Laser technology has developed into an effective tool for treating difficult-to-treat midface disorders such as malar mounds and festoons. While CO₂ laser remains the gold standard for tightening and resurfacing, emerging technologies offer customizable, lower-downtime alternatives, each with unique strengths and limits.

• CO₂ laser (Carbon dioxide laser): The best improves skin texture and tone by treating moderate skin laxity, crepiness, and fine wrinkles, as well as mild festoons and surface-level edema. The ablative fractional technique is used to melt columns of skin. Causes neocollagenesis (new collagen creation) and skin tightening. Improves dermis structure, which reduces fluid pooling. Moderate (3–10 days, depending on settings). Redness may last for several weeks.

• Erbium: Ideal for patients with small wrinkles and superficial laxity who prefer a speedier recovery than CO₂. Compared to CO₂, there is less heat damage, resulting in speedier healing and less tightening at the surface. Shorter (2–5 days). Best suited to mild festoons or early aging.

• Non-ablative fractional lasers: They are best for detecting early symptoms of skin laxity or festoon development. Maintenance following CO₂ or surgery. Patients who cannot withstand downtime. Creates microthermal zones deep within the dermis. Leaves the epidermis intact, making it safer for darker skin tones. Minimal (1-3 days of redness with no peeling).

• Radiofrequency devices: They are ideal for skin tightening, deeper dermal heating, malar mounds, and mild festoons, particularly in the early phases. Minimal to moderate use (1-3 days, depending on device). It is frequently used as a non-ablative adjuvant to laser therapy.

Injectable Options: Fillers, Botox, and Steroids

While injectables are used in aesthetic procedures, utilizing them on malar mounds and festoons necessitates specialist understanding and caution. These disorders have complex anatomy, so using the wrong injectable or injecting into the wrong layer might aggravate swelling, distortion, or drooping.

• Dermal fillers: Tear trough hollowing or midface volume loss accentuates the appearance of malar mounds or festoons. Deeply inserted (on bone, underneath trouble areas) to lift and balance. Avoid walking directly into or over malar mounds or festoons. For patients with lymphatic congestion or fluid retention. When swelling worsened after previous fillers.

• Botox: Malar mounds are caused by an overactive orbicularis oculi muscle. A minimally invasive adjuvant to treat minor bumps with no downtime. Reduces superficial muscular contraction and enhances lymphatic drainage and shape.

• Injectable steroids: They are used to treat scar tissue and chronic edema following surgery. Early or mild festoons with inflammatory/fibrotic characteristics. Reduces local inflammation, fluid accumulation, and fibrotic bands.

Surgical Approaches: When Minimally Invasive Isn’t Enough

When lasers, injectables, and skin-tightening technologies fail, surgical intervention is the most effective and long-term option, particularly for moderate to severe festoons and persistent malar mounds. These operations target the underlying structural abnormalities, such as extra skin, weakening muscle, and lymphatic stasis.

• Direct excision of festoons: Moderate to severe festooning. Sagging, crepey skin with fluid-filled pouches at the lower eyelid-cheek junction. An elliptical or crescent-shaped skin excision directly beneath the festoon area. Removing superfluous skin, underlying muscle, and occasionally fluid-filled tissue. It is conducted with either local or general anesthesia. The benefits include the definitive elimination of festoon tissue, as well as the tightening and lifting of the midface contour.

• Midface lift or SOOF lift (sub-orbicularis oculi fat): Malar mounds caused by fat descent and muscle laxity. Midface sagging, with or without festoons. Lifts and repositions descended midface fat pads (SOOF) through a lower eyelid or temporal incision, which can be paired with blepharoplasty or festoon excision. Benefits include restoring natural cheek contour, smoothing the transition from eyelid to cheek, and improving malar prominence and puffiness.

• Lower blepharoplasty: It includes eye bags and a minor malar mound contribution. Fat herniation, skin excess, or muscle laxity beneath the eyes. Fat is removed or relocated from the inside of the eyelid (transconjunctival) or immediately beneath the lash line (subciliary). Skin and muscular tightness may occur. Benefits include a smoother, lower eyelid shape, which can be paired with festoon excision or laser resurfacing.

• Canthopexy: It is also known as canthoplasty, is a procedure used to prevent or treat lower eyelid drooping following surgery. Typically combined with midface or festoon surgery. Tightens or moves the outside corner of the eyelid (lateral canthus). It provides eyelid stability and symmetry while also preventing ectropion (the outward turning of the lower lid).

Home Remedies: Limitations and Cautions

Malar mounds and festoons are sometimes mistaken for ordinary puffiness or under-eye bags, prompting many people to try home treatments in the hopes of finding relief. While some lifestyle and skincare routines may provide brief or minor benefits, it is critical to realize their limitations, and when DIY attempts may really be harmful. It may provide short relief for modest fluid retention, morning puffiness, surface-level irritation, or fatigue-induced edema.

• Cold compresses: Reduce mild edema through vasoconstriction. The effects are only transitory and will not influence festoons or tissue laxity.

• Caffeinated eye creams or green tea bags: They can help relieve minor under-eye puffiness briefly. There is no influence on structural malar mounds or festoons.

• Salt reduction and hydration: Helps to reduce fluid buildup in mild cases. Will not treat sagging tissue or muscle/fat decline.

• Gentle lymphatic massage: It helps to promote temporary drainage. Does not lift or remove chronic mounds/festoons; may irritate delicate skin if done incorrectly.
  

Tailored Skincare and Lifestyle Changes to Support Treatment

Professional treatments for malar mounds and festoons, such as laser, surgery, or radiofrequency, are most effective when combined with individualized skincare and good lifestyle habits. These not only boost outcomes, but they also assist in sustaining long-term changes and preventing puffiness, sagging, and inflammation from returning.

• Skincare routine: In the morning, avoid harsh scrubs close to the under-eye region and use a gentle cleanser instead. Vitamin C and niacinamide are antioxidant serums that guard against UV rays and photoaging. Eye cream with a high peptide content promotes collagen and firm skin. Every day, even around the eyes, use a broad-spectrum sunscreen with an SPF of 30+ (look for non-irritating mineral options). In the evening, mild cleansing to remove makeup and pollutants. Retinol or retinaldehyde (low strength) stimulates collagen (use only if tolerated around the eyes). Hydrating eye cream containing hyaluronic acid, ceramides, or caffeine for mild puffiness. To prevent trans epidermal water loss (TEWL), use barrier repair moisturizer.

• Targeted ingredients: caffeine (vasoconstriction, mild fluid reduction), peptides (signal collagen production), hyaluronic acid (hydration, skin plumping), niacinamide (anti-inflammatory, barrier repair), and retinaldehyde (gentler retinoid for collagen support).

• Lifestyle adjustments (to eliminate triggers and promote healing): Sleep and positioning, which includes sleeping 7-8 hours per day to assist tissue repair, using an extra pillow to elevate your head and reduce nocturnal fluid collection, and avoiding sleeping face-down, which can exacerbate festoon prominence. Nutritional tips include reducing salt intake to avoid fluid retention, eating anti-inflammatory foods like berries, leafy greens, and omega-3s, staying hydrated, limiting alcohol and smoking, and using sunscreen.

• Manage lymphatic flow and inflammation: By doing a mild face massage (which improves lymphatic drainage), using cold rollers or jade tools (which help reduce puffiness, especially in the morning), and avoiding high-heat situations.