Under Eye Bag and Festoons

Under Eye Bag Surgery

Under eye bags are fat puffy excesses that occur above the upper jaw bone.  Festoons are areas of swelling that occur in the middle of the cheek.  For this reason they are often called “midcheek mounds” or “midmalar mounds”. Patients with festoons often come to us saying they have “bags on their bags”.

Nothing makes a person look older and more tired than under eye bags. Add midcheek mounds to the mix and one can look unhealthy and like something is disastrously wrong.  Festoons can bump up against your glasses and are a cause of extreme self consciousness.

Under eye bags and festoons almost always benefit from aggressive treatments.  Dr. Allan Wulc, a board-certified plastic surgeon at W Cosmetic Surgery®, is a pioneer in the treatment of festoons. He offers patients in Philadelphia—and nationally– effective and innovative treatments.  If the festoons are moderate, patients can  profit from radiofrequency microneedling treatments.   We have presented our technique at national aesthetic meetings and are preparing the largest series in the country looking at this treatment to reduce festoons.  Our specialty procedure, which is reserved for patients with more severe festoons, combines microdroplet liposculpture with dual erbium laser resurfacing.

Under Eye Bag Surgery Results

Not every patient’s journey to rejuvenation of the eye area is the same. Together, we can help you discover the best treatment options to restore youth and beauty to your eyes. Some typical festoon and under eye treatment results are featured in our gallery.

*Each patient is unique and individual results may vary.

Why Do We Get Under Eye Bags?

Under eye bags occur for several reasons.  As we age, various studies using MRI technology have shown that the amount of fat in our orbits and specifically under our eyes increases.  In combination with this, as the decades pass, we lose bony volume in the upper jaw and the eyelids appear to lengthen because of the hollowing of the orbit, creating a bulge as the cheek soft tissues pull down on the skin of our lids, pulling the fat out and creating deeper and darker shadows.

Malar bags or festoons occur for an entirely different reason and are not a result of aging.  Anatomically, the bottom of the festoon represents an area—a so called septum– where the tissues that close the eye come into contact with tissues that elevate the mouth, making us smile and giving expression to our lower faces. This septum can be seen clearly when someone has a black eye:  the blood around the thin skin of the eyelids is held back from heading below this septal demarcation line and you see the bottom of the festoon. The malar septum demonstrated as the low point where a broken blood vessel won’t show up bruising below the septum.

Above this area, in the location of the festoon,  are the lymphatics and the ligaments that hold the cheeks in place. This septum and the tissues above it can swell with varying conditions. 

These include:

• hereditary causes. Festoons can be seen in the very young who inherit them from one side of the family.  They improve with smiling and appear to be the only type that do so.
• thyroid issues.  Thyroid levels that are too high, or too low, or patients with a history of autoimmune thyroid disease (Hashimoto’s thyroiditis).  Often other signs like loss of the outer part of the eyebrow may be present.  They rarely improve with normalization of thyroid function.
• Rosacea.  Treated or untreated, this inflammatory skin condition can cause congestion of the veins and lymphatics that drain the eye and cause intermittent swelling and festoons.
• sleep apnea and sleep apnea treatment.  For unknown reasons, this area is prone to swelling in those whose blood carbon dioxide levels become elevated at night when their respirations slow.  Perhaps their tissues become more sensitized to venous congestion, perhaps their blood vessels are more prone to dilation.  In addition, the sleep apnea mask can put pressure on the cheeks, resulting in an increase in swelling directly in the location that pushes up on the cheek and results in exacerbation of the festooning. 
• the most common cause of festooning we see now is the use of HA fillers under the eyes or cheeks presumably to improve the appearance of the eyes.  These fillers remain in place for years and gum up lymphatic flow, and they may migrate making festoons apparent.  Often a patient will go to a provider who will offer more filler as a means of treatment of the festoon.  This never works and usually makes the situation worse—and the patient more desperate to find a solution—or makes the patient despair about ever finding one.
• smoking and excessive salt intake can worsen the festoon, particularly in the morning when the head lies below the heart and the skin swells.

The Anatomy of a Festoon

It’s a puff of fullness that occurs in the middle of the cheek, like a “puddle” where the eye closing muscle meets the smiling muscle.

Benefits of Under Eye and Festoon Surgery

Many patients are extremely self-conscious about malar bags and have tried dozens of topical remedies with little success. Once bags on bags have formed, cosmetic surgery or other aesthetic treatments may be the only remaining means of effectively controlling the festoons. Patients seek all sorts of treatments in med spas and from plastic surgeons in an effort to rid them of festoons, yet very few surgeons can effectively eliminate them.  Many patients that we see have had several failed treatments before coming in for more definitive therapy.

Common Methods for Treating Malar Bags (Lower Lid Filler, etc)

Even among talented plastic surgeons, treating festoons is not an easy task. There are many different methods that are used, depending on the situation. Each option has pros and cons, and different surgeons have their own opinions about which techniques are the best for creating a consistent, beautiful, and natural-looking result. Dr. Wulc prefers to use his own tested method, but many other techniques are used all over the country. Some of the common methods for treating festoons include:

Blepharoplasty

The popular eyelid surgery blepharoplasty is consistently a top facial plastic surgery each year in the United States. During the surgery, incisions are made in the natural creases of the eyelids and fat and skin are repositioned, tightened, and removed when necessary. Lower lid surgery has been advocated to address under eye bags and festoons.   Lower eyelid surgery to treat festoons involves a lower eyelid skin incision and a skin excision and a suspension of the muscles that close the eye.  Despite being described as effective, it rarely results in improvement of the festoon, and sometimes has inadvertent consequences like causing a droop of the lower lids. 

Direct Excision

Although sometimes used to treat festoons, direct excision under eye bag surgery is risky. It involves manually removing the fat or fat pads beneath the eyelids using Although sometimes used to treat festoons, direct excision under eye bag surgery creates a conspicuous scar at the orbital margin.  While the advantage is that the festoon is removed directly, recurrences are often seen.

Liposuction

A classic procedure for removing fat througA classic procedure for removing fat through small incisions, liposuction techniques have advanced a great deal in the last few decades. Gentler techniques allow sensitive areas like the eyes to be treated. However, this technique often produces inconsistent results and has not worked well for us in the treatment of festoons.  

Lower Lid Filler Injections

Fillers and Botox are often used to help reduce under-eye bags and create a more youthful appearance. While fillers are excellent for treating lines and wrinkles, fillers almost always make festoons worse because they increase congestion of the lymphatics. Hyaluronic acid-based fillers are hydrophilic (they love water) and often will draw more fluid into the malar bags, making them more prominent.

Our practice offers Filler Correction as the first step in rehabilitation of festoons.in the event of a previously botched lower lid filler treatment. Dr. Wulc will examine the work done and decide if a lower lid filler removal is necessary.

Our Preferred Treatment Method

In our experience, none of the above treatments are ideal for treating festoons. We perform eyelid surgery using our technique:  a combination of microdroplet liposculpture and dual erbium laser resurfacing.

Microdroplet liposculpture involves using the patient’s own fat to carefully sculpt depressions and even out the amount of fat where it is lacking in the deep tissues under the muscle of part of the lower eyelid and in the cheeks.  Laser resurfacing helps to improve the skin quality in the area and restore a firm and supple look and is useful primarily to shrink and ultimately resolve the festoon.

Using this innovative method, the removal of even the most problematic festoons is possible. Treatment is typically performed in an outpatient setting. The surgery is painless and swelling lasts anywhere from seven to ten days.

Recovering from Lower Lid Surgery

Patients who undergo our festoon treatment may experience bruising and swelling after surgery. Absorbable sutures are used if any eyelid tightening is required to counteract the shrinkage effect of the laser and to avoid any pulling down of the lower eyelids.  Patients should start to notice results as the swelling and bruising fades, a week or so after surgery. We provide any pain medications—which are rarely necessary as the surgery is not painful– and care instructions for how to speed up the healing process using light and lasers in or office. Activity restrictions are necessary to avoid complications.

Ideal Candidates

Men and women who struggle with “bags on bags” in the lower lids may be good candidates for under eye bags surgery. Healthy adults with realistic expectations are the best candidates for festoons surgery. This is a difficult condition to treat, and patients need to understand the limitations of the procedure. FMen and women who struggle with “bags on bags” in the lower lids may be good candidates for under eye bags surgery. Healthy adults with realistic expectations are the best candidates for festoon surgery. This is a difficult condition to treat, and patients need to understand the limitations of the procedure. It is helpful to treat the underlying condition (such as rosacea or sleep apnea) before attempting surgical correction.  A sleep apnea mask that applies less pressure to the area below the festoon may be helpful. Fortunately, our treatment is applicable to most patients with this condition.  Prior to the surgery, patients will meet with us to discuss their goals and expectations.ortunately, Dr. Wulc’s cutting-edge festoons treatment is more effective and consistent than almost any other treatment for this condition. Prior to the surgery, patients will meet with Dr. Wulc and discuss their goals and expectations.

Malar Bags Consultation

FAQs

Some doctors excise malar bags.  Malar bag excision is always associated with a scar.  The scar heals but not always inconspicuously. It is not our preference and we rarely excise festoons. We find other treatments to be sufficient in the treatment of even the most severe. These include radiofrequency external treatments, Thermitight, Renuvion, midface lift and, most commonly, laser resurfacing.  

Dr. Allan Wulc: A Pioneer Treating Malar Bags

For years, surgeons have struggled to treat severe under eye bags using traditional surgery procedures, fillers, and laser resurfacing. Dr. Wulc has dedicated himself to creating new techniques that are minimally-invasive, effective, and consistent. His method for treating malar bags doesn’t leave any scarring and offers natural-looking rejuvenation that helps patients regain their confidence.

Related Articles

• Festoons: What Are They & How Are They Treated?
• New Treatment for Malar Festoons and Big Eyelid Bags
• Festoons or Baggy Eyelids or BOTH?

Under Eye Bags Treatment

If you are struggling with large under-eye bags, then it may be time to stop using ineffective creams and seek  consultation with a qualified surgeon. Dr. Allan Wulc, MD, FACS, is board certified in Ophthalmology (ABMS). He is board certified in Plastic Surgery by the American Board of Physician Specialists. He is fellowship trained in Oculoplastic Surgery and Orbital Surgery and a longstanding member of the prestigious American Society of Ophthalmic Plastic and Reconstructive Surgeons.  He is additionally board certified in Facial Cosmetic Surgery by the American Board of Cosmetic Surgery, where he served as a trustee for six years. He is a Fellow of the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Cosmetic Surgery, and a Fellow of the American College of Surgeons.

He is known for his training and the incredible results he offers patients in Philadelphia. If you are interested in learning more about your options for treating festoons, please fill out this online contact form or you can call W Cosmetic surgery® at  (610) 828-8880 to schedule your consultation. Serving customers from Plymouth, Philadelphia, Main Line, PA and surrounding areas.

Why choose Dr. Allan Wulc for a Neck Lift?

He is board-certified in:

• Ophthalmology by the American Board of Ophthalmology
• Cosmetic Surgery, Facial by the American Board of Cosmetic Surgery
• Plastic Surgery by the American Board of Physican Specialties
• a diplomate of the American Society of Ophthalmic Plastic and Reconstructive Surgeons.