There are 3 separate entities lower eyelid bags, festoons and malar bags.
Lower Eyelid Bags
Malar pouches, bags or saddlebags are a prominence below the level of the bone rim under the eye due some combination of swelling or edema, drooping eyelid muscle (orbicualris oculi muscle) and fat under the muscle herniating through the muscle. The lower edge of the malar bags is defined or limited by the zygomatico-cutaneous ligament which has also been called the malar septum.
This ligament stops the discoloration of a black eye from spreading down into the cheeks. There is a lot of misinformation on the web regarding malar bags, even on online question boards answered by surgeons. Some people call the bags malar crescent.
The presence of malar bags can be related to previous eyelid or nose surgery independent of who your surgeon was, a complication of dermal filler injections that block normal lymphatic flow, the aging process, genetics, allergies, sinus infections, lack of sleep, water retention (related to menses, kidney insufficiency etc.), liver cirrhosis or thyroid conditions (hypo or hyperthyroidism). The chances of them appearing after dermal filler injection is reduced if smaller beads of filler are placed closer to the underlying bone and aggressive massage of the area is avoided. I get them temporarily when my allergies act up and I lose sleep.
The acute onset of malar bags such as those seen after eyelid surgery is best treated with anti-inflammatory steroids with or without diuretics and sleeping with 2 pillows under your head. Those related to allergies should first be treated with antihistamines and avoidance of inciting allergens. The injection of 20 units of Vitrase (hyaluronidase) will quickly resolve malar bags caused by injection of a hyaluronate like Restylane or Juvederm. Chronic malar bags require a medical workup to assess for one of the causes listed. That involves blood tests such as complete blood count with differential, erythrocyte sedimentation rate, serum protein electrophoresis, cryoglobulin and cryofibrinogen testing, rheumatoid factor, antinuclear antibodies, thyroid levels and liver or kidney function blood tests. A history and physical examination will inform your doctor which if any of these tests would be required..
For chronic malar bags where a medical condition is not present or has been controlled through medications surgery can be helpful. Superficial liposuction (with the cannula holes facing away from the skin) of these malar bags via a small incision near the outer corner of the eye was first described in 1984. More recently this same liposuction via an incision at the nostril rim-cheek crease and suture elevation of the muscle to the temple muscles was described.
This is a patient in whom I sutured the eyelid protruding fat to the deep cheek fat and liposuctioned fat in the malar bag between the skin and the eyelid-cheek muscle. No skin was removed. A similar though usually temporary result can be achieved using dermal filler injections directly over the ligament.
This is a patient who underwent malar bag liposuction and muscle suture elevation elsewhere.