Not All Malar Bags Are Created Equal- Classification and Treatment Algorithm for Malar Edema, Malar Mounds, and Festoons

Goals/Purpose: “Malar bags” are used to describe a broad anatomical problem that encompasses malar edema, malar mounds, and festoons. Each entity has its unique pathophysiology, presentation and necessitates different treatment algorithm. We propose a classification system and a road map for treating these challenging groups of patients.

Methods/Technique: Retrospective chart review of senior author's patients with malar bags were performed.

Results/Complications: Malar mounds, edema, and festoons composes of 5-10%, 10%, and 80% respectively of all malar bag presentation to our practice.

Malar edema is fluid accumulation over malar eminence. They present as pitting edema, and does not improve with the lateral pull test (LPT-lateral and cephalad suspension of orbicularis oculi muscle). There is often a systemic casual event such as food allergy (tyramine), allergic rhinitis, and hormonal dysfunction involving eicosanoids, leukotrienes, histamine, prostaglandins. Mainstay of treatment are diuretics, steroid, antihistamine, leukotriene antagoniosts, Kinesio tape at night, and diet modification. Malar mounds/ congenital festoons are chronic soft tissue swelling within the prezygomatic space containing hypertrophic fat and/or orbicularis muscle. Fat can be found both subcutaneous and anterior to the septum. If symptoms do not improve with two trials of deoxycholic acid injection (two subcutaneous injection of 0.1mL 6 weeks apart), we will proceed with a neurotoxin test where the orbicularis oculi muscle is injected. If bags worsen with neurotoxin, there is orbicularis muscle redundancy. Surgery including subcilliary lower blepharoplasty, muscle suspension, canthopexy, and excision of anterior septal fat will be offered. If subcutaneous fat persists, patient will receive additional injections of deoxycholic acid.

Festoons are senile progressive laxity of skin and orbicularis muscle below the infraorbital rim. These patients will have a positive LPT, and symptoms will worsen with neurotoxins. Definitive treatment for festoon is surgery which include, subcilliary lower blepharoplasty, release of ligaments (orbicularis retaining ligament and zygomaticocutaneous ligament), canthopexy, muscle suspension, temporal lift, and in severe cases brow pexy and a temporal, lower lid, midface tunnel.

Conclusion:

Malar bags are a diverse and complex spectrum of disease presentation, pathophysiology, and therefore require tailored treatment algorithm. These patients often require close interval and intensive follow-ups and many need revision surgery. Taking care of such patients require in depth understanding of the disease, surgical finesse, and most important patience and perseverance in the rather long and challenging postoperative period.