Malar edema: Perspectives from plastic surgery and ophthalmology

Malar edema, the collection of fluid below the infraorbital rim and over the malar eminence, presents a unique challenge to providers in aesthetics and ophthalmology.¹ Despite their seemingly benign nature, the presence of malar edema or malar mounds (chronic soft tissue bulging) can significantly impact a patient’s appearance, confidence, and quality of life.

These visible changes are often the result of age-related attenuation of muscle and facial ligaments, specifically the orbicularis muscle and orbitomalar/orbicularis retaining ligament, which can cause the descent of the lid/cheek junction.² Specifically, malar edema can arise from systemic conditions like hepatic, cardiac, or renal issues; allergies; hypothyroidism; or following cosmetic injections or procedures.³ The delicate superficial lymphatic system of the infraorbital area, along with the malar septum, which acts as a relatively impermeable barrier, predisposes patients to poor drainage and persistent swelling.^4,5

The poorly supported upper boundary of the prezygomatic space, combined with the strongly supported lower boundary, creates the conditions for visible malar swelling.² Although distinct, malar mounds can be mistaken for festoons, which are defined as “cascading hammocks of lax skin and orbicularis muscle that hang between the medial and lateral canthi and may or may not contain herniated fat,” according to Kpodzo et al.² Whereas malar mounds are soft tissue bulges that may be congenital, festoons are age-related, more severe sagging folds with muscle and skin laxity, and may occur as a result of chronic malar edema.³ Therefore, knowing how to perform a thorough clinical assessment and learning the pathophysiology is essential, as treatment may differ.

Clinical and diagnostic assessment

When assessing a patient, it is important to evaluate the visual appearance and the palpable tissue characteristics of the malar region.

• Perform a visual inspection. Malar bags present as a triangle with a medial apex under the infraorbital rim in the prezygomatic space.³
• Ask the patient to gaze upward and downward. If the appearance does not change, the finding is more consistent with malar mounds rather than festoons.³
• Assess for festoons by instructing the patient to contract the orbicularis muscle (by squeezing eyelids together), to observe the muscle involvement in the appearance, and visualize how the fat is displaced from the original position.²
• Conduct a skin pinch test to assess the relative composition of tissue (fat, muscle, skin, edema) and the relative volume. The skin pinch test can also help identify whether the patient has had previous injections of hyaluronic acid (HA) filler, which can draw fluid into the space due to its hydrophilic nature, and can cause edema by applying direct pressure and compression on the lymphatics.⁶

It is equally important to take a full medical history, as many cases of periorbital edema can be caused by an array of local or systemic diseases, allergies, or certain medications.⁷ Lifestyle factors, such as sleep, alcohol consumption, and salt intake, can also heavily influence periorbital appearance.

If patients report a rapid exacerbation of the periorbital area, as opposed to a gradual progression of malar edema over the years, surgeons should be more cautious in evaluating and treating the patient’s condition, as it may be indicative of an acute inflammatory, infectious, renal, or systemic issue.⁷ It is not only critical for specialists but also for physicians across multiple disciplines to develop the knowledge and skill set to identify these conditions and manage them appropriately, either directly or through timely referral.

Treatment pathway for malar edema and mounds

Prior to any aesthetic intervention, the patient should be treated for any underlying causes, whether that involves managing allergies with antihistamines, addressing systemic disease, or making lifestyle modifications. Patients should also be counseled to avoid common triggers, such as excess salt and alcohol, and may benefit from learning simple lymphatic drainage massage techniques to reduce swelling. For many patients, the safest initial step in improving the appearance of malar edema is conservative, nonsurgical treatment.

Following assessment, if HA filler is suspected as a contributing factor to the edema, particularly after confirmation with a pinch test, a preferred treatment is hyaluronidase. In addition, hyaluronidase may also be beneficial in reducing excess swelling and soft tissue thickening, even in cases without filler; however, it must be used judiciously and with precise placement to avoid overdissolving. In selected patients with mild malar edema, conservative use of HA dermal filler may be carefully considered. When placed judiciously and in small volumes, filler can help camouflage surface irregularities, improve natural facial contours, and disguise the mounds by treating the surrounding tissue without significantly exacerbating swelling. I typically use a low G’ (lower viscosity) product and do not exceed 0.5 mL of filler per side in 1 treatment session, as overfilling can lead to worsened puffiness, Tyndall effect, and contour irregularities.⁸

These cases require cautious patient selection and meticulous injection technique, avoiding superficial placement that could worsen fluid retention. It is important to closely monitor for early signs of recurrent or progressive edema, and patients should be educated about the possibility of reversal with hyaluronidase if swelling develops or worsens. Although hyaluronidase is invaluable in aesthetic and ophthalmologic care, its use requires caution. Hyaluronidase is an endoglycosidase that cleaves the glycosidic bonds of hyaluronic acid, a key glycosaminoglycan within the extracellular matrix, degrading it into monosaccharides.⁹ Consequently, excessive dosing should be avoided, and precise placement of the enzyme should be used to minimize excessive dissolution of the surrounding glycosaminoglycans in the treated area.

Alternatively, subtle biostimulators may be employed to activate the body’s regenerative pathways, enhancing collagen synthesis and restoring volume in adjacent areas to disguise or camouflage the malar mounds. Calcium hydroxylapatite (CaHA) is generally more favorable in the adjacent regions (zygomatic arch and maxilla) compared with poly-L-
lactic acid (PLLA). CaHA is less hydrophilic and offers immediate volumization and collagen stimulation without the same risk of water retention that could exacerbate swelling. In contrast, PLLA induces a more delayed response and carries a higher risk due to its inflammatory mode of action, which may worsen tissue edema or create irregularities in the infraorbital and malar zones.¹⁰

For patients predisposed to malar edema, CaHA provides both subtle volume correction and collagen stimulation while minimizing the risk of worsening fluid retention, making it a more reliable option for midface support. In the context of malar mounds, emerging biologic therapies, such as autologous platelet-rich plasma (PRP), exosomes, platelet-derived growth factors, and polynucleotides, are being explored as novel biostimulators to improve tissue quality and support regenerative remodeling. When applied topically with microneedling, these biologics can be introduced into the infraorbital skin, where they can enhance collagen remodeling, improve dermal thickness, and subtly soften the appearance of the overall area. Autologous options, such as PRP and nanofat, can be injected into the infraorbital region to camouflage irregularities by naturally stimulating collagen and improving skin quality.

Although these treatments may be subtle and take more time to reach the desired aesthetic outcome, patients who cannot have filler injected to camouflage their malar edema may be better candidates for these treatments.

Nonsurgical options

Several noninvasive modalities can also provide natural improvement in the undereye region. Laser resurfacing with ablative fractional lasers can be used to help address redundant skin in the infraorbital region, but should be employed only for treating mild festoons and malar mounds.³

Microneedle radiofrequency is another popular treatment option used to treat malar mounds and festoons, as it is said to reduce fat and tighten skin.¹¹ However, because it works by delivering controlled thermal injury through needles, it can also cause localized edema and tissue irritation, and in some cases, may worsen swelling in an already problematic region. Although these nonsurgical treatment modalities may be sufficient for many, those with more advanced cases require surgical intervention as the primary method of achieving meaningful and lasting correction.

Surgical options

Among surgical options, lower eyelid blepharoplasty remains a foundational procedure for addressing malar mounds and associated periorbital changes. Alternatively, direct excision of malar bags can be performed, allowing for the removal of the severe excess skin seen with festoons. Although this approach carries a risk of visible scarring, it may reduce other complications such as ectropion, scleral show, or lagophthalmos.¹² The extent of tissue excision is guided by the severity of laxity and tissue composition, with some patients requiring partial resection of the orbicularis oculi if severely lax, and careful manipulation of the deep adipose tissue to achieve optimal contour.¹²

Asaadi et al describe their surgical approach, which involves creating a skin-muscle flap through a subciliary incision, releasing the orbitomalar and zygomatic cutaneous ligaments, and carefully mobilizing the midface over the suborbicularis oculi fat.¹³ Anterior septal fat, which can be present in both congenital and acquired festoons, can be excised directly through a septal window, “a small opening of the septum on the most prominent part of the lateral fat compartment.”^13,14 The procedure also includes a septal reset with a running 6-0 nylon to reposition tissue, addressing the central and medial compartments of the area.¹³

Some surgeons have performed liposuction of the edema combined with suspension of the lateral orbicularis muscle to the temporal fascia (lateral canthal incision).¹⁵ This is often paired with subperiosteal midface dissection, which releases the orbitomalar ligament and malar septum to improve drainage and reduce malar edema.² Ultimately, the choice of technique depends on each patient’s unique anatomical and clinical presentation.

Malar edema and malar mounds are notoriously difficult to manage due to the anatomy of the prezygomatic space and its poor lymphatic drainage. Noninvasive options, such as appropriate use of hyaluronidase, conservative use of nonhydrophilic dermal fillers, and cautious use of biostimulators to camouflage, can provide improvement in select patients. However, it is critical to recognize when these measures are no longer sufficient.

For patients who remain dissatisfied despite conservative treatments, surgical approaches such as lower eyelid blepharoplasty or direct excision may offer more extensive correction. However, even after surgical intervention, some patients may continue to experience edema, requiring ongoing management and long-term follow-ups throughout their lives.¹³

Optimal management requires precise anatomical knowledge, careful patient selection, and the judgment to know when to transition from noninvasive to surgical intervention. Collaboration between plastic surgeons and ophthalmologists is essential to optimize outcomes, and continued research into regenerative and minimally invasive approaches is needed to broaden future treatment options.

References

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2. Kpodzo DS, Nahai F, McCord CD. Malar mounds and festoons: review of current management. Aesthet Surg J. 2014;34(2):235-248. doi:10.1177/1090820X13517897

3. Newberry CI, Mccrary H, Thomas JR, Cerrati EW. Updated management of malar edema, mounds, and festoons: a systematic review. Aesthet Surg J. 2020;40(3):246-258. doi:10.1093/asj/sjz137

4. Siperstein R. Infraorbital hyaluronic acid filler: common aesthetic side effects with treatment and prevention options. Aesthet Surg J Open Forum. 2022;4:ojac001. doi:10.1093/asjof/ojac001

5. Pessa JE, Garza JR. The malar septum: the anatomic basis of malar mounds and malar edema. Aesthet Surg J. 1997;17(1):11-17. doi:10.1016/s1090-820x(97)70001-3

6. Funt DK. Avoiding malar edema during midface/cheek augmentation with dermal fillers. J Clin Aesthet Dermatol. 2011;4(12):32-36.

7. Rafailidis PI, Falagas ME. Fever and periorbital edema: a review. Surv Ophthalmol. 2007;52(4):422-433. doi:10.1016/j.survophthal.2007.04.006

8. Hong GW, Hu H, Chang K, et al. Review of the adverse effects associated with dermal filler treatments: part I nodules, granuloma, and migration.
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9. Jung H. Hyaluronidase: an overview of its properties, applications, and side effects. Arch Plast Surg. 2020;47(4):297-300. doi:10.5999/aps.2020.00752

10. Nowag B, Schäfer D, Hengl T, Corduff N, Goldie K. Biostimulating fillers and induction of inflammatory pathways: a preclinical investigation of macrophage response to calcium hydroxylapatite and poly-L lactic acid. J Cosmet Dermatol. 2024;23(1):99-106. doi:10.1111/jocd.15928

11. Jeon H, Geronemus RG. Successful noninvasive treatment of festoons. Plast Reconstr Surg. 2018;141(6):977e-978e. doi:10.1097/PRS.0000000000004400

12. Botti G, Botti C, Fabbri M, et al. Direct excision of malar bags: back to the basics. Aesthetic Plast Surg. 2024;48(21):4307-4313. doi:10.1007/s00266-024-04411-5

13. Asaadi M, Gazonas CB, Didzbalis CJ, Colon A, Tran BNN. Outcomes of surgical treatment of malar mounds and festoons. Aesthetic Plast Surg. 2023;47(4):1418-1429. doi:10.1007/s00266-023-03381-4

14. Tran BNN, Luthringer M, Reed L, Asaadi M. Addition of “septal window” to lower blepharoplasty for the management of fat of the lower eyelids. Ann Plast Surg. 2022;88(3 suppl 3):S214-S218. doi:10.1097/SAP.0000000000003129

15. Liapakis IE, Paschalis EI. Liposuction and suspension of the orbicularis oculi for the correction of persistent malar bags: description of technique and report of a case. Aesthetic Plast Surg. 2012;36(3):546-549. doi:10.1007/s00266-011-9838-1