Daniel Ezra, 13 February 2026
Swelling beneath the eyes is one of the most commonly misunderstood facial concerns. Many people assume that any fullness in this area is simply eye bags or a sign of tiredness, yet the reality is often more complex. Before considering any form of treatment, it is essential to understand what you are actually seeing in the mirror.
Festoons and malar bags are both relatively common findings, particularly as the face ages, but they are not the same condition. They have different underlying causes, behave differently over time, and respond to different treatment approaches. Visual assessment plays a far greater role than assumptions, which is why recognising their key characteristics is so important.
In this blog, we explore the key visual differences between festoons and malar bags, explaining how to recognise each condition and why accurate identification is essential before seeking treatment.
Malar bags are soft swellings that sit over the cheekbone, just below the lower eyelid. They are not caused by excess skin or loose tissue draped over the face. Instead, they are related to fluid retention of the underlying malar fat pad and structural changes in the underlying support system of the midface. The swelling tends to have a smooth, rounded quality, and the skin covering it usually remains intact and relatively firm to the touch.
The development of malar bags is influenced by several factors, many of which are interconnected. Age-related weakening of the supporting tissues plays a significant role. As the structures beneath the skin lose their strength and elasticity, fluid can accumulate more easily in certain areas.
Genetic predisposition is another important factor. Some individuals are simply more prone to developing malar bags due to inherited characteristics of their facial anatomy and lymphatic drainage patterns. Fluid retention and lymphatic congestion further contribute to the problem. When the lymphatic system does not drain efficiently, fluid can pool in the soft tissues of the midface, leading to the characteristic puffiness associated with malar bags.
Malar bags present with a smooth, rounded swelling rather than loose or hanging skin. They are often more noticeable in the morning, shortly after waking, and may fluctuate in prominence throughout the day. This variation is linked to fluid shifts that occur during sleep and changes in posture.
The skin surface usually appears intact and firm, without the folding or creasing that characterises other conditions. The swelling sits directly over the cheekbone, creating a distinct bulge that can alter the contour of the midface.
Festoons are draping folds of skin and muscle that hang between the lower eyelid and the upper cheek. Unlike malar bags, festoons involve a combination of skin laxity, muscle weakness and fluid accumulation. They represent a more complex structural issue that extends beyond simple puffiness. The tissue involved in festoons has lost its ability to maintain a smooth, taut appearance, resulting in visible folds that hang or drape across the cheek.
Festoons represent a more advanced structural issue than malar bags. They often persist regardless of the time of day, meaning that the drooping or folding does not significantly improve after a few hours of being upright. This persistence is due to the fact that the problem is not primarily caused by fluid retention but by a loss of structural integrity in the skin and underlying tissues.
Festoons typically do not respond to lifestyle changes alone. Adjustments to sleep patterns, hydration, or dietary sodium intake may have little to no effect on their appearance, as the underlying cause is mechanical rather than fluid-related.
Festoons have a hanging or pleated appearance, with visible skin folding rather than simple puffiness. The fold often sits lower on the cheek than a malar bag, extending further down the midface. Texture changes may be noticeable, with the skin appearing thicker, more irregular or slightly creased. The overall impression is one of tissue that has lost its firmness and is now resting in a draped position, creating a heavier, more pronounced contour change.
Understanding the distinctions between these two conditions is crucial for anyone considering treatment. The table below summarises the key differences in a clear and accessible format.
| Feature | Malar Bags | Festoons |
| Location | Over the cheekbone, just below the lower eyelid | Between the lower eyelid and the upper cheek |
| Appearance | Smooth, rounded swelling | Hanging, folded or pleated skin |
| Skin quality | Skin appears relatively firm | Skin laxity is clearly visible |
| Texture | Puffy or fluid-like | Heavier, looser, sometimes creased |
| Change during the day | Often worse in the morning, may improve later | Usually persistent throughout the day |
| Primary cause | Fluid retention and weakened support | Skin laxity, muscle weakness and fluid |
| Response to lifestyle changes | May partially improve | Little to no improvement |
| Complexity of treatment | Treat the underlying cause, often aggravated by surgery | Potential for surgical excision |
Observing changes between morning and evening can provide valuable clues. If the swelling is significantly worse upon waking and improves as the day progresses, malar bags are more likely. Looking for skin folding versus smooth swelling is another important step. If you can see distinct folds or pleats, festoons are the probable cause.
Checking whether the swelling sits on the cheekbone or hangs below it helps to distinguish between the two conditions. Finally, noticing whether skincare, sleep or hydration makes any difference can indicate whether fluid retention is a significant factor.
Treatments for malar bags and festoons are not interchangeable. An incorrect treatment choice can worsen the appearance rather than improve it. Some injectable or skin-tightening approaches may be unsuitable for festoons and could lead to disappointing results or even complications.
Specialist assessment is often required for accurate diagnosis, as the visual differences can be subtle and the underlying causes complex. Without proper identification, time, money and effort may be spent on interventions that are unlikely to succeed.
The treatment landscape for malar bags and festoons varies considerably. Malar bags may respond to targeted non-surgical treatments depending on their cause. Addressing old filler, fluid retention, improving lymphatic drainage, or laser treatments can all contribute to a reduction in swelling. However, the effectiveness of these approaches depends on the specific factors at play in each individual case.
Festoons often require advanced interventions and specialist expertise. Because they involve structural changes in the skin and muscle, simple non-invasive treatments are rarely sufficient. Surgery to address skin laxity, reposition tissue, or remove excess skin may be necessary to achieve meaningful improvement.
A personalised assessment is essential before any treatment decision. What works for one person may not work for another, and a thorough evaluation by an experienced practitioner is the only reliable way to determine the most appropriate course of action.
The Ezra Clinic offers specialist expertise in the assessment and management of both malar bags and festoons. With a focus on accurate diagnosis and individualised treatment planning, the clinic provides comprehensive care tailored to each patient’s unique needs. The team’s experience in facial anatomy and aesthetic medicine ensures that every case is approached with precision, care and a commitment to achieving the best possible outcome.
