Malar Festoons and Thyroid: What Is the Connection?

Daniel Ezra, 27 May 2026

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Not all under-eye puffiness is the same. Many people notice swelling or heaviness beneath their eyes and assume it is simply a sign of tiredness or ageing, yet for some, the cause runs considerably deeper. Understanding the difference between general puffiness, festoons, and medically driven swelling is the first step towards finding the right solution.

Malar festoons are a distinct and often misunderstood condition involving sagging or swollen tissue in the cheekbone area. Unlike the temporary puffiness that follows a poor night’s sleep, festoons tend to persist regardless of rest, skincare, or lifestyle changes. This can make them particularly distressing for those affected.

One factor that is not always considered in conversations about facial swelling is the role of the thyroid gland. Thyroid dysfunction can produce wide-ranging effects throughout the body, including changes to the face and the delicate tissue around the eyes. Understanding this relationship may help explain why some people struggle to improve their under-eye area despite their best efforts.

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Close-up of a woman applying skincare near the under-eye area.

What Are Malar Festoons?

Malar festoons are pockets of swelling or lax tissue that form along the cheekbone, typically just below the lower eyelid. The term “malar” refers to the cheek or zygomatic region, and festoons take their name from the draped, scalloped appearance they can create across the midface.

It is important to distinguish festoons from other common concerns. Under-eye bags, for instance, form directly beneath the eye and are usually caused by the forward displacement of fat pads as the supporting structures weaken with age. Malar oedema, on the other hand, refers to fluid accumulation in the cheek region and can resemble festoons but has a different underlying mechanism. True festoons involve changes to the skin, muscle, and soft tissue of the malar area itself, often resulting in a persistent, gravity-resistant swelling that does not resolve with simple measures.

This is precisely what makes festoons so challenging to address. They are frequently resistant to topical treatments, have a temporary response to certain procedures, and are often misdiagnosed as straightforward under-eye bags. Without proper identification, patients may undergo treatments that fail to deliver lasting results.

Side-profile close-up of a woman’s eye and dewy skin texture.

What Does the Thyroid Do in the Body?

The thyroid is a small, butterfly-shaped gland located at the front of the neck. Despite its modest size, it plays a central role in regulating many of the body’s essential functions by producing hormones, primarily thyroxine (T4) and triiodothyronine (T3).

These hormones influence metabolism, determining how efficiently the body converts food into energy. They also play a role in maintaining fluid balance, supporting healthy heart function, regulating body temperature, and sustaining the health of skin, hair, and other tissues throughout the body.

When the thyroid produces the right amount of hormone, the body functions in a state of equilibrium. When it produces too little (hypothyroidism) or too much (hyperthyroidism), the effects can be felt across multiple systems, from energy levels and weight to mood and physical appearance.

How Thyroid Dysfunction Affects the Face

Thyroid imbalances can produce noticeable changes in facial appearance, particularly around the eyes and cheeks.

In hypothyroidism, where the thyroid is underactive, the body tends to retain fluid and produce a substance called a glycosaminoglycan in the tissues. This leads to a characteristic puffiness, particularly of the face, that is often described as myxoedema in more severe cases. The swelling associated with hypothyroidism is typically non-pitting, meaning it does not leave an indentation when pressed, and it tends to be diffuse rather than localised to one area. The skin may also appear pale, dry, or dull due to impaired cellular turnover.

In hyperthyroidism, where the thyroid is overactive, the changes around the eyes can be particularly pronounced. Thyroid eye disease, also known as Graves’ ophthalmopathy, is an autoimmune condition closely associated with hyperthyroidism. It can cause the tissues and muscles behind the eye to become inflamed, leading to protrusion of the eyeball, puffiness of the eyelids, and changes to the surrounding soft tissue. Even without Graves’ disease, hyperthyroidism may contribute to periorbital changes that affect the appearance of the under-eye area.

Close-up of a mature woman touching the skin near her eye, showing natural fine lines.

Malar Festoons and Thyroid: What Is the Connection?

The relationship between malar festoons and thyroid dysfunction is not one of direct causation in every case, but there are several plausible mechanisms through which thyroid imbalance may worsen or make festoons more apparent.

Fluid retention associated with hypothyroidism may increase facial tissue swelling, making festoons more prominent. Where festoons already exist due to structural changes in the skin or muscle, the additional fluid load can significantly exaggerate their appearance.

Inflammatory processes driven by thyroid autoimmunity may also play a role. Immune system changes associated with conditions such as Hashimoto’s thyroiditis or Graves’ disease can affect connective tissue, influencing how the face ages and how tissue behaves under stress.

Connective tissue changes are another relevant factor. Thyroid hormones help regulate the production and maintenance of collagen and other structural proteins. When hormone levels are disrupted, tissue integrity can be compromised, potentially contributing to the laxity that characterises festoons.

It is important to be clear: thyroid dysfunction does not directly cause festoons in all individuals, and many people develop festoons without any thyroid involvement. However, in those who are susceptible, thyroid issues may serve to worsen existing festoons or reveal them earlier than might otherwise have occurred.

Signs Your Under-Eye Swelling May Be Thyroid-Related

Distinguishing thyroid-related facial swelling from other causes can be challenging, but certain patterns may offer useful clues.

Swelling that is persistent and symmetrical, appearing on both sides of the face to a similar degree, is more likely to have a systemic cause than swelling that is isolated or varies day to day. Swelling that is consistently worse in the morning, before gravity and movement have had a chance to redistribute fluid, may also suggest a systemic or lymphatic component.

Other signs that thyroid function may be involved include unexplained fatigue, weight changes without changes in diet or activity, sensitivity to cold or heat, changes in heart rate, hair thinning, dry skin, and changes in mood or cognitive clarity. These systemic symptoms, which appear alongside persistent facial puffiness, warrant a proper medical evaluation rather than a purely cosmetic assessment.

If any of these patterns sound familiar, it is worth raising the possibility of thyroid involvement with a general practitioner before pursuing aesthetic treatment.

How to Diagnose the Underlying Cause

Proper diagnosis is essential before any treatment decisions are made. A thorough medical assessment will help determine whether the swelling has a systemic cause, a structural one, or both.

Blood tests form the cornerstone of thyroid evaluation. A standard thyroid panel typically includes TSH (thyroid-stimulating hormone) as a first-line marker, with T3, T4, and thyroid antibody levels providing further detail as indicated. These tests can identify hypothyroidism, hyperthyroidism, and autoimmune thyroid conditions with a high degree of accuracy.

Distinguishing between an aesthetic concern and a medical condition is not always straightforward, and the two are not mutually exclusive. A specialist with experience in oculoplastic or periorbital assessment can evaluate the structural contribution to the appearance, while a physician or endocrinologist addresses the hormonal picture. Ideally, both dimensions are considered together before a treatment pathway is agreed upon.

Beauty portrait of a smiling woman with smooth skin and hands framing her face.

Treatment Options for Malar Festoons

If Thyroid Dysfunction Is Involved

When thyroid dysfunction is identified as a contributing factor, managing the underlying condition should be the first priority. Bringing thyroid hormone levels into a healthy range can reduce fluid retention and improve tissue quality, sometimes resulting in a meaningful improvement to the appearance of the face without any aesthetic intervention at all. Pursuing cosmetic treatment while thyroid function remains unstable is unlikely to produce reliable or lasting results, and in some cases may be counterproductive.

Non-Surgical Treatments

For those whose thyroid function is well managed, or for whom no systemic cause has been identified, non-surgical options may offer modest improvement. Skin-tightening treatments such as radiofrequency or laser therapy can improve the quality and laxity of the overlying skin and, when combined with appropriate lifestyle adjustments, may reduce the prominence of mild festoons.

Injectables, including certain types of fillers, should be approached with considerable caution in the malar area. The tissue in this region is highly vascular, and the anatomy is complex; poorly placed filler can worsen the appearance of festoons or cause complications. Any injectable treatment should be undertaken only by a practitioner with specific expertise in this area.

It is important to maintain realistic expectations. Non-surgical treatments rarely produce dramatic or permanent improvement in true festoons, and patients should be counselled accordingly.

Doctor examining a smiling patient’s neck during a thyroid or throat checkup.

Surgical Options

In cases where festoons are well established and non-surgical approaches have been insufficient, surgery may be considered. Procedures such as malar bags and festoons treatment, lower blepharoplasty, or midface lifting can address the underlying structural changes, repositioning tissue and removing excess skin where appropriate. Surgery is most appropriate when the patient is medically stable, has realistic expectations, and has been thoroughly assessed by a specialist with experience in periorbital and midface anatomy.

Why Treating the Cause Matters

There is an important distinction between treating the visible symptom and addressing its underlying cause. For many cosmetic concerns, the two are closely aligned, but with malar festoons, the interplay among structure, physiology, and systemic health means that symptom-focused treatment alone may yield disappointing results.

Patients who pursue aesthetic intervention without first investigating potential systemic contributions may find that results are inconsistent, short-lived, or difficult to achieve at all. Conversely, those who address contributing factors such as thyroid dysfunction alongside any aesthetic treatment are more likely to experience meaningful and durable improvement.

A thoughtful, long-term approach, one that prioritises understanding before intervention, is almost always in the patient’s best interest.

Close-up of a blue eye, eyebrow, and natural skin texture.

When to Seek Professional Advice

It is worth seeking professional advice if you notice sudden or worsening swelling that does not correspond to obvious causes such as salt intake, allergies, or poor sleep. Swelling accompanied by other systemic symptoms such as fatigue, unexplained weight changes, or temperature sensitivity is also a prompt for medical evaluation.

Persistent concerns that are affecting your confidence or quality of life deserve proper attention, even if previous attempts to address them have been unsuccessful. The combination of medical and aesthetic expertise is often the most productive route.

If you are unsure where to begin, a conversation with your general practitioner is a reasonable first step. From there, you can be directed towards the appropriate specialist, whether that is an endocrinologist, an oculoplastic surgeon, or a combination of both, to ensure that the full picture is properly understood before any treatment decisions are made.

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The Ezra Clinic Approach: A Holistic View on Under-Eye Changes

Malar festoons rarely have a single cause. Structural changes, lifestyle factors, and systemic conditions such as thyroid dysfunction can all play a role, which is why understanding each patient’s individual picture matters before any treatment is considered.

At the Ezra Clinic, every consultation is guided by this principle. As a specialist oculoplastic practice, the clinic brings the anatomical expertise and clinical depth that this complex area of the face demands, recognising not just the aesthetic concern but the factors that may be driving it.

If you have persistent under-eye concerns and would like a thorough, informed assessment, the Ezra Clinic is here to help.

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