Understanding Under-Eye Swelling:
Malar Edema, Malar Mounds & Festoons
Why They Happen and What You Can Do.
What Are These Conditions?
Malar edema, malar mounds and festoons are These terms describe a spectrum of swelling that occurs around the lower eyelids and upper cheek (malar region):
- Malar Edema: Transient swelling of the malar (cheekbone) region. Often worse in the morning or after certain triggers like salt, alcohol, or poor sleep. Typically soft and fluid-like, and may come and go. Note the “doughy” or “fluid-filled” appearance on the picture below.
- Malar Mounds: Persistent swelling over the malar area that does not resolve fully, even after lifestyle changes. This is a more chronic stage where soft tissue starts to hold fluid more regularly. Note the “deflated” and “baggy” appearance below.
- Festoons: The most advanced stage, where chronic swelling and tissue laxity lead to sagging, bag-like pouches under the eyes. These often develop when malar mounds stretch the underlying tissue over time, creating a hammock-like droop.
What Causes These Issues?
These issues are ‘multifactorial,’ meaning several causes may be acting together:
- Lymphatic Flow Impairment: The facial lymphatic system becomes sluggish with age, inflammation, and certain procedures, allowing fluid to collect in the malar region.
- Facial Fillers (HA Injections): Improperly placed midface fillers may stimulate inflammation or may compress and block lymphatic drainage channels, exacerbating swelling.
- Sleeping Position: Sleeping face-down or flat can worsen morning swelling. Gravity plays a role in how fluid pools overnight.
- Diet & Salt Intake: High-sodium or processed diets can promote fluid retention.
- Alcohol: Dehydration followed by rebound fluid retention often worsens morning puffiness.
- Allergies & Inflammation: Chronic sinus inflammation or seasonal allergies can trigger swelling via histamine-related fluid leakage.
- Aging & Tissue Laxity: Over time, collagen loss and weaker facial ligaments allow fluid to accumulate more easily in soft tissue.
- Genetics: Some people are more predisposed to lymphatic stagnation or festoon formation due to facial anatomy.
- Chronic skin inflammation: People with an inflammatory skin condition called rosacea are more susceptible to formation of festoons
Important to Understand
There is no single “cure” for malar swelling. Like rosacea or sensitive skin, it is a chronic condition that must be managed. The goal is control and improvement, not complete elimination.
What You Can Do at Home
- Sleep Smart:
Elevate your head (1–2 pillows or wedge). Avoid face-down or side sleeping when possible. - Anti-Inflammatory, Low-Sodium Diet:
Focus on whole foods, potassium-rich produce (bananas, spinach), and limit salt, and sugar. - Abstain from or at least Limit Alcohol Consumption
- Gentle Lymphatic Massage:
Light sweeping strokes, moving from cheekbone up toward ears. Use in the morning to reduce puffiness. - Cold Compresses:
Use chilled tea bags, jade rollers, or cool gel pads to reduce swelling and inflammation. - Address Allergies:
Consider daily antihistamines and eliminate environmental triggers when possible. - Hydrate Well:
Balanced hydration keeps fluid movement healthy; dehydration can worsen stagnation. - Caffeine-Infused Eye Creams:
May offer temporary puffiness relief and improve skin tone.
How We Treat It In the Office
Treatment is personalized and depends on the stage
(edema, mound, or festoon):
- Filler Dissolution (Hylenex):
For patients with prior HA filler that may be obstructing lymphatics, dissolving filler can dramatically reduce swelling. - Strategic Re-Filling:
In some cases, replacing volume in areas away from lymphatic channels helps restore balance without worsening edema. - Lymphatic Activation:
Microcurrent, ultrasound, and manual drainage can stimulate better flow. - Laser & RF Treatments:
Skin tightening with CO2 laser or radiofrequency microneedling improves laxity and can reduce festoon prominence. - Surgery (for Severe Festoons):
In advanced cases, lower eyelid or midface surgical correction may be necessary to remove or reposition redundant tissue.
Summary
- Malar edema and festoons are not just cosmetic—they’re chronic, fluid-related conditions tied to facial anatomy, aging, inflammation, and lymphatic flow.
- Management, not cure, is the goal.
- With a multi-faceted approach—lifestyle changes, home care, and expert treatments—we can significantly improve the appearance and comfort of these conditions.
Suggestions to improve malar edema:
- Diet: Advise limiting the intake of anti-inflammatory foods, salt, processed meats, sugars, alcohol, and fried foods. It is also recommended to consult with a dietitian for personalized guidance.
- Sleep: Encourage sleeping on the back and suggest the use of a Sleep N Glow pillow for optimal support.
- Lymphatic Care: Recommend lymphatic massages to promote fluid drainage and improve circulation.
- Lymphatic Massage
- Use a Gua Sha stone (aka Jade Roller) for lymphatic massage Sephora
- Gua Sha Video
- Evaluation: Conduct a comprehensive evaluation to assess for any underlying systemic diseases that may contribute to the condition.
