Festoons are swollen, drooping folds of skin and muscle that hang over the cheekbone, just below the lower eyelid. Unlike ordinary under-eye bags, which sit on the eyelid itself, festoons extend down onto the cheek, creating a hammock-like drape of puffy tissue that can make the midface look heavy and tired. They’re sometimes called malar mounds or malar bags, and they can appear as early as your 30s or develop gradually with age.
How Festoons Differ From Under-Eye Bags
The distinction matters because the two problems have different causes and respond to different treatments. Standard under-eye bags are caused by fat pads behind the eyelid pushing forward as the tissue holding them weakens. They sit above the bony rim of your eye socket. Festoons sit below that rim, on the cheekbone itself. The tissue involved is different too: festoons form when the thin circular muscle around the eye (the same muscle you use to squint) becomes loose and waterlogged, draping downward and pulling skin with it.
A key anatomical structure called the malar septum helps explain why festoons look the way they do. This band of tissue runs from the bone around your eye socket and attaches to the skin of your cheek about 2.5 to 3 centimeters below the outer corner of your eye. It acts like a dam. Fluid and swelling that accumulate above the septum get trapped there, which is why festoons often have a distinct lower border and a puffy, water-balloon quality that ordinary eye bags don’t.
What Causes Them
Festoons develop from a combination of factors, and some people are simply more prone to them than others. The major contributors include:
- Sun damage: Cumulative UV exposure breaks down the structural proteins in skin over time. At a molecular level, sun exposure accelerates the destruction of the support matrix that keeps skin firm, which is why festoons are more common in people with significant lifetime sun exposure.
- Aging: As the muscles around the eye weaken and lose tone from decades of blinking and squinting, they become less effective at pumping fluid through the lymphatic system in the cheek area. This leads to chronic fluid buildup, or lymphatic overload, in the tissue above the malar septum.
- Genetics: Some people develop festoons in their 30s or 40s with relatively little sun damage. Congenital festoons have a different underlying structure than age-related ones, with a greater role played by subcutaneous fat deposits rather than fluid accumulation alone.
- Smoking: Along with sun exposure, smoking is one of the primary environmental factors that accelerates skin aging in the face.
Festoons often look worse in the morning, after salty meals, or during allergy season because anything that increases fluid retention in the face makes the trapped swelling above the malar septum more pronounced. Some people notice their festoons fluctuate day to day, while others have a permanently visible drape of tissue.
Why Fillers Can Make Festoons Worse
One of the most important things to know about festoons is that a common cosmetic treatment, dermal fillers, can actually trigger or worsen them. When filler is injected into the midface to correct under-eye hollows or tear troughs, it can cause malar edema: persistent swelling in the cheek area that mimics or aggravates festoons. This swelling is notoriously stubborn, lasting six to eight months in some cases, and responds poorly to massage, elevation, salt restriction, and even steroid injections.
The risk is lower when filler is placed deep against the bone, well below the malar septum, rather than in the superficial layers of tissue. But if you already have festoons or early malar mounds, filler injections in the midface carry a higher chance of this complication. Proper patient selection is critical, and this is a situation where an injector who doesn’t recognize festoons can inadvertently make the problem worse.
Non-Surgical Treatment Options
Mild festoons with mostly fluid-based swelling sometimes respond to conservative measures: sleeping with your head elevated, reducing sodium intake, managing allergies, and using cool compresses. These won’t eliminate festoons, but they can reduce their day-to-day prominence.
For more definitive non-surgical treatment, CO2 laser resurfacing has shown promising results. The laser removes and tightens the outer layers of skin, causing the tissue to contract and remodel. In a clinical study of patients treated with CO2 laser for festoons, 66% achieved complete resolution and another 33% saw partial improvement. The best candidates tend to be those with fine to medium skin thickness and mild to moderate swelling rather than heavy, long-standing tissue draping. Recovery from laser treatment typically involves localized bruising and swelling that clears within seven to ten days, though full results develop over several months as the skin continues to remodel internally.
Surgical Correction
Surgery remains the gold standard for severe or persistent festoons, though no single technique works for everyone. The main surgical approaches include:
Direct excision is the most straightforward option. The surgeon removes the excess skin and muscle directly from the cheek. This approach carries a lower risk of pulling down the lower eyelid compared to other techniques, and it produces long-lasting results. The trade-off is a scar on the cheek, though skilled surgeons place incisions to minimize visibility.
Extended blepharoplasty approaches the festoon through the lower eyelid. The surgeon lifts both skin and the underlying muscle as a single flap, removes excess tissue, and redrapes what remains over the festoon area. This can address both under-eye bags and festoons in one procedure, but it carries a somewhat higher risk of eyelid displacement.
Midface lift techniques take a broader approach, elevating all the soft tissue of the cheek upward and securing it to deeper structures near the temple. Several variations exist, and they’re particularly useful when festoons are part of a larger pattern of midface sagging. These procedures involve more extensive dissection and a longer recovery.
For any of these surgical options, visible improvement appears within a few weeks, but the final result takes six to twelve months as internal healing and tissue remodeling continue. The choice between techniques depends on the severity of the festoons, the amount of excess tissue, whether the cause is primarily fluid, fat, or muscle laxity, and whether the festoons are congenital or acquired.
Why Festoons Are Often Misdiagnosed
Festoons frequently get lumped in with ordinary under-eye bags, and many people spend years trying treatments designed for eyelid puffiness that do nothing for tissue sitting on the cheekbone. Lower blepharoplasty alone, the standard surgery for under-eye bags, won’t fix festoons because it addresses the eyelid without touching the cheek structures below the orbital rim. Similarly, eye creams and topical treatments that target the thin eyelid skin have minimal effect on the thicker, deeper tissue involved in festoons.
If you have puffiness that extends below your lower eyelid onto your cheek, especially if it has a distinct rounded or crescent shape with a visible lower border, you’re likely dealing with festoons rather than simple eye bags. An oculoplastic surgeon, a specialist who focuses on the structures around the eye, is typically the best person to evaluate this area and distinguish between the two conditions.