Eye bags After Botox: Why It Happens and What Can Be Done
- Feb 10
- 3 min read
Malar oedema — sometimes called malar festoons or malar bags — refers to swelling or fluid collections that appear just below the lower eyelid, over the upper cheek area. Patients often describe this as puffiness, bags, or swelling under the eyes that can appear suddenly, particularly after wrinkle-relaxing injections such as Botox.
While this can be worrying, malar oedema is a common and usually temporary phenomenon — and understanding why it happens is key to managing it safely.
What exactly are malar festoons?
The term malar refers to the cheek region, while festoons describe sagging or fluid-filled folds of skin. This area includes both the lower eyelid and the upper cheek, where the skin is some of the thinnest in the body.
With ageing, several changes occur here:
Skin becomes thinner and less elastic
Subcutaneous fat reduces, leading to hollowing around the eyes
Supporting ligaments weaken
Sun exposure and smoking further reduce skin resilience
Some people are genetically predisposed to hollowness or fluid retention in this region, while others never develop it at all.
Why can malar oedema appear after wrinkle treatment?
In some patients, malar oedema develops 1–3 weeks after wrinkle-relaxing injections around the eyes. This timing often causes confusion, as the treatment initially looks successful before puffiness appears. The lag time can also lead to patients going for top ups which can worsen the problem.
The reason for the puffiness is the disruption to how the eye normally drains fluid.
The eye’s natural “pump” mechanism
Blinking and eye movement activate the eye muscle, which plays a vital role in tear and fluid drainage. This is known as the lacrimal pump mechanism.
In simple terms:
Blinking compresses the tear drainage system
This creates alternating pressure and suction
Fluid is drawn away from the eye into deeper drainage channels
It works much like the calf muscles in your legs, which help pump blood back to the heart when you walk.
What happens when this pump is weakened?
Wrinkle-relaxing injections reduce muscle activity — that’s how they soften lines. However, if the lower eyelid muscle is weakened too much, the lacrimal pump becomes less effective.
When this happens:
Tear fluid and lymphatic fluid don’t drain efficiently
Fluid collects in the malar (cheek) region due to gravity
Puffiness or swelling becomes visible under the eyes
This is similar to what happens when you stand still for long periods or sit still for a long flight and your ankles swell — the pump isn’t doing its job.
Why does this happen to some people and not others?
Malar oedema can occur:
After a first treatment
After many years of treatments
Or seemingly out of the blue
Contributing factors include:
Individual anatomy
Pre-existing fluid retention or hollowness
Skin laxity
Cumulative weakening of the muscle over time
In some patients, removing even a small amount of muscle activity is enough to tip the balance.
Is malar oedema permanent?
In most cases, no.
Because wrinkle-relaxing treatments typically last 3–4 months, the swelling often improves gradually as muscle activity returns. However, careful management is important to prevent persistent changes to the tissues due to the prolonged stress on the lymphatics in this area.
Can malar oedema be treated?
Yes — but treatment must be tailored to the cause.
Not all under-eye swelling is the same. Malar oedema can be caused by:
Muscle-related drainage issues
Skin laxity
Fat prolapse
Previous filler
Inflammatory or lymphatic problems
This is why a proper assessment is essential.
In my clinic, I use ultrasound imaging to:
Check for underlying filler or fluid
Assess tissue layers
Identify the true cause of swelling
From there, we can discuss appropriate options, which may include supportive treatments, skin-tightening devices, lifestyle advice, or simply allowing time for recovery.
Can malar oedema be predicted?
Often, yes.
A thorough consultation before treatment allows us to identify patients who may be at higher risk and adapt treatment plans accordingly — or avoid certain injection areas altogether.
When should you seek assessment?
If you notice:
New under-eye puffiness after wrinkle treatment
Swelling that worsens rather than improves
Asymmetry or discomfort
A medical review is advised.
Final thoughts
Malar oedema after wrinkle treatment is relatively common, usually temporary, and very manageable when properly assessed. The key is understanding the underlying cause and avoiding one-size-fits-all injection approach to Botox in the eye region. Proper history taking and assessment before injection is also essential.
Dr Booysen runs a filler and botox complication clinic in Bromley. Book a consultation today at drkimbooysen@gmail.com if you have any concerns about filler complications.
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