I Have Bags and Uneven Eye Lids After Blepharoplasty. What is the Best Way to Correct This? (photo)

It is very important that you and your doctor have a clear understanding about the asymmetries that pre-existed in your face. One of the most common things before surgery is that people have specific complaints about very dominant features that draw attention such as hooding over the eyes and fat pockets under the eyes. After surgery, they study their faces extremely and carefully, noticing a lot of things they didn’t notice before.

I explained in my book, “The Fine Art of Looking Younger” that hollowing and volume loss are part of facial aging. Blepharoplasty procedures alone are part of addressing the problems related to facial aging since extra skin and fat pockets are being addressed.

When I look at the lower eyelids, I think of them not in isolation, but how they relate to the cheek area which is also called eyelid-cheek junction. When I do that, at least prior to surgery, we recognize that there is some volume loss typically in the lower part of the face referred to as the sub-malar area.

Fat transposition and fat transfer are among several procedures that come and go in popularity to address volume in this area. In my practice, I have seen many patients who had fat placed under their eyelids, particularly the delicate skin between the eyelashes and the rim called the eyelid area. Unfortunately, a lot of this fat becomes lumpy, hard and irregular to the point that many of my colleagues do not do fat transfer directly under the eye anymore. There are also patients whose fat gets absorbed by the tissue and it doesn’t stick or stay there anymore.

As a revision surgeon, I have routinely removed clusters of fat under the eye that were placed there with the best of intentions. However, the fat that goes in is accepted by the tissue, so it’s basically a fat graft done with liposuction techniques. When fat is harvested, fibrous tissue and other tissue besides the fat are also harvested. In my practice, I do place fat into the cheek area to give volume just below the eyelid-cheek junction. By doing this, the skin and the soft tissue in the cheek easily accepts the fat and it does not change the contour too radically. I have to take every precaution when doing this because eyelid skin is very thin.

The bottom line is there is no perfect solution for this hollow area. In our practice, we use combinations of hyaluronic acid and something called platelet-rich plasma to help the under eye area. Platelet-rich plasma is drawn from the blood and has active growth factors that stimulate collagen in this area. This will allow the skin quality and thickness to improve, and balance the natural relationship between the eye area, tear trough and cheek area.

As far as the upper eyelids are concerned, I can see that your brows have a little bit of asymmetry. I don’t have enough information whether you had a botox or if you have brow ptosis that could  account for the subtle level of asymmetry. When people have asymmetric brows, I try to maximize the symmetry of the upper eyelids by resecting or sculpting more on the heavier side and less on the lighter side to to balance them out. Otherwise, we also try to do things such as botox to improve the symmetry of the brows. I also noticed that there appears to be a little bit of puffiness under the eyes. It is probably the way the photo was taken but if there is some residual puffiness, I would suggest reducing the puffiness with additional fat resection.

The photos are not enough information to make a definitive recommendation. Understanding that there are a lot of options to address your issue and choosing the one that has the lowest risk and the greatest reward is always the best.  I hope that was helpful, and thanks for your question.

I think you should first try som fillers to fill in the harsh junction between your nasal lower lid and cheek.  This may soften the dark ridge in your photo.  Juvidern, Belotero and Restylane are good choices.  If this doesn't work, a fat transposition lower lid blepharoplasty may help.  Good luck.  I have helped many patients in your boat and there is hope for improvement.

There are two ways that one can go about addressing this problem. If you surgeon is experienced with fat repositioning, then a transconjunctival approach would certainly be  a good option. In someone that has already had the lower eyelid fat manipulated, this may be a more challenging technique, as there may be some scarring that may make the fat less mobile.

In that case, it may be easier to do a combination fat excession, with adjuvant fat grafting to tear trough and cheeks. The fat injection needs to be done quite deep to minimize possibility of contour irregularity.

I've done both techniques, depending on the patient.