Persistent Puffy Eyes After Blepharoplasty, TCA Peel and Tightening

We prefer to combine a minmimally invasive "orbicularis lift" with superiosteal fat or filler injection. This will benefit the 'tired look' that volume depletion gives the lower lids and also avoids complications of open mid face lifts.

At this point, you may want to check into a second opinion. You may also want to be better informed about what "treatments" you are receiving. You want to be very careful around the eye. Also, a little patience may help. It takes a long time for swelling around the eye to resolve and for the tissues to settle. You may see positive results, but it will take time.

I cannot begin to give advice from one photo, physical exam, and no preoperative ones as well. if you have been undergoing several "tightening" procedures without effect, I think it is wise for you too see another surgeon with a great amount of experience with eyelid surgery. An occuloplastic surgeon is an excellent option.

It is difficult to give you specific advice without more close-up photographs of your eyes. That being said, I believe you have a common problem after lower blepharoplasty. I see that you have asymmetric mid-face cheek fat descent - which is not uncommon. I believe that even though your plastic surgeon probably removed the same amount of orbital fat from both sides, the deficient SOOF and cheek fat at the right lid-cheek junction enhances the right lower lid bag. I don't think that skin tightening or TCA peel is the answer either.
I don't think that additional right lower fat pad removal, by itself, is the right answer. Sure the bag would be better, but this leaves an unnatural, flat and long lid margin to cheek distance - which will not improve with time.
The aesthetics of lower blepharoplasty require a new paradigm. Proper analysis of the lid-cheek junction is critical to the surgical plan. During a lower belpharoplasty, it is also important to assess the integrity of the orbital septum. If there is pseudoherniation or laxity of the septum, orbital-septal reset or conservative septal plication can make a big difference. Fat removal is always conservative and canthopexy, canthoplasty and volume replacement are always considered in the plan.
Now after a blepharoplasty, if your orbital septum appears intact, I would recommend volume correction of the lid-cheek junction and tear trough. Your surgeon can start with a HA filler or a more permanent micro-fat graft. Since you are not happy with your outcome after one year, I would discuss some of these options with your plastic surgeon or seek consultation with Board Certified Surgeon who is comfortable with blepharoplasty revisions.

Hi
I am sorry for your concerns.. i usually ask the patient to be patient for at least 6 to 12 months... and I believe you have done exactly that... your pictures shows multiple concerns including 
1. lateral rounding of the lids.. it would be important to analyze for any degree of rounding prior to surgery and TCA peel.  More. Important, based on the rounding, revision surgery through trans-cutaneous approach will carry a high chance of worsening your lateral rounding (scleral show).  Trans-conjunctival approach with canthsl tightening would be advised.
2. Your puffiness appears to be from poor delineation of tarsal muscle from the residual fatbag... upon smiling and tightening of your eyelid muscle, if you can see that fatbag can be pushed back into eye socket and there is a clear tubular delineation of muscle under your eyelid (tarsal muscle), a competent surgeon should be able to remove the residual fatbag and provide less puffy lowere eyelid while better delineating the tarsal muscle which should be carefully maintained to minimize further lateral rounding...
3. Finally, there is a clear tear trough between your orbital rim and Midface which can be softened with filler or fat grafting... 
I can’t emphasize anymore the importance of making sure your lateral eyelids do not roundi down further no matter what further procedures you undertake... Good Luck!