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.

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.

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!

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.

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.

It is important to return to the original physician as long as the patient has confidence the surgeon can correct any complications. If the lower lids are very puffy again after the blepharoplasty, there may not have been enough fat removed from the lower lids. Extra skin can be conservatively removed if there is excess present, but one has to be very careful as not to change the shape of the eyelids. It is probably not advisable to have another TCA peel on the lower lid because of the dark Hispanic skin type.

I find it interesting how many are willing to not answer this question. Okay, first your brows are fine, no brow lift is needed. Yes, your upper lids still have a little extra skin that could be removed. The real problem is at the lid cheek junction. Another physician addressed this but not, in my opinion, the correct procedure. Your problem is that the cheek fat/tissue is falling due to age and gravity. This causes the deformity that you have now. Removing skin of the lower lid would be a disaster. You need elevation of the cheeks, first then removal of the skin. Therefore, you need a midface lift and removal of lower lid skin.
I do these together all the time. The reason is that when you elevate the midface you get extra skin in the lower lid.
A second opinion with another Board Certified Plastic Surgeons is a good idea.

Many things to do or no things to do? What is right? I have read the suggestions below and would be a little confused if I were you.
But to sort out the problems here is the way I see it.
1. You have had many different things done within the last year -- a brief period of time after surgery.
2. You are hispanic with a darker skin type, which puts you at risk for peels and laser procedures.
3. Your upper lids and brow looks a little heavy, but so does the rest of your face. Ethnically, applying a caucasian model to your face may not be correct.
4. Your lower lids are impossible to accurately evaluate from this view, but I am sure that suggesting lots of surgery is not the first thing I would do.
5. Options can include:

a) No treatment.
b) Fat Injections to the lower lids to camouflage tear troughs and cheek ptosis.
c) Lose weight and see your look improve.
d) Slow down and give it more time and then reconsider surgery.
Many doctors, in an effort to make you happy, may rush their time line for your own care, making things worse!

From a less than ideal photo, and not enough views or perspectives, I will hazard an analysis of what I see.
The upper lid position appears good. You have redundancy and heaviness of the upper lids. I also see ptosis (drooping)of the brow with transverse forehead and "11" wrinkles between the eyes (frontalis and corrogators/glabella. It looks like there are some transverse wrinkle at the root of the nose.
Based on these observations, You should at least consider a brow lift, and revision of the blepharoplasty to remove any remaining excess skin, and thin out any fat that makes the lid appear heavy and thick.
On to the lower lids. They seem overall to be in fair position. Centrally, I would like to see the lid higher, and not even see a slip of "white". Laterally, the lid is pulled down a slight bit more.
There are fat deposits that remain and are causing the appearance of bags. At the same time, there is a very apparant transition over the cheek bones. I would consider a secondary (re-do) lower bleph, with repositioning of the lids. I very gingerly remove a LITTLE amount of fat, rather, I would reposition it to smooth the transition between the eyelid skin and cheek skin.
I would NOT EVEN consider any type of laser, peel, or any other skin treatment until your lid have healed and are satisfactory. To add additional trauma to a secondary procedure is to invite badness.
scottkinfw@msn.com
www.drkasden.us

Sometimes the answer to your problems is in analyzing your eyelids from a lateral photo. This is because you cannot tell what sort of support you have from the frontal view. The presence of "bags" after a lower blepharoplasty and the rounding of the lower lid suggests that you might have a situation of "negative vector" where there is a lack of support for you lower lids. Here, your lid and your skin and fat of the lower lid is "hanging over a cliff" sort of like a tight belt below a beer belly. It is not so much a problem with the beer belly, but the presence of the tight belt. You might need something to prevent the belt from slipping under the beer belly. Have your surgeon analyze your problem from the lateral photo.