What are these bulges under my eyes and how can I get rid of them? (Photo)

Question

I've noticed my under eyes have these bubbles which have been getting quite noticeable over the past 6 months. I have had filler in my undereyes 2 years ago with no issues, but have recently had 3 sessions of Hyaluronidase in hopes of getting rid of the bulging, however I have had zero results which has led me to believe they are not from the filler. Please help!

Nelson Lee Novick, MD · Answer

These "bubbles" or what has been termed "Under-Eye Puffy Pillows" is actually lymphedema or lymphatic obstruction secondary to the too superficial placement of a filler under the eyes and/or an inappropriate choice of filler for the infraorbital region. The problem can start either shortly after treatment or may appear much later. It tends to be a persistent problem and, unfortunately, a very difficult problem to treat. I have, however, had gratifying results when treating patients who have come to me for this using an algorithm of varying combinations, concentrations and amounts of intralesional anti-inflammatory agents. You would be wise to consult an experienced, board certified cosmetic dermatologist and best of luck.

Randal Haworth, MD, FACS · Answer

Persistent under-eye concerns may have various causes, such as fluid retention, allergies, or other underlying issues. It's crucial to consult with a qualified dermatologist or healthcare provider to assess your specific situation. They can determine the cause of the concern and recommend appropriate treatments or further investigations. Keep your provider informed about any past treatments, including filler and hyaluronidase sessions, for a comprehensive evaluation.

Mats Hagstrom, MD (license on probation) · Answer

Making an aesthetic assessment regarding the lower eyelid and upper midface. Transition can be complex and even professionals can get confused when trying to figure out what the primary underlying problem is. In your case it would be helpful if you could point out exactly where the area of concern is. Perhaps Take pictures and pointing with a Q-tip to the area of concern or put circles on the pictures showing the exact area that bothers you. I don’t understand why you had dissolving injections, but perhaps the thought was injections had been done incorrectly. In regards to fillers, I cannot overstate the importance of working with people who have a proven track record and have a mastered this type of work, which usually takes decades. Working with facial fillers is inherently fairly simplistic, but getting consistent quality. Masterful outcomes is something on the a few are able to ever accomplish. It’s a bit like art there are only a handful of true masters. 
Beneath the lower eyelids, there are three separate fat pads. Anatomically there’s the skin layer, the particular is muscle then a membrane called a periorbital septum, and below that are the three lower eyelid fat pads. With age, the periorbital septum becomes a weak and with the weight of the eyeball, the three fat pads are pushed forward Showing bulging or pseudo herniation .
You can sometimes look in the mirror, while gently pressing against one eyeball(gently) and see the fat pads begin to protrude. this is fairly typical of facial aging. In a youthful face, the lower eyelid should be tight and snug. Immediately below the lower part of the eyelid, the upper part of the midface should ideally be projecting and appear full. With typical facial aging two areas sometimes reverse. The lower eyelid which is snug and tight in youth begins the bulge and the area just below it, which used to be full and plump begins to look hollow. These two changes happen adjacent to each other and differentiating if bulging of the lower eyelids is the primary problem or a loss of midface volume is the primary problem is an important differentiation when making an assessment and considering treatment options. a lot of people for volume restoration because it doesn’t involve surgery. If lower eyelid, fat pads is the problem because of weakness in the periorbital septum, then removing some of fat pad through an operation called a lower eyelid blepharoplasty either open or transconjunctival may be the correct procedure. To make things even more complex there are other conditions like malar edema and older people sometimes get a condition called festoons, which can also add negatively to this area.
I think your face looks quite good and surgery is probably a bit premature at this time. You can always have in person consultations with providers in your community. This type of work is done by plastic surgeons, facial plastic surgeons, and oculoplastic surgeons. The background is probably not as important as skill and experience per se.
If you opt for working with providers who do volume restoration using fillers, consider looking for the most talented providers in your community. I personally live in San Francisco and typically refer patients to David Mabrie MD in this area. His work with fillers is the best I’ve ever seen. His website has an impressive number of extremely high-quality before and after pictures using only facial volume restoration using fillers. His work is the best I’ve ever seen. I’m not suggesting everybody fly to San Francisco and go see him, but reviewing his outcomes can give people an appreciation of what fillers can do in the hands of someone who is truly mastered their art. 
Best,
Mats Hagstrom, MD

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