Advice on Revision - can these issues be corrected? (Photo)

Question

4 months post transconjunctival lower blephroplasty. Persistent lump since day 1 under right eye. Treated with 3 injections of 5FU and 2 of kenalog. Lump remains, now with atrophy, also crescent swelling under left eye. Very disappointed by results, can these issue be corrected? Performed by double board certified doc. Very frustrated by this avoidable complication in addition to disappointing results overall. Seeking advice on management going forward.

C. Blake Perry, MD · Answer

The “bump” is excess fat that was either left behind or not transposed deep enough into the cheek. In my hands, the only way to treat this is revision surgery where additional fat is removed and/or repositioned.

Mehryar (Ray) Taban, MD, FACS · Answer

You may be candidate for revision lower blepharoplasty but more detailed evaluation in person is needed to determine.

Kenneth R. Francis, MD, FACS · Answer

Dear Warmhearted,
Too often surgeons/physicians are derailed from the sound principles they learned during years of education and training, all in the name of wanting to please their sometimes impatient and overanxious patients.  I am not saying that is the case here since we don't have all of the necessary information to make that determination.  However, 4 months is a short time for surgical healing to have completed.  And you've undergone several injections already, indicating that an even shorter post surgery time period was involved before interventions began.  Finally, EVERYTHING we do as physicians has consequences, even giving a Tylenol, so it's not unusual that you now have some atrophy.  A dose of patience might be in order here.  Good luck!

Mats Hagstrom, MD (license on probation) · Answer

It looks like you need volume restoration in your mid face and tear trough more than you needed fat pad reduction of your lower eyelids. If done well could probably restore the area and make it look quite good now or before the blepharoplasty. 
Take a look at some of the work done by Dr. David Mabrie, MD in San Francisco. His website has hundreds of before and after pictures of facial volume restoration done with fillers. I’m not suggesting you travel to San Francisco if you live far away, but seeing his results gets people to understand what volume restoration in the midface can do in the hands of a talented provider.
The transition of the lower eyelid to the mid face is complex and getting a quality assessment or understanding the problem whether lower blepharoplasty or volume restoration is the correct approach is not always straightforward or easy to do.
I think volume restoration (tear trough, and mid face ) would’ve been a better solution, then volume removal(lower eyelids) in your case.
While the result is not ideal, it is not all that unpredictable based on your candidacy for the procedure.
For providers who don’t have a great deal of experience with a mid face volume restoration they often see the lower eyelids as the main culprit. What those who focus and volume restoration will see if the other way around.
In the end facial aging typically has two opposing volume components that happened immediately adjacent to each other. This anatomic area is complex and not always straightforward or easy to treat.
In a youthful face, the contour of the lower eyelid should be snug with immediate adjacent fullness below the eyelid in the mid face. Which typical facial aging the two volumes reversed. In an eighth face, we typically see a loss of snugness in the lower eyelid with bulging of the lower eyelid, fat pads due to weakness in the Peri orbital septum with immediate loss of volume just below the lower eyelid(tear trough and mid face).
The outcome of any plastic surgery procedure is typically based on the patient’s candidacy for the procedure combined with the skill and experience of the provider. Patients who are not ideal candidates are never going to have exceptional outcomes no matter who does the procedure. A great provider should understand the candidacy of each potential patient and explain to them the type of changes that are possible and not possible with any proposed operation.
I recommend patients have multiple in person consultations before choosing permanent irreversible surgery.
During each consultation, ask each provider to open up their portfolio and show you their entire collection of before and after pictures of previous patients, who had similar body or facial characteristics to your own, depending on what procedure you are contemplating. An experience plastic surgeon should have no difficulty showing you the before and after pictures of at least 50 previous patients for commonly performed operations. Being shot a handful of preselected images, representing the best results other providers career is insufficient to get a clear understanding of what average results will look like in the hands of each provider or how many of these procedures they’ve actually performed. being shown examples of patients who had a different degree of candidacy for the procedure is also inappropriate because this sets expectations inappropriately.
While you were not pleased with the outcome, it’s probably a pretty typical outcome based on your candidacy for the procedure. Not understanding the primary problem is they’re set up for misunderstanding and loss of quality outcomes. Understanding facial aesthetics is not always straightforward and different providers vary in their skill for this. Being able to go through residencies and pass board examinations is unrelated to mastering any one single procedure.
In my opinion, you still remain a very good candidate for restoring your facial appearance, but the approach needs to not focus on the lower eyelid problem as much as the primary facial aesthetics based on skeletal structure, and the indication for volume restoration when needed.
The first step in scheduling any surgical procedure whether it be Primary or revision work is always finding the right provider. This takes work time and effort.
In my opinion this is the best done by having multiple in person consultations, preferably with local providers who had exemplary records and years of experience.
Best,
Mats Hagstrom, MD

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