Under eye bag only appears when smiling - can this be due to left over filler and should I consider a blepharoplasty? (photos)

Hello,

Thank you for your question and for sharing your photographs. Based on the images, it appears that the fullness of your upper eyelids occurs only when you smile. This type of problem is indicative of an orbicularis muscle roll, which can be effectively addressed with a very low dosage of botulinum toxin (Botox or equivalent) treatment to the lower eyelid muscles.

Important Considerations:

1. Botulinum Toxin Treatment: A very low dosage of Botox can help relax the lower eyelid muscles and reduce the fullness you experience when smiling. It is crucial to discuss this treatment with someone who is very experienced with injectable treatments. The dosage needs to be carefully controlled to avoid excess weakness of the lower eyelids.
2. Cause of the Problem: The fullness you describe is not related to injectable filler or fat from within the eye socket. It is specifically due to the orbicularis muscle roll.

I recommend consulting with a qualified and experienced practitioner to discuss this option in detail and to ensure the treatment is tailored to your needs.

A blepharoplasty can be done to release the septum and allow the fat to transpose to take care of the asymmetry.

Best Wishes,

Gary Horndeski, M.D.

Under eye filler can be difficult to remove. Often it takes multiple dissolving sessions. It can also impair the lymphatic drainage of the area leaving the tear trough looking swollen. You need an in person exam to determine the next best course of action. Typically, in my hands, another round of dissolving would be appropriate. I also think you would be a candidate for lower lid blepharoplasty. Best to see an eyelid expert.

Injectors simply do not understand what it takes to remove retained hyaluronic acid filler. I strongly advise against lower eyelid surgery for your issue. You need enzyme injected behind the orbital septum. By the way, bruising caused by filler is very common. Even the enzyme service can cause a memorable bruise on occasion. I suspect that the enzyme treatment will reduce the fullness on the left side but there is no substitute for an in person assessment.

The photographs demonstrate herniated fat in the lower lids, which is best treated with a trans-conjunctival lower blepharoplasty procedure. The incision is located completely on the inside of the lower lid to remove the puffy bags.

The active smiling typically causes several muscles to contract in our face.
The primary smile muscle is the zygomaticus muscle.
It lifts the corners of the mouth up.
We often also contract the orbicularis muscle, which often closes the eyelids a bit in conjunction with smiling.
When we contract and put tension on the orbicularis ocular muscle, we create a redundancy of skin and this often forms lines around the eyes, sometimes called smile lines.
The process will also push back the periorbital fat pads of the lower eyelid, causing them to protrude less in individuals who have a problem with this.
I don’t think there’s anything abnormal about your facial expression when smiling and I don’t think you need intervention.
We would not make an assessment for the need for a blepharoplasty based on how you look during facial expression.
We make facial assessments based on static appearance without facial expression
Best,
Mats Hagstrom MD