Correct Bad Fat Transfer Results with Blepharoplasty?

Question

I had a fat transfer under my eyes because they were so hollow.  Around 6 months later, there was an uneven swelling that hardened into uneven lumps. It made me look like I had pouches.  So I went back to the surgeon who suggested that the best correction to resolve this was to perform a full blepharoplasty. This was 2 days ago and am panicking about what I have done to myself. Was this a bad choice? What options do I have for correcting this?

Brent Moelleken, MD · Answer

If your surgery was six months ago and things have reached a plateau, it is likely that you have a stable problem.  The problem is how to treat it.
Firm lumpiness from fat injection to the lower eyelids is a common problem.  In my experience it is usually necessary to remove the fat injection lumps directly.  This is a tricky proposition, to say the least, because the lumps can be in all layers of the lower eyelid, from the epiperiosteal layer to the shallow subcutaneous layer, with the orbital septum and the orbicularis muscle in the middle.
Often, correction of the problem will involve midface elevation through a cheeklift, canthal restoration to support the amount of work to be done on the different layers, direct removal of fibrous fat injection tissues, possibly placement of new grafts.  In our practice we typically use nontraumatized autologous fat fascial grafts (LiveFill) placed precisely, usually in the eye-cheek junction or the tear trough region.  Or sometimes lumpy fat injection grafts can be removed directly through a transconjunctival approach or directly through the skin through tiny incisions, it all depends.
A traditional blepharoplasty usually involves reduction in fat from the lower eyelid, which would not typically deal with the fat injection lumps.
Your case underscores two points.  First is that the lower eyelid is an unforgiving anatomic area.  Second is that patients should have great caution before undergoing even seemingly minor procedures such as fat injection to the lower eyelid. 
It never hurts to seek several opinions from plastic surgeons with special interest in the midface (i.e. cheeklifts, revision lower blepharoplasty) before proceeding with this next very critical step.

Michael Law, MD · Answer

If you are just two days post-op, give it some time. Fat grafting has gained popularity and now is being performed by many physicians with limited experience and expertise. The newest "problem" in plastic surgery are peoplke who look over-filled. That can be due to fat, or often other fillers that give the face an odd, "domne" unnatural appearance. The problems, can be corrected, so seek out a plastic surgeon with a lot of experience in this area. of course it is best to slect an experienced plastic surgeon with expertise the first time around. I'm hoping that time will take care of your concerns. If not, there are plastic surgeons experienced with fat grafting and blepharoplasty surgery who can help.  Look at many, many before and after images as evidence that a plastic surgeon truly can provide the results you are hoping to achieve.

Lawrence Kass, MD · Answer

Yes. This is an option for you. It will require marking of the fat lumps and tedious dissection and patience by your surgeon. There is no right time to do this but at 6 months, I think you have been sufficiently patient for improvement. I would seek out an oculofacial surgeon listed by ASOPRS.

Raffy Karamanoukian, MD, FACS · Answer

Fat transfer is a well established method of restoring volume to the face.  The amount of fat survival depends on technique of harvest and injection.  Technical considerations may affect volume loss, symmetry, and need for further revision.
The advice of your surgeon on the fat transfer should be heeded.  Nodules arising from fat necrosis may ultimately subside or may remain permanently. If your surgeon believes they will remain permanently, the best option may be to surgically excise the lesions with a blepharoplasty type incision.  Be advised that there are inherent risks associated with a surgical approach including assymetry, scar tissue, eyelid retraction, unsatisfactory results, and need for further surgery.  An experienced blepharoplasty surgeon is advised.

Michael A. Persky, MD · Answer

Hi Luis,
Sorry to hear about your ordeal.  I can imagine how scared and anxious you must be. 
The most important thing for you to do now is to follow your post-operative instructions and stay in close touch with your treating surgeon.  Panicking and searching the web two days after eye lid surgery will not help in your recovery at all.  There is nothing to do at this point but heal as well as you can.  Your surgeon should be able to tell you how he/she feels the operation went.  
As you can see in the other answers here, after 6 months, blepharoplasty is a method of addressing lumps after fat transfer.
After a few months, if there is still a problem, then return to your surgeon for an answer, or if you prefer, consult with the best opthalmoplastic surgeon that you can find.  
Try to relax, turn off the computer, and be patient.  I hope that all goes well and that you heal beautifully.  Be well.
Dr. P

Steven H. Williams, MD · Answer

I think Dr. Wallach thought your surgery was two days previous and if that were the case I completely agree with his assessment.    However, if you had fat transfer 6 months ago then you may have issues with the fat not surviving or scar tissue forming where the fat transfer was attempted.
The lower lid and area below the lids is one of the more delicate places on your body and small amount of tissue can make a big difference.    When I was in training at Yale University, we had a professor who had spent considerable time analyzing this area and the best way to restore a "hollowed out" look.  He correctly concluded that in lower lid blephs when people remove fat, it tends to make people look more gaunt and that the problem is that fat in that area has descended and can be restored by positioning it at a level consistent with its position when you were younger.
The difference between fat transfer and this technique is you're not devascularizing (cutting of the blood supply) to the fat you're moving so it is more reliable and produces a more predictable result (critical in an area where the skin is so thin).  In addition - you may have needed a procedure to tighten the skin of your lower lids to begin with and it is possible the fat transfer has emphasized this need.  It is difficult to suggest specifically what you should do without a close examination but at 6 months out I think it is likely that you should consider a revision to improve the look of the lower lids.
I hope this helps.
Steven Williams, MD

Walton Montegut, MD · Answer

This is a good question.  Fat transfer under the eye is a great procedure.  However, it is a delicate one and is easy to have complications from it if not performed correctly.  It is easy to have complication if the surgeon is not experienced.  I have been treating this area with filler and fat for a long time.  It must be done with fat in a certain way for the best results.  It must go in smoothly and in layers, etc.  When there is a problem, the surgeon must be adept at solving it.  This is difficult to find.  These are new problems in plastic surgery because this is a new procedure and surgeons just do it, not thinking about what if there is a problem.  When there is a problem, and it occurs most frequently in the eye area, then most do not know what to do about it.  Each problem is different, and unique.  I always say, THE SURGEON WHO CAN TAKE IT OUT, is THE SURGEON WHO CAN PUT IT IN CORRECTLY.  You cab get great results in this are, and just as many bad because it is a delicate area.  Each problem is handled differently, and maybe a bleph will do it, and maybe not.  The good news is, there are surgeons out there , look carefully, who may be able to fix the problem.  Since this is a delicate area, one must be careful to have the proper procedure the 1st time and avoid a complication.  This is a great procedure for this area when performed correctly the 1st time.  Hope this helps.  Your Face is your Diamond.  Polish it well, and you will Shine Brilliantly.  Good luck

Jeffrey Marvel, MD · Answer

A blepharoplasty is one option to correct an undesireable outcome.  I have done this on occasion with success.  The procedure is very similar to a standard lower blepharoplasty.  The injected fat is usually easily located and removed.

Boris Volshteyn, MD, MS · Answer

Dealing with complications of plastic surgery is never easy. It is frustrating, disappointing and worrisome. Unfortunately, even in the best of the hands, it is a way of life.
	
	Lumpiness and bumpiness, skin irregularity and some thickening after fat grafting is normal. Usually, with massage and occasional steroid injections these problems can be managed well. Unfortunately, sometimes, more aggressive approach is needed.
	
	The area of the lower eyelid and its junction with the cheek is one of the more challenging areas of the face.  Having with cheeks, better definition can create a significant improvement in appearance. However, it is very easy to end up with the problem.
	
	Since it has been 6 months since his previous surgery, I believe, you have given enough time for the postoperative swelling to resolve and now you can analyze the problem. The only person who knows where the fat was placed during original surgery is your existing plastic surgeon.  Following his or her recommendations at this point is the best solution.
	
	Just like fat grafting can effectively complement blepharoplasty, blepharoplasty can help complement and help with correction of imperfections that appear after fat grafting. Traditional blepharoplasty incision gives your surgeon approach that can be used with a variety of techniques.

	I am confident, your plastic surgeon will be able to use that to you benefit and this approach will allow your surgeon to tighten the skin, removal some, or majority, of excessive fat deposits and improve the overall appearance of the eyelid.

	Unfortunately, every surgery can have complications. You need to discuss with your surgeon possible complications associated with blepharoplasty and then have a joint decision of whether additional improvement of your eyelid shape justifies additional risk. The decision is between you and your plastic surgeon.
	
	Sincerely,

	Boris Volshteyn M.D., M.S.

D.J. Verret, MD · Answer

At this point, I would wait. 2 days after any surgery is not a good time to evaluate the results, especially with blepharoplasty surgery. From what you describe, it sounds like you had appropriate treatments. I would wait at least a month, and sometimes several months, before determining the success or failure of the treatment.

Correct Bad Fat Transfer Results with Blepharoplasty?

Answers (15)

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