Lateral Lower Eye Hollowness After Lower Eyelid Surgery. Next Option?

4 months ago I had lower eye surgery to correct a tear trough deformity (arcus margillis release fat repositioning). Although this surgery helped with the tear trough area I still have hollowness in the lateral portion of the lower eye, where the cheek meets the lower eye. Lower eyelid pinch, laser and filler have been suggested. What is the best option?

Doctor Answers 9

You do not demonstrate a malar bag!

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Lower eyelid surgery does make the lower eyelid less full.  I think your surgeon probably did a great job for you.  Of course you did not provide before photos.  However you have very thin lower eyelid skin.  What impressess me is that you do not look like you have had eyelid surgery.  

I agree that you do have a visible orbitomalar groove.  This is not the same thing as a "malar bag" which would live just below the hollow you demonstrate in this photo.  Fixing this is very difficult considering how thin your lower eyelid skin is.  I think filling this hollow would be very difficult.  Not impossible, just very difficult because the skin is so thin.  So the real question is how much does this bother you?

What about upper eyelid ptosis as suggested by another poster?  Sure you have a tiny amount of upper eyelid ptosis.  Please do not run out and have surgery for this now.  At some point it might be beneficial to have this addressed but my recommedation would be to avoid additional eyelid surgery at this time if possible.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Lower lid hollow after surgery

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Lin- Nice job with the photo.  The lower eyelid contour issues can be difficult to illustrate unless no direct flash is used.  Your photo shows a hollowing along the outer aspect of the rim, unmasking a "malar bag" in the process.  In my experience this is one of the pitfalls of the arcus marginalis release and fat repositioning, in that it only fills the inner half of the rim area.

At this point, you have three basic choices: Enjoy the partial correction, and do no more surgery.  Second, have more surgery done, releasing the orbitomalar ligament, and doing a cheek lift and orbicularis (the muscle that encircles the eye) sling.  Or three, use fillers to address the hollow.  Keep in mind that even synthetic fillers, such as restylane or juvederm last for many years when placed in the eye area.

In summary, there is a possibility more can be done and you should discuss this with your surgeon.  If he/she fills they can do no more, you can certainly see another physician for a second opinion.  There are many very capable eyelid surgeons in your area.

Yoash R. Enzer, MD

Yoash R. Enzer, MD, FACS
Providence Oculoplastic Surgeon

You may be a candidate for a well-performed Injectable Filler procedure to add volume to your lower eyelids.

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I read your concern and reviewed your photo. You may want to consult a specialist comfortable using fillers in your delicate lower eyelids. This is an unforgiving area so the expertise of your doctor is critical. I prefer to use Silikon-1000, an off-label filler for permanent results.

I hope this is helpful for you.

Dr. Joseph

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 435 reviews

Try filler first!

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Fat repositioning is excellent for the medial tear trough, but is often inadequate laterally. The lateral orbital fat is a different type of fat, more fibrous and harder to reposition. This hollow you have should be easy to treat with a filler.  Midface lift is a longer term solution but is a much bigger procedure than filler.  You may also still have some residual swelling in the "malar bags" that will improve over the next year or so.

J. Charles Finn, MD
Raleigh-Durham Facial Plastic Surgeon
5.0 out of 5 stars 7 reviews

Restoring youthful fullness to the lateral orbital rim

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  A correction may include a re-elevation of the skin flap, a suspension of the orbicularis muscle, repositioning of any residual fat to fill in the hollowed out areas and elevation of the lateral malar fat pad to fill in the lateral hollow.

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Another option is fat.

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Hello Lin,

Another option for revolumizing this are is the use of autologous fat.  Micro fat grafting can fill up this area and remove the "hollow" look that you complain about.  Ask your surgeon about this option.

Good luck, 

Dr. Shah

Manish H. Shah, MD, FACS
Denver Plastic Surgeon
4.8 out of 5 stars 69 reviews

Fat Grafting following Eyelid surgery

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Many of my brow-upper lid junction structural fat grafting patients have come to my practice for the correction of hollowness created by the over-zealous removal of fat during an upper blepharoplasty surgery. I am continually amazed at how many cosmetic surgeons practice 1970's-era blepharoplasty surgery in the 21st century. I almost never remove upper lid fat during blepharoplasty surgery, and in many cases I actually add fat at the brow-upper lid junction. Fortunately, essentially all cases of post-blepharoplasty hollowness can be improved dramatically by structural fat grafting. It is a more challenging procedure, as scar tissue must be overcome to create space for the grafted fat, and in many cases it takes more than one fat grafting procedure to restore adequate fullness in these patients.
Lower lid hollowness following an overly aggressive lower blepharoplasty can likewise be improved. One must exercise care and caution, as lower lid skin and the underlying soft tissues are usually quite thin, and thus the lower lids are less able to conceal grafted fat. Fat grafting must be preformed conservatively here, with a plan for secondary and occasionally tertiary fat grafting procedures depending on the 'take' of the initial fat grafting surgery.
Many patients referred to me for treatment of these frustrating and difficult post-blepharoplasty problems have reported more than just a cosmetic improvement. Excessive removal of skin and fat during upper and lower blepharoplasty can impair normal lid function and cause or aggravate dry eye syndrome. In some cases the fat grafting procedure will restore suppleness and flexibility to peri-orbital soft tissues, make eyelid closing easier, and improve the truly irritating and aggravating symptoms of dry eye syndrome.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Lower eyelid surgery or fillers

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you may have some hollowing or the malar bag as noted.    it is possible you have both.

the simplist start is a filler such as juvederm.. this can be disolved if it doesnt look right.  silikon is permanent  and may not be the best start.

if you like the appearance with juvederm , than fat grafting (or silikon) can be considered.  

more surgery would be my last choice

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 116 reviews

A few thoughts to improve your eyes

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It seems that you have what are called "malar bags". This can be difficult to correct with eyelid surgery alone.

You may need a cheek lift or facelift. I think that a filler or fat grafting would be a reasonable simple alternative that would be helpful too.

Your photograph also suggests that you have marked retraction of the skin of the upper eyelid and some drooping of the upper eyelid suggesting that the levator muscle, which lifts the eyelid, has become partially detached. This can be repaired by re-attaching the muscle to the eyelid.

Rodney A. Green, MD
Cleveland Plastic Surgeon
4.8 out of 5 stars 24 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.