I am unhappy with my lower bleph results 4 months post. What can I do at this point to achieve better results? (photos)

Your right cheek seems to be more full that the left 4 months after arcus marginalis release surgery.  While this area will continue to change to a small degree, you are not likely to see much change here.  This means that it is reasonable to consider what can be done to make the too sides appear the same.  Donot laser or botox this area.  It will not address the lack of fullness on the left side.  I do not recommend reoperating on the lower eyelid to further adjust the transposed fat-the risk of harm and the low likelihood of successful outcome does not make this intervention warranted.  Your very best option, is likely your very best option before your surgery, which is lower eyelid/top of cheek fillers.  The key is finding a very artful injector to perform your treatment.  They need to very much understand what is bothering you about the cheek.  Restylane is the preferred product for this treatment.  

From the photos provided, it appears that volume loss and inadequate replacement likely account for the tear trough line still present following the surgical blepharoplasty. Since volume depletion is at the heart of the problem, it is hardly surprising then that Botox, which is used to treat hyperfunctional facial expression muscle action and chemical peels, which are used to treat surface discolorations and irregularities, were not helpful in this case. Volume loss requires volume repletion. My choice for this region would be Belotero Balance, since this filler possesses little chance of leading to the unwanted, bluish Tyndall Effect that may be seen when other hyaluronic acid fillers are injected superficially within this thin, delicate region. Smoothing this area in this fashion is nearly painless (contrary to  popular misconception), takes only minutes to perform, and gives rise to results that are typically immediate and gratifying.Consultation with a board certified core aesthetic physician with extensive expertise and experience in injecting the periorbital region is strongly urged.

Thank you for your pictures. I'm sorry that you're unhappy with your results. It seems that you still have fullness of your lower eyelid. This is most likely due to your reposition fat. None of the previous treatments in my opinion are going to correct your issue. The only way to reduce that fullness will be to remove the fat.

The lower eyelid and upper cheek area has many potential cosmetic treatment options, which can be confusing for patients. While a lower eyelid surgery with fat reduction or fat reposition is appropriate for some, this plastic surgery may not sufficiently reduce the signs of aging. Adding volume with either fat injection or facial fillers (ex. Restylane) can help further reduce wrinkles or sagging tissue. If you haven't already, then ask your plastic surgeon if adding volume (fat or filler) would be appropriate for you.Best,Dr. Chaboki

You still have some volume deficiency in the lower eyelids.  This can occur when there is not a lot of fat to reposition.  You should try some HA filler here - restylane or belotero to give it  a little more volume and smooth out the contour.   

Your narrative does nor explain your dissatisfaction. You appear to have lower eyelid grooves between your lower lid fat and cheeks. In our practice we prefer to fill these grooves with Silikon-1000, an off-label filler for permanent results. This would only make sense if your lower eye lid grooves are your source of concern. Hope this helps you.Dr. Joseph

The dissatisfaction that you are having following fat repositioning is why I stopped doing the procedure.  There is a limited amount of fat which can be recruited so that there is often incomplete volume correction. It is also common to appear as if the fat was moved down the cheek without improving the appearance of the bag.  Lasering will not correct this as correction requires additional volume.  My only comment regarding restylane is that we have seen a lot of patients who are 2 - 4 yrs following restylane to the lower lid who are experiencing swelling in the lower lid.  This easily treated by hyaluroniase but as you are a young patient micro fat grafting will give a more permanent result.

You have mild tear troughs. Before having any material placed in this area, ask to see evidence of the results they are claiming can be achieved. In my opinion, structural fat grafting is the only way to address hollows under the eye or tear troughs. You should see before and after photos of at least a dozen patients from three perspectives. The results should include some immediate post-procedure, weeks later, months later and even a year later.  The under eye area is very delicate and requires expertise, precision and patience on the part of a surgeon. 

Four months is a reasonable time to have waited after blepharoplasty to see the final results.  Though things may still change a little bit, usually one would not expect a lot of improvement after 4 months.  If the under eye area seems hollow, injectible fillers are quite effective and last quite a long time (in some cases put o two years).  In our New Jersey plastic surgery practice, we favor Voluma for the cheek area, which its he latest FDA approved HA-based filler.  It is effective and has a good safety track record.

You may benefit from Restylane in the tear trough to fill things out a bit.  I personally think that fat injections have their limitations, as demonstrated here, and that there has already been too much trial and error.  I am uncertain why Botox and a peel were elected before filler in your case. Preop photos for comparison would have been helpful.