Under Eye Bags Still Prominent After Blepharoplasty

Dear Dr,
It's already 3 months since I had transconjunctival lower blepharoplasty done
however the problems I encountered since 1 month after surgery still persists. (hollowing under my lid and my under eye bags are still very prominent under lights)

I'm not sure the bags are due to edema or residue fats, my surgeon say my eyelid need few months to settle down but it seems like I look worse before my surgery.
I'm really worried, depressed and regretting for my decision; your advice will be greatly appreciated.

Thank you very much.

Doctor Answers 8

Revision surgery

The goal of a transconjunctival lower blepharoplasty is to remove the fat bags underneath the lower lids. It is impossible to have residual fat bags and hollow eyes at the same time. If there is still fat residual remaining in the lower lid, this can be removed through an additional transconjunctival approach. If there is hollowness in the eyes, this can be addressed through fat repositioning or reimplantation. It has been three months after the surgery and most of the healing has been accomplished at this point, and it is acceptable to proceed with a revision surgery.

Seattle Facial Plastic Surgeon
4.8 out of 5 stars 143 reviews

Likely you will need a revision

Nowadays we strive to remove enough fat to improve the appearance of the lower lids without removing so much that the patient is left with a hallow look. The transconjunctival approach is excellent for this. However, it the approach is done low in the conjunctiva than appreciation for SOOF fat is not appreciated.

SOOF fat or subobicularis oculi fat is fat deep to the muscle but superficial to the septum. This is more common in certain ethnic groups. I think that is the fat you're seeing. The tear trough deformity is secondary to the SOOF fat remaining. I doubt you'll need filler if this fat is remove.

Christopher L. Hess, MD
Fairfax Plastic Surgeon
4.4 out of 5 stars 33 reviews

You can try Restylane injections.

To Pufferfish,

Hi..I certainly see what you mean. Unfortunately, I don't think this will go away after 3 months.

Restylane injections, in VERY small amounts, injected DEEPLY and carefully, just under the bags, can make this area look better. But be sure you see someone with experience.

Otherwise, you will need a surgical revision, repositioning the remaining fat.

I know this is not what you wanted to hear.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
4.8 out of 5 stars 9 reviews

Fatty herniation

Your result from the lower eyelid surgery can be better. You have negative vector and this means that your check bone is not providing enough support fo the fatty tissue that surronds the eye. As Dr.Fechner answered your question ,you have multiple option.

1) lower belpharplasty and tear trouph implant to support the eye fat pad

2) filler to augment the soft tissue( temporary and may have problem with the puffiness

I would wait at least 6 month

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.8 out of 5 stars 122 reviews

Wait and let yourself heal after blepharoplasty

Without seeing your before photos, it is difficult to give a definitive answer. However, what you are experiencing is something every surgeon has had on occassion. I would suggest waiting until your surgeon feels things have settled down to the point where you could consider either additional fat removal or possibly filling in the trough area, probably with Juvederm. The other option is to leave well enough alone, as there may have been something about your particular anatomy and healing that limited the result.

Be patient, and discuss your concerns with your surgeon.

Darrick E. Antell, MD
Manhattan Plastic Surgeon
4.7 out of 5 stars 34 reviews

More time to heal is almost always a good idea

Dear Pufferfish,

Transconjunctival lower eyelid surgery removes fat from the lower eyelid. The goal is to improve the contour of the lower eyelids. It is unclear if the fullness seen in your lower eyelids actually represents true herniated orbital fat or merely the descent of the cheek fat that once met the lower eyelid fat to form a continuous fullness into the lower eyelid crease.

Certainly the residual full in your lower eyelid does represent residual lower eyelid fat. However, I would not fault a surgeon for leaving too much fat. Although it can be frustrating to need a revision surgery to remove more lower eyelid fat, this demonstrates a commendable restraint on the part of the surgeon. Leaving too much fat is easier to correct than taking too much fat.

The challenge of any eyelid surgery is getting everything just right. As fat is removed in the lower eyelid, the relative hollowness caused by the fall of the cheek fat that occurs in all of us can be much more visible. That is why there has been a trend toward conserving the lower eyelid fat. In a procedure called an arcus marginalis release, the lower eyelid fat is actually moved as a living graft from the lower eyelid into the top of the cheek to partially filling this hollowness.

Regarding your situation, I think that where you are now is a very good preview of where you will be in three to 9 months. I think it is reasonable to wait a few more months and let the tissues heal but it is likely that you will feel motivated to have a revisional surgery to make your lower eyelids better. Do make sure that you and your doctor are on the same page regarding what you are look to a achieve with the touch up surgery if that is what you elected to do.

Please remember to share you further experiences with the Realself community.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Puffiness after lower blepharoplasty

At 3 months, you are probably looking at about 95% of the final result.

From the photo I get the impression that your problem lies not in the fat herniation ("puffy") of the lower lid region but also in the hollowness of the tear trough. Further improvements can be accomplished in 3 ways:

1. additional fat removal

2. filling of the tear trough (fat transfer, injectable fillers).

3. combination of both.

I would wait for a minimum of 9 months before considering any surgical procedures (fat removal or fat grafting). Injectable fillers could be placed a little earlier.

I encourage you to stay in touch with your surgeon so that he can monitor your progress and advise you accordingly.

Frank P. Fechner, MD
Worcester Facial Plastic Surgeon
4.6 out of 5 stars 48 reviews

Puffy eyes 3 months after blepharoplasty may require revision and fat grafting

The fullness at the bottom of your lower eyelids following transconjunctival lower eyelid blepharoplasty may be edema but is more likely residual fat.

Did your sureon perform fat grafting or fat repositioning? If so, the fullness may go daown with massage over the repositioned or grafted fat.

If the surgeon did not do fat grafting or fat repositioning then a revision procedure may be required.

Fat can be harvested from tour abdomen and transplanted into the hollow area below the eyelashes, this would smooth the contour of the lower eyelid. I would also release the arcus marginals to allow the bottom of the lower eyelid to redrape.

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.