Under Eye Bags Still Prominent After Blepharoplasty

Question

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.

Kenneth D. Steinsapir, MD · Answer

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.

Darrick E. Antell, MD, FACS · Answer

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.

Frank P. Fechner, MD · Answer

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.

William Portuese, MD · Answer

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.

Christopher L. Hess, MD · Answer

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.

Under Eye Bags Still Prominent After Blepharoplasty

Answers (8)

Answer: Revision surgery

Answer: Revision surgery

Answer: Likely you will need a revision

Answer: Likely you will need a revision

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Under Eye Bags Still Prominent After Blepharoplasty

Answers (8)

Answer: Revision surgery

Answer: Revision surgery

Answer: Likely you will need a revision

Answer: Likely you will need a revision

Browse related questions

Recommended reading

Everything you need to know about Eyelid Surgery

Our mission is to create a world where every investment in modern beauty is Worth It.