Tear Trough Area Lump After Fat Transfer

Question

I had fat transfer done in April 2008, and after two weeks, a visible lump formed  on my right cheek and a larger bulge on my left side, but it's visible only when I'm smiling and laughing. Since then I seeked the advice of 5 other doctors, all unwilling to touch my face, all telling me different times (from 6 months to 3 years) to wait it off. What can I do besides waiting for months or years "to see" if it will go away? Can I get a proactive approach to a solution instead?  Thank you so much.

Brent Moelleken, MD · Answer

There is nothing wrong with waiting until a problem is stable, and at that time reassess critically to see if any revision surgery needs to be done.  Usually this timepoint is some time after six months.
Fat injection fat can sometimes be aspirated with a very fine liposuction canula.  In my experience, however, this is sometimes touch since the fat that does survive tends to be very "gristly" and does not aspirate well through a canula.  Sometimes the adjacent native fat is more vulnerable to the suction and well intentioned suctioning of the tougher fat injection fat can actually cause irregularities that compound the initial problem, not improve it.  Usually when we revise the lower eyelids and have irreguarities from prior fat injection grafts, we remove them through direct incisions.
At the time of any revision, we assess for why the patient had the fat injections in the first place.  Was there hollowness in the lower eyelid area?  Was there drooping of the cheeks that could benefit from a cheeklift?  There are many types of cheeklifts, so which one?  Would the patient benefit from moving up the thicker cheek tissue slightly to cover the lower eyelid hollowness?
Will the patient be better and more simply served with volume replacement with temporary Hyaluronic acid filler?  Or a nontraumatized fascial fat graft such as LiveFill placed directly into the tear trough or eye-cheek junction?
All these revision procedures have risk with them, so we have a candid discussion on how bad the problem really is, and whether revision surgery is even indicated.
The lower eyelids are the most delicate area in the entire body, for fat injection or any other procedure because of the extremely thin lower eyelid skin and the difficulty in correction of problems if they do occur.

Michael Law, MD · Answer

I'm sorry you have had this experience. The results of fat grafting should be smooth and natural both in look and in feel.  I'm sure this is very frustrating for you. It does make sense to have a limited waiting period before going forward with corrective surgery. Without photos it is impossible to tell you what options would be best for you. However, I wonder why you have sought the advice of 5 other doctors? Certainly patients will sometimes seek the opinion of another plastic surgeon, and that can be a prudent thing to do. But ideally you would have taken a long time checking the credentials of your plastic surgeon and finding someone with compassion who really listens to you and understands your goals before you commit to surgery.

Lawrence Kass, MD · Answer

You need to find an oculofacial plastic surgeon who is willing to help you. I would check the directory of ASOPRS. I would consider conservative steroid injections or surgical excision if necessary. Good luck!

Larry S. Nichter, MD, MS, FACS · Answer

I agree with the advice of the other physicians you consulted for several reasons - not all fat survives and sometimes the fat necrosis/liquefaction process of fat cells that do not survive will create inflammatory lumps or nodules that overtime will self correct or can be aspirated if liquefied. On the other extreme, you will not know if this is because too much fat was injected until several months.The bottom line is that many factors are at play and waiting is the best medicine. Massage may help and will allow you to feel that you are part of the healing process. After 6 months to a year your condition should stabilize and your surgeon can direct you as to what if any procedure might be corrective.

Amir M. Karam, MD · Answer

Without examining you or looking at a photo, it is hard to give you sound advice.  But, the first step is to find an experienced fat transfer surgeon who performs many treatments around the eyes.  As a general conservative approach, the first step is often direct micro-aspiration during the early phases (i.e. within a month).  The fat is still soft and can potentially by suctioned out.  This can be coupled with massage, but massage alone rarely treats the problem completely unless it is subtle.
Next step would be to inject the fat with a very dilute steroid.  Often this will take several treatments.  This is a delicate area so it is important the injections are done very conservatively and placed in the correct levels to avoid complications.  Unfortunately, if the lumps are because of too much fat placed into a given area which resulted in a raised lump, many times it will require a direct excision through a small skin incision. Depending on the location, it can be done through a blepharoplasty incision, but often times, a direct incision over the lump is more effective.  But if the size is diminishing with time, then I would certainly advice waiting it out.

Michael A. Persky, MD · Answer

Hi Femme Fatale,
Sorry to hear that you are suffering from fat graft complications.  Most importantly you should continue following the advice of qualified and experienced fat transfer surgeons.
Accent XL is a non-invasive method of sculpting fat.  It may be possible to smooth your "lumps" with a series of treatments.  This area is extremely delicate.  Your evaluation should be performed by someone with a great deal of experience. 
Microliposuction may help if there is a palpable mass of fat.
Dr. Few has given you very good advice.  Patience and waiting as the five docs that you have consulted with won't get you into any additional trouble. 
Hopefully your problem will resolve soon.  Be well.
Dr. P

David Shafer, MD, FACS · Answer

With fat grafting or any procedure, it is possible for you to develop "lumps," especially if you are being injected by an inexperienced injector.  However, now that you have a lump it is best to wait some time before jumping into additional operations or procedures.  These additional procedures are not without their own risk.  It is important to seek the opinion of your surgeon and, possibly, other surgeons as you have.  With out examining you myself, it is hard to give you specific advice.  However, if you have seen 5 other surgeons and no one is suggesting an intervention at this time, I would tend to trust their advice.  If you can find someone that says they will intervene, that may not be the correct answer.  Most of these things improve with time, but I know that waiting is very difficult.  Good luck.
David Shafer, MD
Shafer Plastic Surgery

Paul Fortes, MD · Answer

If these lumps are still present in the tear trough for over a year, they are unlikely to go away.  In general, fatty lumps in the area of the inferior orbital rim (eye socket) can be accessed through the same incision used to perform a lower eyelid lift.  I suggest seeking a consultation with a board-certified plastic surgeon experienced in aesthetic surgery of the lower eyelids.  Best of luck.

Boris Volshteyn, MD, MS · Answer

The lump on the cheek may represent either a part of routine lumpiness or irregularity after fat grafting that will improve on its own. Sometimes, injection of steroid can help. Alternatively, if the symptoms did not improve small excision may be needed to correct the deformity. Prior to deciding to any surgical intervention it is important to give enough time for swelling of the tissues to settle down appropriately. Sincerely, Boris Volshteyn M.D., M.S.

Zain Kadri, MD · Answer

The problem you hane is not unusual and I have seen similarly affected patients who needed surgical revision. For some reason the fat injected in the perioorbital area tend to survive and thrive- may be because of the rich blood supply. I beleive the the fat was injected under the muscle in your case and that is why the lump becomes prominernt when you smile as the muscle contract over it bringing it in relief. This fat is going to be with you for good. Only reasonable and sure way is to have open incision bleparoplasty to clean it up and tighten up your lower lid.

Tear Trough Area Lump After Fat Transfer

Answers (17)

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