Lower Blepharoplasty - muscle injury (Photo)

I have 3 balls connected by sinew in the lower bag space, evident immediately after surgery. The balls/sinew run from one corner of the eye to the other. with this is retraction and loss of elasticity of the lid. I am now 6 weeks post surgery. Constant daily massage has not affected the size/placement of balls although have helped the retraction (somewhat). My surgeon has no idea what the balls are. I see him again at 9 weeks. how do we fix this, as I now still have a bag caused by the balls?

Doctor Answers 5

Your eyelids can be fixed.

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This is a nightmare.  I am so sorry that what was supposed to be a wonderful experience has turned out this way.  I am concerned that the nodules could represent a low grade infection.  I encourage you to get a second opinion from a fellowship trained oculoplastic surgeon who is not invested in this surgery.  You need to heal for many months before reconstructive surgery is a consideration.  However it may be necessary to biopsy one of the nodules.  This could represent a chronic infection like atypical mycobacterium.  It could also simply be inflammation but I would consider emperical antibiotics for this.  The massage is not likely to help these eyelids and may be causing inflammation.  Download my free ebook which discusses how these eyelids are repaired.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

The balls on your eyelids could be nodules caused by fibrosis, and may need the help of an eyelid specialist to resolve

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Thank you for your question. You’ve submitted several very well taken photos describing your situation after undergoing eyelid surgery approximately 6 weeks prior. You state you developed these 3 balls at the lower part of the eyelid that were present from the beginning of the surgery. In addition, you describe the situation of some eyelid retraction and laxity, and you are very concerned about the presence of these little balls at the bottom of the lower eyelid, so you’ve been constantly massaging them. You want to know what to do, and you are seeing your doctor again at the 9 week point.  

I can certainly understand the reasons for your concerns. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years, and revising complications related to cosmetic surgery is a significant part of my practice. People come to us from all over the world for issues like yours. I am not saying necessarily you need any revision surgery. I think it’s a little early to tell, but there are certain elements of your procedure I’m going to help give you some idea of what my thought process would be for someone like yourself who comes to our office.

The presence of these discrete elevations or, what we refer to as nodules from the time of surgery makes one think of some basic issues of the process during surgery, and why those areas form. I think they are under the category fibrosis. At the time of surgery, you’re not going to have fibrosis because they happen with healing, but they can represent areas of fat just partially in those spaces, or areas of muscle, or blood, so there are definitely a few ideas for this. The possibility of an infection is there, but it is generally unlikely because this area is very vascular so it tends not to get infected, but it is something to consider. What comes to mind is when I look at something like this, seeing it in a photo and then on physical exam, I try to feel if it’s soft, rubbery, or hard, which help a physician determine an option as to what to do for those areas.

There are options from this stage, and also moving forward. In general, if there is a question about scarring or fibrosis, it is typical to inject low dose steroid or anti-inflammatory into those areas to try to soften them. Massage and observation are appropriate strategies to see how things turn out. The major issue for you now is observation because with time and healing, often these little irregularities improve. The majority of people who I treat in your age group, I do what is called transconjunctival blepharoplasty, which means going from the inside the eyelid to address the fat pockets. In your situation, you had what is called transcutaneous blepharoplasty, so your surgeon chose to do an external approach. With that external approach, to get to the fat pockets there was a skin muscle flap which separates away from the support of the eyelid, which the muscle contributes to, and when it is repositioned, sometimes the surgeon will trim extra skin. Typically that’s the reason why a surgeon does it because they want to reduce some skin with a perception it will tighten the lower eyelid, but it contributes to the retraction and laxity of the eyelid.

The decision to do revision surgery typically is deferred. In my practice, unless somebody has an issue where there is exposure of the eye, or problems that are clearly significant enough to require earlier intervention, I generally recommend conservative management. Conservative management includes what you are doing which is massage and observe. As far the nodules are concerned, the question of management still depends on examination - if they are present and persistent throughout your healing process, then some type of revision has to be done because if it’s not improving from conservative therapy, massage, and steroid injection.

I think the first line is something to discuss with your operating surgeon. Ask about steroid injection, a clear explanation, and ask what they think. I know your surgeon stated that they don’t know what it is, so if your surgeon doesn’t know , then it is advisable to meet with a Fellowship-trained oculoplastic or oculofacial plastic surgeon to at least get an additional opinion. When people come to me for a second opinion, I never disparage the doctor who previously performed the surgery. In fact, I don’t even ask, and just give you my thoughts. Sometimes a physician can be so immersed in their procedure they might not think of possible other issues they may not recognize, or are just not thinking, so a fresh set of eyes can’t hurt this situation. There are times where I’ve brought to life something the patient was not aware of, then I said speak with your doctor, say respectfully you had a second opinion, and this was discussed, then ask their thoughts. I think that a good physician will appreciate another doctor who is not undermining them, but actually trying to do the best for their patients.

I think that is something worthwhile considering since your doctor said they don’t know what that is. Consider a second opinion, and think what these nodules require in terms of intervention such as steroid injection, which is probably the first line of treatment, then be aware of the eyelid position moving forward. In our practice, we have patients who come from all over the world who have a single most common issue which is lower eyelid retraction after lower eyelid blepharoplasty, and it typically requires a fair amount of revision work to get the eyelid to a better position. Monitoring this and making comparisons before and after surgery with the eye shape. Hopefully, you will get closer to your original shape and will ultimately be pleased with the final result, and there is a likelihood of that if there isn’t too much compromise in the eyelid structure. I hope that was helpful, I wish you the best of luck, and thank you for your question.

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Lower blepharoplasty complications, asymmetry, vision impairment, skeltonization

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The cause of your preoperative deformity was a genetic too large Orbit which caused a fat herniation from inside the Orbit. 

The skin and fat removal by a classical lower lid Blepharoplasty do not solve the problem and open the door to a lot of complication as lumps and scleral show!

Stem cells injection could repair and cure the genetic deformity.

Roger Amar, MD
London Plastic Surgeon

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Revision lower eyelid retraction surgery after lower blepharoplasty

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Give it another 2 months. If no improvement, see an oculoplastic specialist for possible treatment. See link below too.

Fibrosis and scarring.

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I am sorry that you are having these problems. The first thing I would say is that or someone of your age, it would be very unusual to have an anterior approach blepharoplasty, this is almost always done through the back of the eyelid without leaving any skin scars allowing for a reduced risk and complication profile. This makes me wonder whether there is something unusual that the surgeon may have seen or done.The lumps are likely to be areas of fat fibrosis, and we do rarely see the eye socket fat clumping together in nodules which are often quite hard. These seldom persist for so long. I would consider a steroid injection into the lumps sooner rather than later at this point, but this must be done judiciously as excess steroid can actually lead to fat necrosis.  Discuss these options with your surgeon. I think you need to see an oculoplastics specialist if you are not getting any improvement.Best of luck with your further treatment.

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