How Eye Bags can Worsen Since Filler Treatment, and a Definitive Puffiness Treatment

By: Amiya Prasad, M.D.

Thank you for your question. You submitted several photos and you describe in detail in your question that you had Restylane placed in your tear trough in 2015 and that with time, the area appeared to get swollen, pillowy appearing. So you underwent some dissolution or dissolving of the filler. And then you went back a couple more times to fully dissolve what may have been some residual filler. And now you’re concerned that the eyes look puffy.

Well, I reviewed your photos and I certainly can share with you what I believe is the situation in the absence of a physical exam. A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Helping people with rejuvenation under the eyes whether it’s surgical procedures or injectables is something we do tremendous volume every day in our practice. So I can certainly tell you that I’m quite familiar with this particular case scenario.

So to begin with, it is my perception that you probably are dealing with in 2015 with a concern about hollow appearance of the lower eyelid. When a lower eyelid appears hollow, it can be combination of issues, one area being the hollow appearance of the tear trough, the orbital rim, as well as the cheek area. When I look at a person’s eyes, I look at not only just their eyes, I look at their eyelid to cheek relationship and it is important with whatever strategy we’re employing to help someone look better.

Now that being said, when I look at the photos you submitted, the puffiness that you are, I believe, concerned about appears to be an area that’s above the tear trough or adjacent to it. Now that puffiness is not likely to be filler based on the way it appears on the photos especially with the photo with your eyes looking upward. That puffiness from my perspective is something called lower eyelid fat prolapse. Lower eyelid fat prolapse means that the fat that’s normally around your eyes pushes forward and creates a bulge. Now most likely or possibly, I would say that in 2015, you may have had a slight amount of puffiness which initially may appear to look like a hollow. As I explained to my patients, when someone perceives a trough or hollow, it’s often because of the contrast between the elevation or the mountain that’s next to a valley.

How Eye Bags can Worsen Since Filler Treatment, and a Definitive Puffiness Treatment

So the contrast is an issue. So when the eyes are slightly puffy, it is up to a point, within our ability, to add filler into the tear trough at that eyelid junction with the tear trough and under eye slight fat prolapse and create a continuity. And that’s one of the nice things about having the tool of having fillers. Now my suspicion is that with time, that puffiness further advanced and it became more prominent and it was maybe perceived as being resulting from the filler.

There are many people who actually, when filler is placed, can have that filler in this space last for years. And I certainly have had my share of patients who have come who had fillers who needed dissolving and removal. And when you dissolve these fillers, you actually see the underlying structure. And when you see the underlying structure, it gives you a better, of course, overall understanding of the true natural anatomy of that patient. So in your situation, I think that you’re probably dealing with lower eyelid fat prolapse.

Now that being said, again without several different views and a 3 dimensional evaluation, consultation, it is possible for you to consider the two typical options: one is to add filler again in a strategic way recognizing that there’s fat pockets that are responsible for this prominence and the other is to consider a procedure called lower eyelid fat blepharoplasty. Lower eyelid blepharoplasty in our practice, for the most part, we do something called a transconjunctival lower eyelid blepharoplasty. This is an approach where we go from behind the eyelid to sculpt the fat pockets that have herniated forward and prolapsed forward so that there’s no more bulge. Now people are often concerned about looking hollow or looking overdone. Well, the way I explain it is the idea and the goal is to try to achieve a look as if you never had the under eye bags. It doesn’t mean that you may not still need filler for the tear trough area or for the relative hollow but it’s important to at least understand the anatomic spaces that the interventions are trying to address.

So it’s important to at least entertain that concept. A lot of people who prefer to have minimally invasive types of procedures, but actually injectable fillers are comparable to surgery. Once you’ve passed through the skin, it is an invasive procedure in my opinion. I would say that, how we help people alleviate their concerns about general anesthesia and surgery is that we do our procedures under local anesthesia, LITE™ sedation in our own office operative facility certified by the Joint Commission.

So in many ways, it makes it as close to a minimally invasive procedure like injectables but in an operating room setting to address the true issue which is the fat pockets. Again, it is important to have a proper evaluation maybe a fresh set of eyes. Perhaps, if you weren’t seeing a cosmetic surgeon for your injectable fillers, you may want to entertain the option of at least consulting a cosmetic surgeon or an oculoplastic surgeon about this situation where you need a truly clear diagnosis of the presence of puffiness, the presence of hollowness and what is the best option and strategy that works best for you.

So I hope that was helpful, I wish you the best of luck and thank you for your question.

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