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 in your question that you developed these 3 balls at the lower part of the eyelid
that were present from the beginning of the surgery.
In addition, you have described the situation of some eyelid retraction and laxity and it
appears that you are very concerned of course about the presence of these little balls at
the bottom of the lower eyelid that you’ve been doing constant massage and again they
have been present since the beginning of surgery.
And you want to know what to do.
You are intending to see your doctor again at the 9 weeks point.
Well, certainly I can understand the reasons for your concerns.
A little bit of background, I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
In fact, 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.
And people come to us from all over the world for issues like yours.
Now, I am not saying necessarily that you need any revision surgery.
I think that’s a little bit early to tell but there are certain elements of your procedure
that I’m going to help give you some idea of what might my thought process would be
for someone like yourself who comes to our office.
So the presence of these discrete elevations or we can refer to them as nodules from the
time of surgery makes one think of some basic issues with the process during the surgery
and why those areas form.
I think that it would all be basically under the same category of what we call fibrosis.
Now of course, at the time of surgery, you’re not going to have fibrosis because that’s
something that happens with healing but these areas can represent areas of fat that were
just partially in those spaces.
It can be on areas of muscle, it could be areas of blood.
There are definitely a few ideas that can go with this.
The possibility of an infection is there but it is generally unlikely.
This is an area very vascular and it tends not to get infected but it is also something
to consider but I think that the question that 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 is it soft, is
it rubbery, is it hard.
That helps a physician determine an option as to what to do for those areas.
Now, there are options from this stage as well as moving forward.
And 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 get them to soften.
Massage is certainly an appropriate strategy and observation to see how things turn out.
For me, that’s of course, the major issue for you now but it is also has been an observation
that with time and healing, a lot of times these little irregularities do improve.
Now the majority of people who I treat who’d be in your age group, I do what is called
transconjunctival blepharoplasty.
That means going from the inside the eyelid to address the fat pockets.
In your situation, you have what is called transcutaneous blepharoplasty.
So your surgeon chose to do an external approach.
With that external approach, what is developed to get to the fat pockets is called a skin
muscle flap.
And that skin muscle flap separates away from the support of the eyelid which the muscle
contributes to and when it is repositioned, sometimes your surgeon will trim extra skin.
Typically that’s the reason why a surgeon will do it because they want to reduce some
skin with a perception that it will tighten the lower eyelid.
So that is contributing to the retraction and laxity of the eyelid.
Now, the decision of doing 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 do recommend
conservative management.
Conservative management such as what you are doing which is to massage, to observe.
And as far as again the nodules are concerned, the question of management still depends on
examination.
If they are present and persistent throughout your healing process, well then some type
of revision has to be done because if it’s not improving from conservative therapy, massage
and steroid injection.
So, I think that’s the first line and this is something to discuss with your operating
surgeon.
Ask about steroid injection.
Ask if there is a clear explanation and ask what do they think.
I know that your surgeon stated that they don’t know what it is so if your surgeon
doesn’t know what it is, then it would be probably advisable to meet with a Fellowship-trained
oculoplastic or oculofacial plastic surgeon to at least get an additional opinion.
You know when people come to me for a second opinion, I never ever disparage the doctor
who previously performed the surgery.
And in fact, I don’t even ask.
I just give you my thoughts.
Sometimes a physician can be so immersed in their procedure they might not think of possible
other issues that they might not recognize or are just not thinking and so a fresh set
of eyes can’t hurt this situation.
There are times where I’ve brought to life something that the patient was not aware of
then I said speak with your doctor and say respectfully that you had a second opinion
and that this was discussed and what are your thoughts.
And I think that a good physician will appreciate another doctor who is not undermining them
but actually try to do the best for their patients.
So, I think that is something worthwhile for you considering since your doctor said they
don’t know or have an idea of what that is.
So, consider a second opinion and think what these nodules will be requiring in terms of
intervention such as steroid injection which is probably likely to be the first line of
treatment and then of course 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 in order to get the eyelid to a better position.
So monitoring this and just making comparisons before and after surgery with the eye shape.
Hopefully you will get closer to your original shape and you 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.
So I hope that was helpful, I wish you the best of luck and thank you for your question.