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September 09, 2009

Under Eye Bags Caused by Muscle Hypertrophy

Hi, This has been a problem since I was a little girl.  Now I'm 40 and want to improve the appearance of my under-eye bags, whether it is with surgery or fillers.

I look tired all the time and my bags just keep getting bigger as I age. I went to another consultation for blepharoplasty (eyelid surgery).

The doctor told me there's nothing that can be done, because it's all muscle and not fat. Could I have hypertrophy?  What can I do?  I can't stand to look at myself or have others look at me.  If there is surgery for this, what is it called?

-Shellee

Shellee's undereyes 

Dear Shellee,

Find an experienced Botox injector.  Ask for 1 unit of Botox in the roll under each eyelid.  This might solve your problem without surgery.

(If your plastic surgeon is up on the latest treatments, 2.5 units of Dysport would also work.  Dysport is probably equivalent to Botox.)

Do be aware that this is a tricky use of Botox/Dysport.  There are a few potential (albeit unlikely) risks...

  • Lowering the lower eyelid margin (so that you see white beneath your green irises)
  • Loosening the tension on the fat beneath the eyes, such that bags really do become apparent (I agree with your current analysis.  You do not have fat bags, just excess muscle.)
  • Causing your eyes to become dry and scratchy

I highly doubt that you will have problems, but other plastic surgeons might be hesitant to give my suggestion a try.  This is definitely a Botox/Dysport use for experienced injectors only.

If the Botox/Dysport is unsuccessful, the injector could try more.  Or, a little filler in the upper cheeks (at the infraorbital rims--the bony rim beneath the eyes) can smooth the area out.  My favorite is Sculptra.

(By the way, the world's 2nd most beautiful woman--Angelina Jolie--also has muscular rolls beneath her lower eyelids.  Shellee, you're in good company.)

Angelina-jolie-eyeliner

(Who's the world's most beautiful lady?  My wife, of course!!)

Sincerely,

Mike Pickart

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Comments

tracey

i had botox 3 weeks ago, after 4 days i noticed i have bags under my eyes which i never had before, is this caused by botox? some days they are heavy and other days they are small, i am havin plenty of rest to reduce them but they dont go, would be glad to hear a reply thanx.

Michael Pickart


Dear Tracey,

Your under-eye bags MAY be caused by the Botox.

Let me step back and clarify the picture:


Normal under-eye bags can be caused...

by excess fat (most commonly)
by excess muscle (less commonly)
Botox is a muscle relaxant.

If the under-eye bag is caused by excessive muscle, then the Botox will relax that excess muscle.

The relaxed muscle will atrophy.
The bag will look like it has gone away.
In fact, the muscle is just temporarily paralyzed; when the Botox wears off, the muscle will regain its bulk and the bag will return.
Angelina Jolie is a gorgeous lady, who has small under-eye bags from excessive muscle. If she were interested, she would be a good candidate for Botox!
On the other hand, if the under-eye bag is caused by too much fat (which is, by far, the more common situation), then Botox will not help.

Botox only works on muscle, not fat.
ButBotox will still be helpful to diminish crows feet and to raise the tail of the eyebrow.
The muscle around the eyes is called the orbicularis oculi.

This is an important muscle. It helps you blink.
Unfortunately, it also causes crows feet and contributes to frown lines between the eyebrows.
The orbicularis oculi also provides some dynamic support to the fat around the eyeballs.

This means that the orbicularis oculi helps hold the fat inside the orbits.
To some degree, the orbicularis oculi helps prevent fatty under-eye bags!
If a patient does not have under-eye bags, and if she receives Botox to diminish under-eye wrinkles, the orbicularis oculi will be weakened.

A more relaxed, weaker muscle will not be able to help hold the fat inside the orbits, around the eyeballs.
If the other structures that prevent fat protrusion are also weak, then the orbital fat will bulge out into the lower eyelid area.
So, in effect, Botox can inadvertantly produce under-eye bags.
This is unusual, but I have seen it before.

Tracey, this is all relatively complicated physiology. Please re-read the above so that you know the factors involved. Then, call your plastic surgeon. If you are dissatisfied, I am sure that he will want to know about it. I cant make diagnoses over the internet, and I certainly cant offer therapies. He might be able to help.

You are always welcome in my office in California! It might be a long flight (since I noticed that you are from the UK), but I have number of English, Scottish, and Welsh patients, and we seem to get on very well!!

Sincerely,
Mike Pickart


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811


To: info@pickartplasticsurgery.com

Emy

HI, thanks for the great info. I had a Blepharoplasty on the lower lid a month ago. I had fat bags which looked more severe on the left eye. The doctor said I have to do both eyes.
Now the bags r gone but the other eye, the right one has this enlarged muscle on the lower lid, as the doctor said after the surgery.
I still have one eye looking more tired than the other.
Any solution to either developing the left eye muscle or to just hiding the enlarged one in my right eye.

thanks in advance.

Michael Pickart


Dear Emy,

Please return to your surgeon to express your concerns. Dont lose hope! You may just have some residual swelling that will resolve spontaneously.

Even if your outcome is as good as it will get, there are minor revisions that can be performed non-surgically (such as with Botox) that can improve a result.

My best wishes to you,
Mike Pickart


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811

To: info@pickartplasticsurgery.com

Jennifer

I had Botox injections for crows feet. 3 days after I developed pretty bad under eye bags. My eyes are extremely tired feeling most of the day. I am horrified. I realize that there is no anti-Botox but is there anything to help with the eye puffiness and tired heavy feeling in my eyes? I have tried sleeping more. Cut out salts and sugars. I am running to get rid of excess water retention. Tried pep h under my eyes. Eye creams with caffeine. Nothing is helping. Is there anything a doctor can prescribe?

Michael Pickart


Dear Jennifer,


I wish that you did not suffer this side effect! Maybe you can find solace in knowing that you are not alone. Increased under-eye bags is a rare complication of Botox--but well-described.


Anatomically, fat is positioned around the eye balls to cushion the globes in case of trauma. The fat is held inside the bony orbits by static walls (known medically as septa) and by dynamic muscles (such as the orbicularis oculi muscle, which is also the cause of crows feet).


When your doctor injected Botox to relax the lateral/outer portions of the orbicularis oculi muscles in order to minimize crows feet, some of the toxin must have diffused towards the inferior/lower portion of the orbicularis oculi. The subsequent weakening of the inferior/lower orbicularis oculi muscle diminished the dynamic barrier against fat protrusion. Subsequently, fat is able to poof out. This makes you look more tired and puffy.


Unfortunately, there is no quick fix for this complication. Facials with microdermabrasion or mild chemical peels might provide some mild skin tightening, thereby minimizing the puffiness. Minimizing salty foods can decrease the hydration of fat, and help make the fat throughout your body less full.


The good news is that Botox does wear off spontaneously--within 3-6 months. Please let your plastic surgeon know about your complication. At the minimum, he should modify his technique the next time that you try Botox. Dont sour on Botox or Dysport! They are wonderful medications, and they usually work terrific!!


Sincerely,


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811

To: info@pickartplasticsurgery.com

Louise

Hi there,

I have been trying to find someone who may be able to give me some impartial advice about a botox procedure that I received which has caused considerable side effects to my face.

I have been receiving Botox for around three years now and for the majority of the time have had the following areas injected:

Forehead
Glabellar Lines
Bunny Lines
Crows Feet


I changed clinic earlier this year and had Botox injected for the first time by them on the 13 July 2010. When injecting my eye area, they covered a new area that I had not had before, directly under my lower lash line. 1 unit of Botox was injected in the middle of each lower lash line and I was told this would 'open' my eyes up to give 'an almond shaped appearance'. I was not informed of any potential side effects that this treatment may cause. My eye area was line free (I am a twenty nine year old who does not smoke, drink or go out in the sun). I was having injections around my eye as a preventative measure.

In the week preceding my treatment, I was horrified to find that both of my lower eye lids had collapsed and where there was tight line free skin before, I was now faced with deep, dark hollows in both lower eyes and the skin was loose and crepey. I looked about ten years older and extremely tired. My eyes were raw and sensitive and became constantly dry and at times I found water trickling down my cheeks due to the lack of tension in my lower lids.

I contacted the provider to ask what was going on and was told that my eyes would return to normal in six weeks. After six weeks my eyes were worse and then I was told 12 weeks before they would return to normal. It is now six months and my eyes are still the same, they have not returned to normal. I have noticed a very slight improvement but they are nowhere near what they were before.

I am contacting you in a state of despair as this clinic have been very dismissive of my concerns and I have been completely unable to get any advice from anyone else as there are no helplines or organisations who are knowledgeable enough to discuss the matter. I am, however, led to believe that it is unusual for the under eyelash area to be injected and am hopeful that you may be able to advise on this and also whether my eyes are likely to return to normal.

If you were able to give me an honest outlook of what I may expect, I would be very grateful.

Kind Regards

Michael Pickart


Dear Louise,


I am sorry that you have had such a bad outcome. My heart goes out to you.


The lower eyelids are an area which I uncommonly treat with Botox (or Dysport). Nevertheless, the excess rolls of orbicularis oculi muscles do respond well to just 1 unit of Botox per side. However, laxity of the lower eyelids is a known risk....


The amount of white sclera below the brown or blue iris can enlarge.The lower eyelid can hang away from the eyeball--an ectropion. This can cause irritation.The subsequent irritation can lead to increased tearing, known as epiphora.

I have not had a patient with prolonged laxity, like you are having. Normally, Botox does wear off within 3-6 months. If I had to guess, I do think that you will get better spontaneously.


However, you need to see a Board Certified Plastic Surgeon or Oculoplastic Surgeon. In the USA, our most important society is known as the American Society of Plastic Surgeons. I think that the equivalent societies in the UK are the British Association of Plastic, Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons. Please look up these organizations on the internet, and find an appropriate professional in your area.


Also, I would like you to see an ophthalmologist--an eyeball specialist. You need to make sure that your eyeballs (especially your corneas) are adequately protected, so that your vision is not threatened.


Honestly, I do think that you will improve. I have never heard of such a prolonged and unfortunate result from Botox.


If you are ever in California, I would be happy to evaluate you myself: 805-648-4567.


Sincerely,
Mike Pickart


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

428 Poli St.,#2C, Ventura, CA 93001
(805) 648-4567 | fax (805) 641-0811

To: info@pickartplasticsurgery.com

Rookshire

Mike,

I had a lower belph 3 weeks ago, I understand I am early in the healing process. I believe I have orbicularis oculi muscle hypertrophy, as my eyes have hollows after the swelling has died down, but enlarged bulges under the incisions just like Shellee. I cannot believe I traded one problem in for another and it makes me so angry that my surgeon did not do anything about it nor did he tell me! Could I be blowing this out of proportion, could it just be residual swelling or hypertrophy?

Michael Pickart


Dear Rookshire,


I am sorry that you are not satisfied with your early result. However, it is hard for me to make therapeutic suggestions. Please contact your surgeon, and discuss with him your concerns. The bulges may just be residual swelling, and, with another few weeks of patience, your outcome may still be terrific.


Please dont fret yet! Do call your doctor. Ask him to reevaluate.


Sincerely,
Mike Pickart


Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

1746 S. Victoria Ave., #250, Ventura, CA 93003
(805) 654-8800 | fax (805) 654-8802

To: info@pickartplasticsurgery.com

Rookshire

Dr. Pickart, I want to thank you so very much for answering my question above as I'm sure you are a busy surgeon. If you have a moment, I hope you don't mind me asking one more question. I did ask my surgeon his opinion on my eyes, and he told me it was residual swelling. In this case, is there anything you could recommend I could do to further help the swelling go down? Such as warm/cold compresses, orbicular muscle massage, supplements? Also have you had any patients who have had similar swelling that has gone away with time?

Michael Pickart


Dear Rookshire,

Yes, I have had patients like you who have had prolonged swelling. On occasion, the swelling required months of patience. Very frustrating for patient (and surgeon).

My suggestions:


Head elevation: Use an extra pillow at night
Cold compresses
Massage
Lots and lots of patience

Good luck! I bet that all will be well when it ends well.

Sincerely,
Michael C. Pickart, M.D., F.A.C.S.
Pickart Plastic Surgery, Inc.

1746 S. Victoria Ave., #250, Ventura, CA 93003
(805) 654-8800 | fax (805) 654-8802

To: info@pickartplasticsurgery.com

Amber Douglas

Hi there! I had my first Dyport injections on April 28th with a Dermatologists for my Crows Feet, and Frown Lines. I bruised immediately from the Crow Feet injection, and no bruising on Frown lines. I noticed within 3 days that my crows feet were smoothing out, but there were still a few wrinkle left at my 2 week check up appointment(May 16th). At that appointment I explained and asked about the small wrinkles still left. She said she would inject 5 units more on each side a little lower(not under the eyelid). So, I gave that 2 weeks and it ended up looking worse. I developed a crinkle-wrinkle right above my cheek bone, so when I smile there is a line wrinkle that is very apparent right above my cheek. I went and got a a second opinion with a plastic surgeon (RN nurse). She said she has seen this before and that if she injected 2 units right under each eye that this should help. Now 8 days later my eyes look baggier than ever and the crinkle-wrinkle is worse. Not sure what to do. Now I'm worried that it's not going away. I rather have the crows feet. I look more tired and older. What should I do? Should I go back to the Dermatologists or Plastic Surgeon (not the RN)?

Rookshire

Dr. Pickart,

I hope you remember me from a few months ago (a couple posts above) I wanted to let you know that 6 weeks after surgery my surgeon said I looked like I was 6 months out of surgery! My eyes look -fabulous- after my blepharoplasty. Thank you for giving me recommendations, they really helped! All it took was lots and lots of patience like you said!

tracy  Lee tulloch

please go to facebooku will see i dont have bags. doc did crows lines and now I look 10 years older and cont know what to do -doc said cause my skin thin has water.another doc said botox is injec into muscle not skin.doc gave me premizone to take water away - tues after mothers day I had it done you will see pic's of me and daughter who wedding is coming up

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