In blepharoplasty, is lower lid fat repositioning a better choice than fat removal for undereye bags?
Eyelid Fat Repositioning Vs Fat Removal for Eyebags
Doctor Answers (19)
Lower eyelid fat pads or "bags"
As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.
In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.
Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.
Structural Fat Grafting of the Lower Lid
As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.
In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.
Eyebags Fat Removal Can Leave Hollow Eyes Fat Repositioning or Grafting Better for Natural Look
Modern Blepharoplasty for Eye Bags emphasizes conservation of tissue including skin and fat.
Older Blepharoplasty techniques removed skin and aft and ofetne left the eye looking hollow and lid position pulled down=Sad Eyed Look or Houndog Eye.
Today many Plastic Surgeons are using a Transconjunctival Blepharoplasty which is done inside the eyelid and avoids a visible incision and removal of skin.
Rather than removing fat the fat is transferred or grafted into the tear trough area which plumps the dark circle under the eye and freshens the upper mid face.
It depends on your anatomy
The proper treatment of the lower lid is a very complex and much debated subject. Suffice to say that the old fashioned treatment of excessive fat removal is no longer done because of long term hollowing of the lid. Fat repositioning, fat removal, arcus marginalis release, septal tightening and many more, are all acceptable procedures to rejuvenate the lid. Be sure you go to a Board Certified plastic surgeon who does a significant amount of lower lid surgery to sort out what is best for you.
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Trend is toward fat repositioning
As stated in the previous answers, there is no single best procedure for everyone, you would need to be evaluated. The fat removal procedure has been around for a long time and gives good results in the short term. However, since fat is lost around the eye with aging, the trend now is to preserve it and use it to advantage by repositioning. This can also help smooth the transition from the eyelid into the cheek which is a more natural and youthful look.
The million dollar question
Fat removal by the transconjunctival approach is a relatively easy procedure, and generally gets good results.
However, hollowness can result.
Replacement of volume with fat injection, nontraumatized fascial-fat grafts has the possibility of leaving lumpiness, whether temporarily or permanently.
A conscientious surgeon will balance the merits of each, explain them carefully to the patient, and help them decide which is the best for their needs, tolerance of problems postoperatively, and their individual anatomy.
Lower eyelid fat repositioning and limited fat removal can both be valuable
There has been a very strong trend in eyelid surgery (and in facial surgery in general) toward fat preservation and away from fat removal.
That said, every case must be individualized. Sometimes fat removal is still a valuable option.
In many cases, I will sparingly remove fat from certain areas and reposition most of the fat over the bony rim.
Experts in eyelid surgery will customize their surgery to a patient's individual anatomy rather than always sticking with one set technique.
Mark J. Lucarelli, MD, FACS
Lower lid blepharoplasty improvement
The improvement of the lower eyelid complex is complex and includes the following approaches:
- Correction with filler (fat, HA) (See below weblink for just filler)
- Reposition of fat
- Removal of fat lower eyelid
All of the above are extremely technique sensitive and both the choice and application of the technique are surgeon dependent.
Depends on patient's anatomy
This is a very controversial topic in the field of blepharoplasty surgery. Repositioning is an excellent technique for excess fat bags within a person’s orbital anatomy that has a very shallow and gaunt lower eyelid. The lower eyelid repositioning can help with the tear troughs. If there is normal anatomy, simple blepharoplasty with fat removal would be the preferred choice.
Fat repositioning AND removal for eye bags
Invariably, when a patient comes in for an eyelid surgery consultation, they are focused on just the bags under the eye when they should also be aware of the crease or "tear trough" under the fat over the bony rim. This area should be addressed for an ideal result.
Fat repositioning is a nice advancement, but the results can be a little variable and can result in longer swelling. Fat transfer is our method of choice because it is easy, gives a great result, and the healing time is shorter.
The combination of partial fat removal of the eyelid bags and fat injection over the bony rim in the tear trough should give an excellent result.
Fat removal and fat or filler transfer is our preferred technique
Our procedure for lower blepharoplasty has explored most of the available options for rejuvenation. We did fat excision followed by fat transposition and now fat excision with orbital rim augmentation with microfat transfer or filler. This technique addresses the mulifactorial nature of lower lid aging. The lower lid skin is treated with different technique depending on the amount of lax skin present.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.