Is a transconjunctival blepharoplasty right for my genetic under eye bags? (photos)

I’m a board certified cosmetic surgeon certified by the American Board
of Cosmetic Surgery. My background is also in eye surgery and oculofacial
plastic surgery with a fellowship training in the American Society of
Ophthalmic Plastic and Reconstructive Surgery. I’m also a specialist in
cosmetic reconstructive surgery of the eyes. I’ve been in practice in Manhattan
and Long Island for over 20 years.



Under eye bags are caused by fat prolapse and there are many options to
address it. However, many patients are afraid that they might look hollow after
eyelid surgery. Your concern about hollowness is actually about lower eyelid
retraction where the eyelid is pulled downward causes which causes more of a
hollow look than the absence of fat under the eyes. There is a relationship
between the eyelid area, the orbit or the space around the eyes, and the cheek
area. If someone has a very flat appearance, sometimes they may interpret that
once the bags are gone, they look hollow. When I assess a patient, I always
look at these relationships and discuss with them what they expect after
surgery. Sometimes, the tear trough area, the eyelid cheek junction, and the
submalar area can be relatively hollow. All of these go under the umbrella of
hollowness.



Unfortunately, you feel that you can’t trust the doctor and that’s not
a good thing. You should feel comfortable with your doctor. Anyone who has trained
in a surgery specialty, who performs cosmetic surgery and has a lot of
experience with eyes, certainly draws from their experience to give you an
opinion. When the doctor says that the transposition may not stay where you
want it to, certainly I would say that this doctor is correct. For several
years, the idea of moving fat from the orbit into a space below the orbit, has
come and gone in different ways. There will always be doctors who would
disagree in what they do but there is also a lot of difference of how they do their procedures.



From my own experience with fat transposition, it does have a place but
it does have a limited indication. As a specialist, I see a lot of patients who
have procedures like this who come in 2 years later and still look puffy. It’s
because the transposed fat didn’t stay where it was intended. Part of it may have disappeared and the rest
of it ended back into the eye socket.



In my consultations, I tell my patients that the puffiness under the
eyes is caused by fat that has moved forward and creates that herniated look.
Now imagine what your eyes would look like if you didn’t have the fat there. That
means the eyelid would follow the natural shape of the eye and will follow the
shape of the rim. If there is volume loss along the rim or below it, then that
can be addressed in a variety of ways.



I think you should meet with other doctors to get more confident about
which doctor you feel comfortable with. In your situation, I would perform a
transconjunctival blepharoplasty which means a procedure done from the inside
of the eyelid. We often combine this treatment with platelet-rich plasma (PRP).
It helps with skin quality and volume of improvement in the eyelid-to-cheek junction.
This combination has been very successful for us for the past 20 years of
practice doing this type of approach whether it’s resection, transposition or
any other variations. There is an art to doing this so an artistic eye, a sense
of proportion of how much to take and leave behind are also important factors. The
success of the procedure also depends on the individual patient and other
factors such as skin thickness, skin quality, the risks and benefits. You have
to think of all these things and have these factors articulated clearly so you
can make an informed decision. I hope that was helpful, I wish you the best of
luck, and thank you for question.



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Mrs Magellan,Puffy fat can be repositioned safely without an external incision especially in someone your age or the layers that hold the fat in can be tightened to give you a smoother look.  It may be however that you really need some filling beneath the eyelids to improve your cheek/lid junction.Find someone experienced and trust their judgement - you should get a good result.

Some patients do have a genetic predisposition to excess lower eyelid fat accumulation. These patients are excellent candidates for trans conjunctival blepharoplasty.   The correction typically last many years if not a lifetime. If you have a mild tear trough issue, then fillers can complete the job.