Eyelid Fat Repositioning Vs Fat Removal for Eyebags

It’s a great question and one that many are confused about.  I always remove the excessive fat and usually some skin as well.  The concept of repositioning the fat makes no sense to me.  If you have that done you will probably be back eventually to simply remove that fat,  which should have been done initially.  Some plastic surgeons are obsessed with making things complicated but I prefer to keep things simple.  I have irrfitmed thousands of lower lid procedures and have never had s patient complain of removing too much fat or asked for fat to be replaced.  This whole fat repositioning thing is being oversold.

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.
Dr. Miller

It's not unusual for patients to develop prominent periorbital fat pads with normal facial aging. When this situation arises, a variety of treatment options are available. Both blepharoplasty with fat resection and blepharoplasty with fat pad re-positioning are commonly utilized alternatives. The specific procedure chosen will depend upon the patient's aesthetic goals and anatomic findings. It's important that treatment be individualized to accomplish the patient's goals.Each of these procedures offers advantages and disadvantages. Historically, fat pad resection has been used extensively, but recently plastic surgeons have stressed the importance of fat preservation. This is especially true when tear troughs are present.If you're considering blepharoplasty surgery, it's important to consult a board certified plastic surgeon with experience in this area. This surgeon should be able to determine which surgical option is best for you.

The decision of fat removal or fat repositioning is based on what the eyelids look like. If there is a large volume of fat, it may be completely excised or partially excised with some repositioning towards the cheek. In cases where there is mild to moderate extra fat with a hollowing beneath it, moving the fat to the hollowed area is appropriate. Make sure your surgeon is comfortable with both techniques. 

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

Madison, WI

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.

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.

There is not an "ideal" surgery what fits every patient. There are several surgeries that are customized for the patient's specific anatomy. If you have excess fat but a fairly smooth lid-cheek junction, then removal of the fat may work well for you. If you have excess fat but a distinct lid-cheek junction, then it may be better to reposition the fat to help smooth out the transition. If you provide pictures, then we may be able to give you more specific advice. Good luck.

After careful examination of a patient's lower lid and cheek anatomy, approximately 80 to 90% of patients benefit from filling of the tear trough area in addition to reducing the puffy under eye area.
Because our patients don't just want to have puffiness removed but rather want to look better (and yes, there is a difference between these 2 goals), we perform some fat repositioning in most of our lower blepharoplasty patients. Alternatively, some blepharoplasty surgeons prefer the combination of some fat removal and filling the tear trough with fat grafting (a.k.a. fat transfer). The outcome can be quite similar although adding fat transfer to the blepharoplasty may be more cumbersome.
Because we understand that the hollow lower lid is unattractive (and worsens even over the years), some form of volume enhancement is beneficial for most people seeking a lower eyelid lift.

Dear Crystalgurl,
The transconjunctival lower blepharoplasty with removal of lower eyelid fat can be a fantastic option for the right person. The key with any surgery is case selection. So a young person with just a bit of a lower eyelid bulge will have a great results with a small resection of lower fat using this approach. However, take too much fat or in individuals with a whole lot of lower eyelid issues like skin and eyelid laxity, cheek descent, etc and now you have a situation that will not do well with this approach.
Conserving the lower eyelid fat is helpful when there is enough lower eyelid fat to be rotated into the top of the cheek in association with a hollowness in the under eye area. Again the key is individual selection. Generally individuals with thicker skin and good integrity of the lower eyelid ligaments do best with this type of procedure.
Bottom line is that not every approach is right for every situation. The choice is much more art than science.