Transconjunctival Blepharoplasty - I am stuck between fat grafting, repositioning, or nothing at all. Recommendations?

Based on your photos, you are a great candidate for transconjunctival blepharoplasty with fat transfer. This should result in a much smoother lower lid/cheek complex. No skin incision, removal or canthoplasty is needed - always risks for complications. Fat repositioning can be done, but occasionally it can result in a little lumpiness. Be sure to see a facial specialist for consultation.

Due to hollowing and puffiness under the eyes, a person can appear older and tired. Currently, the tear trough under the eyes is deeply set, and the fat above it protrudes, creating a noticeable step-off that makes the hollow look even deeper.
In such cases, since there is no visible sagging of the skin under the eyes, the tear trough can be released from the inside through the conjunctiva, and the protruding fat can be redistributed to smooth out the area, resulting in a more even and youthful contour under the eyes.
Conjuctival under eye fat repositioning

In your case augmentation of cheek bones with implants would be best way to correct malar hypoplasia (small cheek bones). This should be supported with lower blepharoplasty, periorbital fat grafting, upper blepharoplasty. In person consultation with a board certified plastic surgeon with experience in these procedures is recommended. Good luck.

Thank you for posting the photos. They are very helpful. Based on these photos, you are an excellent candidate for a transconjunctival lower blepharoplasty with fat repositioning. You do have subtle lower eyelid retraction with prominent eyes. You could consider retraction repair with an internal graft at the same time as the blepharoplasty. This would not only create a more almond shaped eyelid, it will also decrease the risk of dry eye post-operatively. Fat grafting or a tear trough implant are options to help create a bit more fullness to your central cheek. I do both of these procedures, but prefer the implant as it is much more predictable than fat grafting. You can learn more about these procedures using the link below

Your right upper eyelid does seem "puffy" and is likely related to fat and a subtle upper blepharoplasty would improve the symmetry, though you could also consider the left upper eyelid as well to improve the irregular crease on the lateral aspect of your eyelid.
Please consider an Oculofacial plastic surgeon for your surgery.
Virtual consultations are available for out of town patients.

In the midline of your iris, you can see that there is white that shows between the iris and the lower lid. This is called scleral show and can be associated with thyroid disease or other things. You need to be evaluated for that before doing any surgery. A lower blepharoplasty can make that much worse. For the upper eyelids, you need to have both upper eyelids done so you have symmetry when done.

Best Wishes,

Gary Horndeski, M.D.