Lower Eyelid Bleph w/ Fat Grafting vs. Just Fat Grafting Around Eyes?

I am 39 year old female. I have been to 3 different plastic surgeons for lower eye puffiness. One recommends just fat grafting around eyes and maybe removing a little bit of fat from the bulge. Another surgeon, who is a facial plastic surgeon, recommends a lower eyelid bleph w fat grafting. And the third surgeon, who is an oculoplastic surgeon recommends canthopexy??? Why so many different opinions?

Doctor Answers 8

Blepharoplasty With Fat Grafting vs Fat Grafting Alone For Puffy Eyes

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Thank you for your question. I would say that the skill and experience of the surgeon that you choose is the most important factor in your decision. The best surgeon rather than a particular technique will most often achieve the best result.

Many surgeons today add fat into the depression or dark circle underneath the "eye bag" to camouflage the puffiness and smooth the eyelid. The benefit of this is that by avoiding fat removal and skin removal you avoid the hollow eye deformity and possible change of eyelid shape.

For mild to moderate puffiness of the lower eyelid fat alone can achieve an excellent result.

I avoid fat injections-I don't like traumatizing the delicate eyelid structures with needle injections and injected fat does not survive as well as a composite fat graft-a whole piece of fat.

Key points for me:

  1. Transconjunctival incision-inside the eyelid-avoid a scar and change in eyelid shape
  2. Release the Arcus Marginals-allows graft to be placed into the Nasojugal Fold-the depression beneath the lower eyelid
  3. Harvest a Composite Fat Graft from pubic area-best fat for grafting, well hidden scar under pubic hair
  4. I do not use Fat Repositioning of eyelid fat-leaving vessels attached to eyelid fat can cause fat to retract back into puffy area and can make eyelid look hollow in some cases
  5. Adding new fat to the upper cheek lower eyelid area can help rejuvenate the midface
  6. Be certain eyelid support is adequate-if eyelid is lax a canthoplasty or pexy is necessary
  7. For severe puffiness or eye bags some fat can be removed with this approach
  8. If excess eyelid skin is present a skin pinch Blepharoplasty can be done to tighten the eyelid without violating eyelid support

Choose your surgeon carefully-ask to speak to patients who have had the procedure.

Fat Grafting Lower Lid Blepharoplaty - View Many, Many Photos

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Obviously it appears as though there are as many opinions on fat grafting as there are plastic surgeons, and this must be profoundly confusing to prospective patients. 

In order to get a sense of the level of experience and expertise a plastic surgeon has, look at the quality of the before and after images they have available. A  lnk to my gallery of before and after images is below.

It is important to view many, many photos as evidence of their expertise. Of course, viewiing photos is just one step, but an imprtant step.

A number of physicians  have made dogmatic statements about various procedures that may very well represent their own personal experience and preferences, but that do not necessarily provide interested laypersons with a balanced and accurate view of the options currently available for restoring facial soft tissue volume.
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.
 Because of the tremendous variability in all of these factors, there is tremendous variability in fat grafting results.  To perform fat grafting successfully and reproducibly a surgeon must employ careful preoperative planning, appropriate instrumentation and meticulous surgical technique.  It is not something you can 'rush through' or spend just a few minutes on during a larger surgical procedure.  The unfortunate reality is that not everyone who performs fat grafting is willing to put in the level of education, training, investment in instrumentation and operative effort required to produce aesthetically ideal results.
One must also have an aesthetic vision for ideal and youthful-appearing facial fullness.   Just like traditional facelift surgery can be overdone or performed incorrectly to produce an unnaturally tight, pulled, 'windswept' look, fat grafting can be overdone to produce an excessively full and even bizarre postoperative appearance.  Too much fat grafted into any area (or any fat placed where it doesn't belong) looks unnatural.  It's analogous to breast augmentation results: if the surgeons selects an appropriate implant volume and positions the implants correctly, the patient gets a beautiful, natural-appearing breast enhancement.  If the surgeons stuffs a pair of 500cc implants behind the breasts of an average-sized patient, then that patient ends up with a cartoonish 'boob job'.  I think many of the unfavorable results in fat grafting are from the overzealous placement of excessive amounts of fat, which may have been the inevitable response to the recent paradigm shift in aesthetic facial surgery: away from the 'wind tunnel look', and towards the restoration of soft tissue volume.
Here is one patient’s experience with fat grafting posted to RealSelf:
Fat is great when used JUDICIOUSLY and CONSERVATIVELY, but too much of a good thing becomes a nightmare and deeply regrettable. Make sure your surgeon listens, draws up precise operative plans beforehand and makes plenty of time for you and your concerns. Do NOT take it lightly.
I couldn’t agree more with this patient’s response to her experience with fat grafting.  Just like breast implants, or liposuction, or browlifts, too much of a good thing is not at all a good thing.  And cosmetic surgery (and this includes the preparation for surgery) of any kind without attention to detail and a focus on natural-appearing results will leave patients feeling disappointed at best and feeling disfigured at worst.  Now regarding whether or not fat grafting is a surgically sound concept…
For transferred fat to truly qualify as a 'graft' the following must happen: living tissue must be transferred to a new location, and that tissue must gain a blood supply at the new location which provides oxygen and nutrients which allow it to persist indefinitely as living tissue.  We know that with appropriate instrumentation and technique this is achievable, so one of the opinions expressed in this thread that "most of the cells from fat injection are dead " is simply untrue (and structural fat grafting, to be clear, does not involve 'injection' of fat).  MRI studies have shown that with appropriate technique grafted fat persists long-term as living, vascularized tissue in the recipient site.
It is also well-established that adult human fatty tissue contains stem cells that have the capacity to repair damaged or injured tissues, and stem cells can be concentrated during the fat harvesting process.  This effect has applications in both cosmetic and reconstructive surgery.  Fat grafting is now being used, for example, as a means to stimulate the repair of chronic, non-healing wounds.  Several centers have reported on fat grafting immediately below non-healing chronic wounds resulting from radiation therapy for cancer, with rapid improvement and eventual healing of wounds for which no other wound treatment was successful.  The development of stem cell therapies involving the harvesting and processing of viable human fatty tissue is one of the hottest topics in both clinical and experimental medicine today.
When performed correctly fat grafting actually has the capacity to heal, revitalize and rejuvenate the local tissues at the recipient site.  I have treated a number of patients with facial fat atrophy following overly aggressive 'non-invasive' rejuvenation treatments including Thermage, Fraxel and IPL.  Most of these patients report not only an aesthetically  pleasing and permanent improvement in facial soft tissue volume, but also an improvement in the quality and vitality of their facial skin.
I perform extensive facial fat grafting during most of my facial rejuvenation procedures, and it is the very first thing I do - before making any incisions to lift the brows, eyelids, face or neck.  Fat grafting allows me to obtain results that are simply not possible with conventional, subtractive surgical techniques alone.  Patients frequently return for grafting of additional areas after their initial experience with strucutral fat grafting.  To characterize it as the pointless and potentially harmful placement of non-viable tissue is an opinion only, and it is an opinion with which quite a number of plastic surgeons who successfully rejuvenate faces (and breasts and bodies) with fat grafting would vehemently disagree, myself included.
Solid fat/fascia and fat dermis grafts are another means by which facial soft tissue volume may be significantly and permanently enhanced.  As with fat grafting, survival of the grafted tissue is variable and some of the graft material is reabsorbed.  As with fat grafting, potential complications such as infection and cyst formation are possible.  And as with fat grafting, appropriate preoperative planning and surgical technique are required in order to obtain ideal and lasting results.  In my opinion structural fat grafting is more versatile, as fat can be easily and rapidly added to any tissue plane (level); and it has the added benefit of the ‘stem cell effect’ which is difficult to quantify but unquestionably present in many cases.
Both structural fat grafting and fascia-fat (or dermis-fat) grafting can be competently performed (or not) by Board-certified plastic surgeons.  Neither should be trademarked or considered proprietary.
As with any surgical procedure take time researching your plastic surgeon. Schedule several consultation, view many photos from many patients, each from multiple perspectives (start by looking at photos on this website) and speak to former patients of any plastic surgeon you are considering.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.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Fat grafting eyelids

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Fat injections may be used to smoothen contours of the eyelid cheek junction. Blepharoplasties help reduce excess skin, bulging fat, and excess muscle. Preparation of your surgery plan involves an aesthetic judgement which can vary from surgeon to surgeon.

Ronald Shelton, MD
Manhattan Dermatologic Surgeon
4.9 out of 5 stars 39 reviews

One problem, several solutions.

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You have come face to face with the art of cosmetic surgery. There are usually several ways to obtain a result, each with its own pros and cons. My advice to you is to find a surgeon that you feel comfortable with and review before and after pictures of the surgeon's work. Once you feel confident, follow the surgeon's advice, as it will usually provide you with the best result.

Paul Vitenas, Jr., MD
Houston Plastic Surgeon
4.8 out of 5 stars 116 reviews

Lower lid puffiness treatment

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It sounds like a large portion of your puffiness is due to lower eyelid area volume loss. It can be a judgement call whether any lower eyelid bulging fat needs to be removed. Often at your age, just improving the volume helps, but this really needs to be assessed in person.

A canthopexy procedure would help to tighten the lower eyelid. Done alone, it wouldn't help with your concern regarding lower eyelid puffiness but is sometimes done in conjunction with lower eyelid blepharoplasty approaches where there is a concern that the lower eyelid will be pulled down after surgery.

Thomas A. Lamperti, MD
Seattle Facial Plastic Surgeon
4.9 out of 5 stars 22 reviews

Improving Lower Eyelid Bags with Surgery or Fat Graft

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Hi miamij,

Lower eyelid procedures to reduce bags vary greatly, largely due to a patient's unique anatomy, personal preference, and a plastic surgeon's experience & preference. There normally isn't one answer, but rather many good options to rejuvenate the face. Both fat injections and lower eyelid surgery are good options for appropriate candidates. Another option to consider for younger patients like yourself, to further complicate decisions, is facial filler injections such as Restylane or Juvederm. Only after a comprehensive evaluation can an eye specialist help determine appropriate options for you. Best of luck.

Dr. C

Houtan Chaboki, MD
Washington DC Facial Plastic Surgeon
4.9 out of 5 stars 89 reviews

Lower Eyelid Rejuvenation - Different Opinions

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If you would be able to go to 3 plastic surgeons for a facelift and afterwards look at the result, you would certainly look at 3 different versions of yourself. We base our recommendation not only on your anatomy but also on our own aesthetic preferences.

It sounds like, you would benefit from some filling of your tear trough depressions. In order to help you make your decision, have the surgeons demonstrate to you before and after photos of patients of somewhat similar lower lid/ cheek problems.

Canthopexy tightens the lower lid and is indicated if your lid would be loose.  

Frank P. Fechner, MD
Worcester Facial Plastic Surgeon
4.6 out of 5 stars 48 reviews

Lower lid surgery

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You ad so many different opinions because of each persons evaluation of the problem and how to correct it. it  is also based on each individual's expertise with one procedure or the other.

In general at today's understanding of aging, is that we loose fat in the face with age.therefore one had to be very conservative removing fat from the face or the eyelids.

in the eye lids the nore fat you remove the more hollowness of the eyes you will get. In few conditions some fat need to be removed but the majority need to be redistributed to fill the tear trough.

In many cases filling the tear trough will even the lower lid and rejuvenate it. But the filling of the lower lid require extreme expertise otherwise you will get lumpy . I start with a filler that I can reverse like Juvederm.

If you like the results i then do micro fat transfer, Fat and fillers has to be injected in small amounts deep to the muscle.

Canthopexy is used for lax lower lid, at 39 I doubt you are very lax. however the canthopexy will support the lower lid to prevent ectropion.

Fat can be distributed in the lower lid through a Transconjunctical approach and the skin is treated with laser for tightening. This will decrease the risks of complications.

The most important aspect of cosmetic surgery is that it is an ART and a SCIENCE. Familiarity with different approaches and understanding what each procedure can and can not do is very important

Continue your consultations till you are comfortable with the surgeon, his expalnation and his/her expertise.

it is also important to find the surgeon who will spend the time to explain all different approaches and analyze your particular situation and the logical approach. Do not base your decision based on financial basis or magical surgery that is used for advertising and loring the patient in

Samir Shureih, MD
Baltimore Plastic Surgeon

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.