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

I'm only 28, but all my life I have hated my hereditary undereye bags - thanks Dad! I think I am ready to take action, but I am extremely nervous. One of the doctors I consulted with spoke against simply "repositioning" the fat because "it doesn't tend to stay where you put it"... not sure of the truth of this. My main concern is that he will not be conservative enough and too much fat will be removed, eventually giving me a hollow look... either soon after the surgery or as I age.

Doctor Answers 12


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The trans-conjunctival approach to cosmetic lower eyelid blepharoplasty is very favorable. Instead of approaching the fat pads from the outside (trans-cutaneous blepharoplasty) the dissection is actually performed from behind, within the eyelid.
The trans-conjunctival blepharoplasty is usually combined with an external skin pinch, to remove the redundant skin, once the fat pads are removed and deflated.
Lower lid Blepharoplasty may be performed with a combination of local anesthesia as well as light IV sedation anesthesia. General anesthesia is not necessary, although patient preference should always be taken into consideration.
Hope this at least provides useful information. Good luck and best wishes. Dr. Shah

San Antonio Facial Plastic Surgeon

It's a two part process

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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.

Jeffrey H. Spiegel, MD
Boston Facial Plastic Surgeon
4.5 out of 5 stars 70 reviews

Puffy eyes at 28

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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. 

Richard W. Westreich, MD
Manhattan Facial Plastic Surgeon
4.9 out of 5 stars 55 reviews

Under eye bags

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Thanks for your pictures. You do have under eye bags which are fat pockets that have herniated. You would do great with transconjunctival lower blepharoplasty, It will significantly improve your look. You may also want to consider some under eye laser resurfacing to further help firm and tighten some of the skin on your lower eyes. Conservative removal would be ideal to prevent future hollowness. Good luck !

Dilip D. Madnani, MD, FACS
New York Facial Plastic Surgeon
4.8 out of 5 stars 104 reviews

Fat issue in lower lid

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You might be an excellent candidate for fat removal through a transconjunctival approach.  You also may be a good candidate for some tear trough filler to camouflage the region.  Best of luck.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Transconjunctival Fat Removal Versus Repositioning

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Your concerns are valid but you have missed a subtle point in that your "herniated" fat is not symmetrical and it appears that the lateral compartment of the lower eyelid fat is in a normal position. Depending upon the thickness of your skin and the depth of the groove under the fat you could consider:doing nothing, repositioning the fat below, removing some (careful) excess fat or putting the fat back to it's previous positioning by tightening the septum
Best of luck
Cap Lesesne,MD

Cap Lesesne, MD
New York Plastic Surgeon

Transconj bleph

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There is little reason to be removing fat in a blepharoplasty unless someone has a huge amount of prolapsed fat.  You are correct in your fear of hollowing if fat is removed.  With the amount of fat you have and the hollowing in the tear trough, I would do a fat repositioning.  Once the fat is there is won't move later on. 

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 31 reviews

Trans-conjunctival blepharoplasty is best for young patients with bags under their eyes

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The incision for a trans-conjunctival blepharoplasty is inside the eyelid. Extra fat is removed. For older patients, this is often accompanied by a hollow beneath called a tear trough. In that case instead of just removing fat, we transpose part of the extra fat into the hollow. This converts a "hill-valley-hill' appearance to a nice smooth transition of the lower eyelids to the cheeks.

Steven J. Pearlman, MD
New York Facial Plastic Surgeon
4.9 out of 5 stars 141 reviews

Trans-conjunctival approach for fat removal in the lower lids

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When patients  have genetic deposition of fatty deposits in the lower lids at an early age, a trans-conjunctival approach with a conservative fat removal is the best option. this involves making 2 small incisions on the inside of the eyelid. You are correct that too much fat removal can leave the eyelids appearing hollow, but not enough removal results in residual puffy eyes. At age 28, no skin tightening is required from the outside

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

Lower eyelid bags

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Hi. You are right to be concerned about over aggressive lower blepharoplasty. Removing too much fat can create a hollowed out appearance. This can worsen with age. Also, in my experience, when used appropriately, fat repositioning usually holds well.

From your photos, you look like you may do fine with conservative fat removal alone - although an in person exam is needed to determine this. Typically, fat repositioning is preferred to conserve volume and fill the tear trough. Most age related lower eyelid "bags" are due to a combination of weakening of the orbital septum (which normally hold the fat back in the eye socket) and loss of volume in the cheek. This exposes the rim of the eye socket which enhances the baggy appearance. Repositioning the fat in these cases can blend the eyelid-cheek junction.  However, you are young and it sounds as if you have always had lower eyelid bags. This is usually due to a hereditary excess or prolapse of fat. In these specific cases, conservatively removing a small amount of fat can give great results. 

An in person exam with an oculoplastic surgeon would help to confirm if a removing or repositioning fat is the best option for you. Hope this helps. Ira Vidor, M.D.

Ira Vidor, MD
Newport Beach Oculoplastic 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.