Why is a fat transfer recommended for doing my lower blepharoplasty? And what will happen if I don’t include that procedure?

Hi there,
I do believe there is a role for fat transfer in many patients.  It has nothing to do with ectropion, which is completely unrelated.
My feeling is that fat transfer is really useful in three situations:
1. Thin patients, particularly men, with really thin midface regions.  In this patients, pure removal of the fat can lead to a “long eyelid” look (think Stewey from Family Guy).  This is not a refreshing look.  Fat transfer keeps a little more volume in the lower lid and mitigates that risk,
2. Older patients with midface descent and unmasking of the bony eye socket rim.  The transferred fat can soften that bony contour.
3. Regular  patients with a lot of transconjunctival fat.  Sometimes the fat keeps flowing, and even with careful attention to the amount resected; it occasionally seems like a little bit of the fat comes forward postoperatively, leading to a little focal puffiness. By transferring the fat and “locking” it into position, that risk is reduced.

The downside of fat transfer is I find that it can lead to some low grade swelling for several weeks.  Patients are not overly bothered, as it is mild.  But definitely it prolongs the healing period a little bit.
Hope this helps
JDW

Many times an eyelid procedure is combined with fat injections if there is significant hollowing in the area. This improves a sunken appearance. Without it, you will get the result from the eyelid surgery but the volume may not correct. Hope this helps.

Great questions!
A transconjunctival (inside the eyelid) incision during blepharoplasty does have lower risk of ectropion (rolling out of the eyelid) when compared to a subciliary incision (under the eyelashes). However, this does not guarantee you won't have ectropion, but does lower the risk.
As far as fat transfer, this varies based on patients. The options you have are fat transfer from elsewhere in the body vs fat transposition which utilizes the fat already around the eye and repositions in areas that are deficient. Certain patients (very hollowed out or minimal fat) may be better candidates for fat transfer as there is not enough around the eye to account for the hollowing/tear troughs. There is alot of controversy because different patients benefit from different techniques and some surgeons prefer one over the other. I think you can get good results from either technique in the right hands.
Lastly, you can have fat transfer during or after blepharoplasty. Most would recommend getting this done at the same time to save you a second anesthetic/procedure, but it is not unreasonable to wait and see how things look before considering fat transfer. For fat transpostion however, this needs to be done at the same time as blepharoplasty as the fat pads must be visualized to reposition them.
Hope this helps!Kyle Kimura, MDFacial Plastic and Reconstructive Surgery

If the fat transfer is done well to the lower lid, then patients are very happy with it.  However, if there is some lumpiness or irregularity in the lower lid, patients are none happy with the results and can be very difficult to correct.  Fat transfer to the lower lid is not always required. 

Another technique that can be considered is fat transposition.  Instead of removing all the excess fat in the lower lid, I perform a procedure where the retaining ligaments are released allowing the excess fat to drop down and fill in the space of the tear troughs.  I have found that patients are the happiest with this technique and have had the most consistent results.  I do not routinely do fat transfer to the lower lids, although I will often times do fat transfer to the anterior cheeks right below the lid skin for the most dramatic improvement.

Dear lisa.777,You are bringing up a great and interesting question. Fat transfer to the cheek provides support to the lower lid, which may reduce the risk of ectropion. There is not good data on it, but it intuitively makes sense to most surgeons. This is because the eyelid and cheek interact and support each other. A droopy cheek is like a poor foundation of a house, and can make the walls (eyelid) sink.Good luck,Nirmal R. Nathan, M.D.

Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgeons
Fellowship-trained Craniofacial Surgeon

A trans. cong. lower lid bleph. only removes fat from the lower lid. The skin pinch does'nt cut through the muscle and therefore reduces the risk of ectropion. Two fat statements. What kind of fat? Thicker particulate fat or nano fat? There are multiple complications with fat, besides the fact that most of it resorbs. Asymmetric bumps, yellow fat showing through the skin and the rare cases of blindness. I don't like to inject fat around the eyes.

Lisa777  Thank you for your questions.  Photographs would best help; as well as an in person consultation to determine your best course of action.  Fat transfer to the cheeks helps to decrease the " tear trough " area and support the cheek which is the foundation  for the lower eyelid.  More important, for many, is avoiding the skin pinch if concerned about ectropion.

For the lower eyelids, fat transfer helps to obliterate a deep tear trough and an orbitomalar groove.  Periorbital fat can also be used for this but fat grafting is more versatile.  

Fat transfer for lower lid blepharoplasty is used to permanently fill volume deficits  beneath the lower lid bulge and can enhance the appearance of the result from lower lid blepharoplasty.  Without photos it is difficult to say whether this would be useful in your case.

good morning!All of the above procedures you mention are well studied and widely used- it really depends upon your anatomy and what is needed to give you the result you desire.It is always a good idea to have at least one or two more consults with other board certified plastic surgeons in your area who perform a lot of lid surgery- ask to see before and after photos- they should have a fair amount to show in a busy practice.  See if their opinions are similar and make your decision.I hope this helps

Dear Lisa,Thank you for your question but unfortunately without examining you or at least photos, it is very difficult and misleading to advice you.  Fat grafting has often the advantage of rejuvenating and improving the quality of the skin; the idea of a transconjuntival blepharoplasty is not to touch the orbicularis oculi muscle and reducing the trauma and possible ectropion; a skin pinch goes in the same direction. Best way forward is to see a few experienced surgeons, raise your questions after an adequate physical examination and then compare advice.All the best for your journey.Andrea Marando