Would you recommend fat repositioning or fat removal with fat grafting for my lower blepharoplasty? (photo)

Question

I’ve a lot of research on lower blepharoplasty and have had one consult so far. The first doctor recommended fat removal (with fat transfer(transconjuntival) He suggested a skin pinch but I’m afraid of eyelid retraction or having any change to the shape of my eyes so suggested a tca peel (ZO 30%) as an alternative. My question is, I’ve read that the “new way” for lower blepharoplasty is to reposition the fat and not remove it. That it has a better blood supply . However I’ve also read that the fat can migrate back to where it came from? On the flip side, I know a lot of the fat with a transfer can be absorbed back into the body and there are also risks of it being lumpy. Does someone with a higher metabolism run the risk of more fat being absorbed? I just keep going back and forth what the right approach is? Looking at my eyes, which technique would you use? My concerns are the hollowness below the fat pads and the redness. Also, does one technique last longer than the other? Thanks!

Kenneth D. Steinsapir, MD · Answer

You should be very concerned about a skin pinch. Looking at your photos, it is a possibility that you do not need a skin pinch, laser, or chemical peel. The “new way”you are describing of preserving lower eyelid fat and repositioning it into the top of the cheek is called arcus marginalis release and has been around for 30 years. Done properly, the fat does not retract . It is much better than over resetting the lower eyelids (still too common an outcome).I see 3-4 new consults every week of people with issues with lower eyelids/cheek fat grafting so I am not a fan. I think you could reasonably just start with a bilateral lower eyelids transconjunctival arcus marginalis release. If it ultimately turns out that your lower eyelid skin would benefit from tightening, it can always be done if needed, but it is not clear you need it. There is no substitute for a detailed in person assessment. Less is more.

Oliver Chang, MD · Answer

Based off your photos, you have fat likely in the lower eyelid that needs to be removed as well as some fat that can be transposed / transfixed and fat grafting to areas that will help with camouflaging some facial fat descent or atrophy. So a mixture of the treatments would probably be best, so you likely won't have the issues you are concerned about long term from just having it done one way. Also CO2 to the lower eyelid after the surgical part is done would help with some of the skin laxity to maybe avoid any skin pinch resection and to keep it transconjunctival.

Earl Stephenson, Jr., MD, DDS, MBA · Answer

Dear Dt,

Thank you for your pictures. If you are concerned about abnormal position of your lower lid, it is reasonable to have your lower eyelid surgery with a transconjunctival approach. In my opinion, if there's hollowness, I tend to use the fat that was removed as a graft. You are correct that, fat repositioning maintains its own blood supply and heals  more consistently because of its blood supply, but it does seem to retract or feel tethered. I can never seem to get the fat exactly where I like it. Using free fat graphs and allowing the body to recreate the circulation to that fat and is  more effective in my hands.

It appears that she will have some skin and a pinch blepharoplasty would not be a bad idea and possibly skin tightening procedure either with a TCA peel, or a CO2 laser.

I would get several other consultations for certified plastic surgeons to get the best recommendations possible.

Best wishes,

Earl Stephenson, Jr, MD, DDS, MBA
ESJ Aesthetics

Gary M. Horndeski, MD · Answer

I recommend fat repositioning.  Fat grafting can leave contour deformities.  The repositioning is permanent because gravity will hold it in place.

Best Wishes,

Gary Horndeski, M.D.

Mehryar (Ray) Taban, MD, FACS · Answer

The gold standard is lower blepharoplasty with repositioning of the eye fat bags, with rare exceptions. That's because the shifted fat bags still have blood supply intact and will predicably survive. Fat injection is much less predictable and should be reserved for certain patients. See an expert.

Would you recommend fat repositioning or fat removal with fat grafting for my lower blepharoplasty? (photo)

Answers (7)

Answer: Fat repositioning

Answer: Fat repositioning

Answer: Fat repositioning or fat removal with fat grafting for my lower blepharoplasty?

Answer: Fat repositioning or fat removal with fat grafting for my lower blepharoplasty?

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Would you recommend fat repositioning or fat removal with fat grafting for my lower blepharoplasty? (photo)

Answers (7)

Answer: Fat repositioning

Answer: Fat repositioning

Answer: Fat repositioning or fat removal with fat grafting for my lower blepharoplasty?

Answer: Fat repositioning or fat removal with fat grafting for my lower blepharoplasty?

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Recommended reading

Everything you need to know about Eyelid Surgery

Our mission is to create a world where every investment in modern beauty is Worth It.