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

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.

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.

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