Why are some surgeons still against fat-pad repositioning as part of lower blepharoplasty?

They are stuck in the past. They were trained a certain way and never evolve. That training may have been at an Ivy League university but it does not matter. They are basically doing what they were trained to do by their fellowship preceptor. Yes, fat transposition is more work and can be associated with post-surgery inflammation. However at the end of the day, people need volume in their under eye area. I have patients who 20 years after their arcus marginalis release surgery in their under eye and still do not need fillers. Don't expect this surgeon to modernize. Find a surgeon who offers the approach you are interested in, Stick to your guns and don't be gas lighted by a surgeon stuck in the past.

This technique was first described and implemented approximately 25 years ago. One would think that if results were spectacular, everybody who performs lower blepharoplasty would be utilizing this technique. Personally, it does not make sense to me to move orbital fat into an area that it normally does not belong. I hope this helps! Sincerely, Dr. Joseph

Some surgeons prefer to do fat grafting while others prefer fat repositioning or doing nothing. The concern with fat repositioning is that the fat wants to go back and relapse. I have some friends who are great at fat repositioning and get great results. I prefer to perform fat grafting using fat harvested from the abdomen or thighs. I feel that I have much better control of where I place the fat and there is no relapse possible but there is some fat resorption over time. I believe that creating a youthful convexity is important to obtain the best results.

Sometimes, all it takes is one patient with a bad outcome to “scare” a surgeon away from trying certain techniques. There is no body of evidence for MOST things in plastic surgery because studies are not well funded for cosmetic medicine, study sizes are small since they are often single surgeon, and results are often subjective.

My advice is to either decide you appreciate this surgeon’s aesthetic (based on before and after photos) or find another surgeon. ENT and plastic surgeons can be just as qualified as oculoplastics to perform these procedures.

It is always individual decision. Most surgeons using transconjuctival approach will combine resection of the excessive fat pads and transposition of the small flaps over the orbital rim to provide some augmentation of cheek/lid junction. We use fat grafts for patient who need it rather than HA filler. Combination of specific procedures is individual choice which depends of the patients needs but also, surgeon’s preferences. Hope this helps.

There are lots of ideas that seem to make sense and then when you personally do them you don't get the results you want. Fat repositioning can work nicely. But, depending upon how much fat you have and how deep are the grooves you need to fill there may not be a good match. If you have less eye fat than you need to fill the groove the results will be disappointing. Your surgeon may have decided that in his experience he too often has too little fat for the change he wants to provide so he stopped doing it. Or, he may not have learned how to do it. Who knows? But, he likely has a plan which works well for his patients.
I do both (repositioning and filler) depending upon the needs of the individual.

Fatpad repositioning sounds like a great idea, but in reality it doesn't work very well, since the fat pads themselves are not strong enough to hold the stitches in place to keep the fat in the new position. The fat ends up retracting back into where it started, and therefore has a high revision blepharoplasty rate. In our practice, we will occasionally do a fat repositioning/grafting on the upper lids when the the upper eyelids are very hollow.

I would imagine this well-trained surgeon has a history of practice preforming lower lids and trying different techniques. Likely the results he gets by fat excision and HA filler avoids some complications that he dislikes (and can be costly to fix) and overall provides an equal if not better result in his hands. Every surgeon will go through trying new techniques that have theoretical benefits, however in the end, unless it proves superior in their practice he or she will not adopt it. That's the Art of Surgery.All the evidence in the world does not compare to 2 or 3 poor outcomes for a single surgeon.If you are seeking a particular technique for your lower lids, I would suggest you get a second opinion.

There are three separate fat pads in the lower eyelid.
They are deep to the lower eyelid and deep to the Periorbital septum.
The volume deficit that needs to be corrected in individuals who have a tear trough, deformity or lack of volume in their upper mid face is pretty far from the origin of the fat pad.
The fat pad also isn’t like a yo-yo attached to a string that can be wheeled around and placed anywhere you want.
The fat pad is usually short and repositioning. It generally requires putting tension on the fat pad in order for it to be in the correct position.
It is not at all accurate or predictable.
I would say repositioning fat pads is not standard of care, but some providers seem to get good results.
Doing this maneuver will inevitably lead to hire revision rates.
Volume deficits below. The lower eyelid is a complex problem that is difficult to treat.
Repositioning other fat pads is one option that some providers find useful.
There’s a reason it is not standard of care.
Your oculoplastic surgeons approach seems legit, and is what most providers would probably recommend.
It is my preferred method as well.
Best,
Mats Hagstrom, MD