Lower bleph (with or without fat transfer) or fat grafting injections? (Photos)

Please help me decide, as 3 different surgeons suggested 3 different solutions for my eye bags that I've had for the most of my adult life and they're getting worse. With the upper bleph, which I will do, should I do a lower bleph with or without fat transfer, or should I go for fat grafting injections? Thank you so much!

Doctor Answers 12

​I think there are two problems of your lower eyelids.

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I think there are two problems of your lower eyelids. 

First of all the baggy appearance that you called eye bags. Second, your lower eyelid height (vertical length) is too tall. The first one is cause by protrusion of the fat bags (orbital fat). 

The fat is naturally inside a tissue bag called the orbital septum, during the aging process the bag gets loose and the fat inside can look protruded from the outside. 

This first problem needs to be corrected by lower blepharoplasty. In my clinic we use a method called septal reset, which focuses on the tighting of the tissue bag itself. 

The second problem is also the result of aging and is caused by the descent of malar fat pads. 

Youthful lower eyelids have a much shorter vertical height because the fat pads are located more superiorly. So some doctors might recommend fat transfer or injection to put some fat tissue where the original fat pad was lying. 

We, on the other hand, sometimes use this method but also consider a midface lift. This procedure directly relocates the inferiorly displaced malar fat pads to a more superior (youthful) place. The conclusion is we recommend you have a lower blepharoplasty with a midface lift (this can be done by the same incision). 

Thank you,

South Korea Plastic Surgeon

Lower Bleph

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You have puffiness.  If the fat is not removed/repositioned, I don't think it will accomplish what you want.  I would definitely not recommend fat grafting as the addition of fat will make this look overfilled and puffy.  Not what you are hoping to achieve, I'm sure.  While fat addition may improve the shadowing, it won't do what you want.

John Bitner, MD
Salt Lake City Facial Plastic Surgeon
4.9 out of 5 stars 92 reviews

Lower bleph (with or without fat transfer) or fat grafting injections?

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The best method for treating under eye fat bags is transconjunctival lower blepharoplasty with fat repositioning which is long lasting and gives smooth natural under eye appearance. Best to see an oculoplastic surgeon for evaluation. See following video and link too.  Other options include fat or filler injection but with variable pros/cons. 

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 91 reviews

Lower bleph indications

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Thanks for sharing your question. I can appreciate your concern.

If the lower eyelid bags are of your concern, then surgery should provide the best outcome. You have moderate fat pad excess, a prominent arcus marginalis, and minimal skin excess. 

Injections alone would not correct the problems and may worsen the current condition.

Finally, make sure that you have a consultation with a board certified plastic surgeon.

Wishing you the best in your journey

Upper and lower eyelid surgery candidate

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From the limited photographs, it appears that there is excess skin and fat on the upper lids, mild ptosis, and herniated fat pads in the lower lids with scleral show. A very conservative upper eyelid blepharoplasty can accomplish removing the extra skin and fat in that location. And in-person examination is required to determine ptosis. The fatty deposits in the lower lids can be removed  conservatively with a trans conjunctival approach with the incision placed on the inside of the lower lid, which has been the gold standard in our practice for over 25 years. For more information  and many examples, please see link and the video below

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

Lower lid bag removal or reposition

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I recommend you lay flat on your back and look in a mirror. If you like what you see, then have the fat pockets removed. If it looks a bit hollow or you see a tear trough you don't like, then have some sort of fat reposition or grafting.

Daniel Lensink, MD
Redding Oculoplastic Surgeon
5.0 out of 5 stars 4 reviews


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I would be very cautious with a lower lid procedure for you. You have some lower lid retraction already and any lower lid procedure can worsen this. A transconjunctival incision (inside the eyelid) is probably the best approach for you. No skin or muscle removal!!! The amount of orbital fat protruding and causing your lower eyelid bags is not quite enough to adequately fill the lid/cheek junction (tear trough). The additional fill you need can be achieved with a fat transfer or fillers. 

Bradford A. Bader, MD
Plano Facial Plastic Surgeon
5.0 out of 5 stars 9 reviews

Lower bleph

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Injecting filler of any kind into the lower lid is difficult and often results in unattractive results. Fat injections are the worst because they are almost impossible to correct if you don't like them. At least with filler, you can dissolve it if you find the results not to your liking. But you have bulging fat pads in the lower lids that most patients find unattractive and transferring that fat into the dark tear trough generally results in a dramatic improvement with a youthful appearance. Just be sure you choose your surgeon with care for her/his experience. BTW, it appears you have some degree of ptosis of the upper lids and a standard blepharoplasty may not be the correct procedure so when interviewing your plastic surgeon make sure he/she understands how to correct that issue also. 

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 29 reviews

Lower bleph

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You do not have a lot of fat prolapse here.  Your lid can be easily improved with some HA filler into the tear trough.  YOu have some ptosis of the upper lids which can be helped with a ptosis repair surgery.  See an oculoplastic surgeon to evaluate the eyelid  muscle function and decide what surgery would be best for you 

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

It is improbable that you will be happy with fat grafting for this area.

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No one should diagnose your lower eyelid without physically putting their hands on your face to examine the lower eyelids to determine what makes your lower eyelid configuration.  Less is more with lower eyelids.  Do not let a surgeon cut the lower eyelid from the outside which will weaken the motor function of the lower eyelid. You really do not have significant herniated lower eyelid fat.  I might recommend a chemical peel and lower eyelid filler as an alternative to surgeries that have a significant risk of complications.  You also have significant upper eyelid ptosis with a compensatory brow elevation.  Consider additional consultations if you do not have a solid feeling for the surgeons you have seen.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

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.