Lower blepharoplasty: remove the fat or simply redistribute it? (Photo)

Redistributing the under eye fat bags is definitely better than just removing it so to avoid sunken hollow eyes after. And that is best done using transconjuntival approach.

There is no absolutely correct answer, and final decisions on whether to remove fat or just redistribute really depends on findings at surgery.  You have a relatively flat cheekbone and would certainly benefit from fat grafting in that area.  You should absolutely have the partition between cheek and orbital fat opened (arcus marginalis release) which will help smooth the area out.  You should get a nice improvement.  The lowest risk of eyelid malposition is through a transconjuctival approach

You have some moderate fat, more on the left side in this photo.  There are some surgeons who only remove fat.  This can produce an excellent result, but may also cause some hollowing of the lower lid with more of a dark circle than before. Many surgeons now will try to preserve the fat and move it down into the tear trough to create a smooth contour between the cheek and lower lid. If you have a lot of fat, some may also be excised.  Remember that all surgeries can have complications, so just doing a fat reposition does not guarantee an excellent result. Look at some before and after pictures to make sure you like the surgeon's work.If you don't want surgery, some filler into the tear trough will help to smooth out the area so the fat is not as obvious.  The HA filler in this area can often last 1.5 - 2 years.    

Thanks for the question.  Since it appears you have a significant amount of fat, you may need some removed, while some you reposition.  I typically reposition the nasal most fat pad and remove the central and lateral ones, being careful to remove only the fat that is in excess.  Good luck!

Though an in person consultation is always ideal, based on the photo you posted, I would recommend fat repositioning rather than excision. Volume preservation is an important feature of the modern facial rejuvenation paradigm. Sometimes, some eyelid fat may need to be removed. In your cases however, I believe that repositioning will work well and preserves volume. 

Great question. There seems to be a movement away from aggressive fat removal and towards fat redistribution in plastic surgery. The reason is the fat serves as a natural filler and can be used effectively to smooth the transition between the lower eyelid and cheek. 
A full, detailed exam of a patient's anatomy is needed to know which approach would be best. I have performed both aggressive fat removal alone as well as repositioning with conservative fat removal. The approach is based on the anatomy as well as the patient's desires. I believe reasonable results can be obtained with both approaches. 
Best wishes, 
Rohit Jaiswal, MD 
Plastic Surgeon; Las Vegas, NV 

Hello and thank you for your question.  The
best advice you can receive is from an in-person consultation.  Based on
your photographs, you may benefit from a lower eyelid blepharoplasty with septal reset.  This decision should
be based on a detailed discussion with equal input from both you
and your surgeon.   Make sure you specifically look
at before and after pictures of real patients who have had this surgery
performed by your surgeon and evaluate their results.   The most
important aspect is to find a surgeon you are comfortable with. I recommend
that you seek consultation with a qualified board-certified plastic surgeon who
can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.  FACS
Harvard-trained plastic surgeon

This is an excellent question! I think that fat is a valuable resource and can’t fathom why anyone would want to throw away something so valuable! Re-distributing the fat is a little bit more work, but the results are so much better.

'Never' and 'Always' are not helpful words, as they are used to convince you that any alternative approach is wrong.  Many patients with prominent fat pads who are under 40 yrs benefit from fat pad removal, and you should include a discussion of fat grafting to your upper cheek to improve the volume deficit here.  Fat grafts can be permanent and will spare you years of repeated filler injections.  Fat redistribution (moving the extra orbital fat into your hollow area) is appealing in its 'efficiency', but stretching out the existing fat really limits how much and where you put the fat and limits what you can accomplish relative to grafting.  Please also ask your surgeon to asses your left upper lid for ptosis.

If you consult with 5 surgeons regarding under-eye rejuvenation you will likely get 3-5 different opinions.  I'd be wary of someone saying you need to do something a certain way.  An experienced cosmetic eyelid surgeon will have a philosophy about their practices but will also be able to modify their approach to meet your needs.  In your situation you're likely to get good results with either transconjunctival fat pad reduction (conservatively), transconjunctival fat repositioning (with some reduction), or transconjunctival fat pad reduction with fat grafting.  SOOF lifting is less common and won't directly address your prominent fat pads. I would typically recommend you see a cosmetic oculoplastic surgeon and ask to look at photographic examples of similar patients they have helped; perhaps ask to speak to a previous patient.