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.

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. 

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.    

Removing fat, redistributing fat, tissue fillers (to hide the fat), as well as fat grafting are all viable techniqes to address lower eyelid bags.  Sometimes removing excess skin along with a lateral canthopexy may also be needed depending on what your issues are.  Every case is different because every patient is different so there is no standard or "best" approach.  The trend in the past decade has been to be less aggressive fat removal as it can produce a more "hollowed out" look that can be difficult to correct years later.  If you do have a lot of fat, it's reasonable and a good idea to remove some, either as a stand alone procedure or in my experience, combining it with another procedure to smoothen your lower eyelid- cheek junction by doing tissue fillers or fat grafting (so you don't have to remove as much fat or try to do it all with fat removal which can result in that hollowed out look).  Adding fat grafts or tissue fillers to the tear troughs/ lower eyelid grooves and upper cheeks can give you a more complete rejuvenated look as it's often times your midface sagging that accentuates or is the cause of your lower eyelid bags/ dark circles.  Whichever technique a surgeon recommends is the one he/ she is comfortable with or has experience with.  While there are risks for tissue fillers and fat transfers to the lower eyelids, there are also risks for removal of fat.  One has to choose the procedure that offers the best results with the risks the patient (and surgeon) is willing to take.  Look at each surgeon's body of work (lots of patient before and after pics, reviews, patient recommendations), complication rates and philosophy, and choose the one who you feel comfortable with.  I feel it's always best to choose someone who has a lot of experience with all the above so that he will be well versed in all the techniques and really be able to know which option is best for you.  Best wishes.

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 

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

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.