Under eye fat grafting - too risky?

Question

I’m a woman and I’m in my 40s. I have mild to moderate under eye bags with significant orbital hollowing. I know that the current trend is to remove the eye pads and then do an under eye fat graft. I will only move forward with a reputable oculoplastic surgeon . However, the more I read about fat grafting, the more concerned I am about the risks. To the experts on here, could you please provide your opinion on the following: - How often does lumpiness occur under the eyes following fat grafting, and how is this corrected? - Considering that only around 70% of the fat will get a blood supply, is it a good idea to over-fill? What if 100% of it takes? - Is there any area of the body (e.g., abdomen, back) that is a better donor for the fat? - Is it true that fat grafting is not permanent and that most of it will be gone in 5-10 years?

Kenneth D. Steinsapir, MD · Answer

Yes I have colleagues who love fat grafting and push this method with lower eyelid surgery. They likely actually believe that in their hands it delivers superior results. Surgeons thinking they can deliver superior results when really don’t is a reoccuring theme. Much of my practice is devoted to fixing botched eyelid surgery. I see 3-4 new consults every week for issues caused by grafted fat. One reason surgeons like this surgery is that it can be 6 or more months after surgery before swelling resolves. During that time the swelling often makes the face look better. It gives surgeon plausible deniability if the eventual result is not everything that was hoped for. Your research on fat graft survival is not accurate. There is no such thing as 70% graft survival. Studies suggest that graft survival, irrespective of how grafted fat is processed, is about 30%. Because of the lack of predicability, prudent surgeons do not overfill. There is no practical means to remove excess grafted fat. The lower eyelid/cheek junction is layered and these delicate layers glide over each other so in youth and beyond smiling does not cause weird heaping of the upper cheek when we smile. Grafted fat damages these layers. The result is weird, thick heaped lines during the smile. There is no fix for this. A better option is transconjunctival arcus marginalis release surgery. Here your natural fat pads are released into the top of the cheek to address the under eye hollows. Because the lower eyelid fat is repositioned it no longer makes the eyelid bag. For many, I combine this with a transcutaneous midface lift to recruit cheek fat into the area of relative weakness under the eye. This addressed the lower eyelid issues without the irreversible scaring fat grafting causes.

A.J. Amadi, MD · Answer

Dear Thriving197622
Your statement that "the current trend is remove eye pads and do under eye fat graft" is not accurate. I would say that most Oculoplastic surgeons are using "fat repositioning" technique to repurpose the prolapsed fat to the hollow of the tear trough, rather than removing the fat and fat grafting. 
This is often the only technique necessary, as long as the excess eyelid fat is enough to fill in the volume loss.
In patients which have more hollowing in the tear trough than the repositioned fat can fix, my preferred method of adding volume to the tear trough is a tear tear trough silicone implant which is specifically designed for this area and is further customized to the patient's anatomy. The implant is permanent, much less likely to create contour irregularity, and does not resorb like fat grafting, nor migrate or cause swelling like filler. It is done at the same time as the fat repositioning and recovery is essentially the same. Virtual consultations are available as are before and after photos which can be shared at that time. See below for more information.

Dallas Buchanan, MD · Answer

Thank you for your great questions. Let me try to give a quick rundown of your questions. Lumpiness occurs in 100% of fat grafting cases early on but usually subsides within 3-6 months postop. Long term lumpiness is rare, I would estimate less than 5%. There is no assurance out there that "70% of the fat will get blood supply" as this depends on the fat, the surgeon, and the patient. Some people get 20%, some people get 50%, some people get 100%. The thing about fat is not that it is dangerous but that it is unpredictable. Because of that, I rarely if ever overcorrect. I would much rather go back and add more than figure out how to remove too much (translation - this is not easy). You can get donor fat from anywhere. For females I prefer lower abdomen or lateral hips. And for your last question, that is absolutely not true. The fat that is transferred that survives the transfer (see above about unpredictability) will become a permanent part of your body and will be with you forever. However, will natural aging and time, we lose facial fat and it can be due to natural aging or from weight loss that it can appear that the grafted fat is going away, but so does the natural fat in the face. It is likely due to aging rather than the fat "going away." A good surgical result should last you 10-15 years. And one last thing - there are plenty of surgeons out there who are excellent at peri-orbital surgery who are not "reputable oculoplastic surgeons." Wink wink. 
Hope this helps!
Dallas Buchanan, MD
VIVIFY plastic surgery
Tampa, FL

Under eye fat grafting - too risky?

Answers (3)

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