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?

Pedro Literas, MD · Answer

Fat grafting to the lower eyelid and tear trough region can produce excellent, natural-looking results when performed conservatively and in the appropriate patient. However, your questions are very reasonable, as this area is one of the most technically demanding regions for fat transfer.Lumpiness and irregularities are uncommon in experienced hands but can occur, particularly when fat is placed too superficially, in excessive amounts, or as larger parcels. Mild irregularities can sometimes improve over time, while more significant issues may require steroid injections, needle release, camouflage with additional fat, or surgical revision.Regarding overcorrection, most experienced surgeons do not intentionally overfill the lower eyelid significantly. Fat survival is variable, and excessive initial volume increases the risk of prolonged fullness and contour irregularities. The goal is generally slight undercorrection rather than aggressive overcorrection.As for donor sites, there is no strong evidence that abdominal fat, flank fat, or thigh fat consistently produces superior long-term survival. Surgical technique, fat processing, and recipient-site characteristics are generally more important than the donor location itself.Finally, successful fat grafts are considered long-lasting and potentially permanent. Once transferred fat establishes a blood supply, those fat cells behave much like fat elsewhere in the body. While some volume loss occurs during the healing phase, the fat that survives beyond the first several months often remains for many years. Changes in weight, aging, and facial tissue descent can still alter the appearance over time, which may lead some patients to seek additional treatment years later.For patients with both prominent fat pads and orbital hollowing, lower blepharoplasty combined with conservative fat grafting can be a very effective approach when performed by an experienced oculoplastic or facial plastic surgeon.Pedro Literas, MD, FACSFacial Plastic Surgeon and Facial Rejuvenation Specialist

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

Julian De Silva, MD · Answer

Your caution is well placed, and you have clearly done your reading. For mild-to-moderate bags sitting above genuine hollowing, my preference is usually to reposition your own orbital fat down over the rim to fill the hollow, rather than remove the fat and then graft new fat back in. Repositioning uses the fat that is already there, so it avoids the unpredictability of graft survival you are worried about. Where fat transfer is used, lumpiness under the eyes is uncommon in experienced hands. If it does happen, it is usually from placing too much too superficially, or from using a technique not specifically refined for facial surgery. It is managed conservatively at first and, if needed, with small touch-up procedures. I have used fat transfer effectively in this area in my patients for more than ten years, and do not see lumpy results. Graft take is variable, which is exactly why conservative, layered placement matters. For your anatomy, a fat-repositioning lower blepharoplasty may give a smoother, more natural result than removal-plus-grafting. I would examine your lid tone and the true depth of the hollow in person before advising, and I would choose an oculoplastic or facial specialist who routinely repositions fat, not only removes it. Best of luck

Michael McCracken, MD · Answer

First of all, I think you are right in seeking out an oculoplastic surgeon for your eyelid surgery.  
If you have enough eyelid fat to move some of it down into the tear trough (fat repositioning) and you are worried about fat grafting under the eyes, you will likely benefit from fat repositioning under the eyes.  If this is the case, you don't need to worry about fat grafting under the eyes, which is obviously a concern to you.  
I perform some cases with fat repositioning and some with fat transfer under the eyes, and I don't see much difference in long term results.  However, if you would like to augment your cheek volume you will need to add fat transfer to the cheeks as there is not enough lower lid fat to reposition into the cheeks.  The good thing about fat transfer to the cheeks is that the cheek tissue is thicker than the eyelid tissue and therefore any small lumps are hidden.  
As with any othe procedure, surgical outcomes in both fat grafting and fat repositioning are technique dependent so it is important that you find a surgeon with a lot of experience in these techniques.

Under eye fat grafting - too risky?

Answers (6)

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