Transconjuctival Blepharoplasty and Fat Grafting
Transconjuctival Blepharoplasty and Fat Grafting together for lower lids can be a great plan. Fat grafting should not be an afterthought with surgery, but should in fact be part of under eye rejuvenation. Please look at my gallery for examples
The treatment of your lower eyelids depends on the anatomic abnormality. Often times patients will describe "bags" under their eyes, which can be many different things. The fat may be removed very conservatively, but what may be more critical, is to reposition the fat so as to regain a smooth lower eyelid to cheek transition. A photo would be very helpful to help diagnose your condition and render a reasonable treatment plan.
This area of the face is very unforgiving, and I recommend consulting with a board certified plastic surgeon with experience in this area prior to scheduling any procedures.
Transconjunctival blepharoplasty with immediate composite fat grafting is your best option
Your surgeon is correct. The transconjunctival blepharoplasty avoids a visible blepharoplasty incision and more importantly preserves eyelid shape. Traditional external incision blepharoplasty can injure the support of the lower eyelid and result in a sad eyed look or hound dog eyes.
I prefer open composite fat grafting to fat injection. During the transconjunctival blepharoplasty I graft the excess fat that has been removed into the lower area beneath the lower eyelid to plump the dark circle and rejuvenate the upper cheek-eyelid area.
This is easily done during the surgery. In my experience, the composite graft survives well, does not require repeated injections, and is less likely to create visible lumps as often happens with fat injection.
Transconjunctival blepharoplasty and fat injection to lower eyelids
This solution may not be as silly as it sounds on first blush.
The bulge of fat is due to a bulge in the infraorbital fat behind the orbital septum. Transconjunctival blepharoplasty removes the fat, causing it to bulge less.
The hollowness most patients complain of is lower than the infraorbital fat bulge. There are two basic solutions to this problem:
1. Take the existing fat and redistribute it. This requires dividing the orbital septum at the arcus marginalis, a maneuver that can predispose to pulling down of the lower eyelid. This can be done through an incision in the lower eyelid and also through a transconjunctival incision.
2. Take the fat out of the transconjunctival sac and then put in separately a graft into the hollow area below the eye
Of the two, I have come full circle and no longer do fat repositioning. The grafts tend to clump and retract to where they had been previously. Often, the lower eyelid bulge returns. I think this is due to the fat still being attached to the lower eyelid fat pocket. If the fat is detached in order to avoid this problem, it becomes no different than a separately placed graft. Plus the arcus marginalis layer has been violated, predisposing in my opinion to the potential of scar formation. The most quoted series in the literature is only 24 patients, far too low to be confident of the safety of dividing the arcus marginalis method, in my opinion. I have seen plenty of unhappy repositioning patients where they did get alteration in eye shape (usually drooping, usually subtle but nonetheless there).
So we are back to square one, as they say.
I prefer to reduce transconjunctival fat and then place separate grafts, but not fat injection, where the grafts are largely traumatized, but untraumatized fat fascial grafts (LiveFill (R), almost always in combination with an ultrashort incision cheeklift (USIC). This elevates cheek volume.
Even with these 3 measures, patients must expect conservative results. That's how tricky the under eye area is if you don't want to subject the patient to great risk of lower eyelid eye shape change.
Just my opinion.
Fat Grafting vs. Repositioning in Lower Eyelid Surgery
Thank you for the question. This area is the subject of intense debate in the plastic surgery community over the past few years. The lower eyelid bags are related to the forward movement of the fat that cushions the eye. This is accentuated by fat loss and sagging in the cheek tissues. In many younger patients, conservative reduction of the fat bags is enough to soften the lower eyelid appearance. Unfortunately, this can lead to a hollow appearance or make the tear trough area look worse. Some surgeons treat this issue by placement of fat grafts (generally borrowed from the abdomen). In my practice, I often perform an operation for the lower eyelids that takes care of both of these issues at the same time. This is an extended lower eyelid lift with fat transposition. This operation uses the fat bags that are already present to fill in the tear trough area. If extra skin is present, this can be trimmed as well. If not, the incisions can be made inside the eyelid (transconjunctival). In a very small number of cases, I will add additional fat grafts from elsewhere. This is typically only in patients who are very thin or have had their lower eyelid fat removed in a prior operation. Best of luck moving forward!
Transconjunctival approach is the best approach for fat removal.
A transconjunctival blepharoplasty is the best way to remove orbital fat that is creating a bulge in the lower lid. Fat transfer into the sunken area also works quite well and can be performed better through a transconjunctival approach. It is not a good idea to have the external approach because the muscle is transected, becomes weaker and can pull down changing the shape of the eye, giving some scleral show.
Transconjunctival Blepharoplasty with fat grafting can be an excellent procedure
The bulge of excess fat creating the "bag" under the eye is reduced nicely by transconjunctival resection. If there is not a lot of excess skin, then there is no reason to perform an external incision and incur the slight increase in risk. Along with the fatty bulge, people often have a crease or "tear trough" under the eye along the bone, and placing harvested fat in this crease can fill it and create a very smooth line from the eyelid to the cheek when combined with transconjunctival fat resection. This smooth transition is noticeable sign of youthfulness. Good luck.
Reasonable approach for hollow eye area
It seems very reasonable based on your description to decrease the excess fat that causes bulging of the lower lid. This can be approached either from inside the eyelid of through an incision on the outside. Most skilled, experienced Plastic Surgeons would be comfortable with both approaches.
An adjuvant to the procedure would be utilization of the removed fat to help fill in the tear trough (nasojugal fold) or the deep fold that sits below the bulge. This can be done via a variety of different methods and most surgeons have their own preference.
Spend time speaking with your surgeon. If what your surgeon tells you makes sense to you and you have established a good rapport, then it sounds like a worthwhile patient-physician relationship, which by the way is one of the keys for success in Plastic Surgery.
Need pictures to determine for sure
It is always better to avoid external incisions when possible. I have been doing the transconjunctival procedure for 25 years and prefer it to other approaches. Usually conservative removal of fat is performed so it is rare to add fat in this situation. If a hollow trough is present below the prolapsed fat it is preferable to transpose or move the fat into the deformity rather than removing it.
Your question is not specific enough to render a recommendation. Sunken eye, hollow eye, and bags are not anatomical terminology. They are descriptive. A surgeon would have to determine what the hollowness is due to, why an eye looks sunken, and what makes the bag. There are variations in bone, muscle, fat that make all of our eyes different. A bag can be caused by excess fat, loose skin, reactive edema, underdeveloped orbital bone, pigmentation, etc. What makes sense surgical is dependent on the specific anatomical situation as well as what you want to look like as a post-op result. I suspect that you have bags of the lower lid that may or may not due on part or wholly to either excess fat or loose membreane/muscle, as well as a hollowness below the bag that can be due to soft tissue thinning or sagging or underdeveloped orbital bone or any combination. In addition, there are many possible approached to the same anatomical situation and you and your surgeon need to come to terms with the risk and benefit of each possible approach to determine which is most appropriate.