Transconjunctival Blepharoplasty and Fat Grafting for Hollow Eye Area?

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.
Best wishes,
Dr. Bruno

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!

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.

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.

Dear Pepys
It is impossible to know your issue without a personal consultation.
However, in general it is always much safer for you to have lower eyelid surgery from behind the lower eyelid transconjunctivally. Then the fat is removed from the lower eyelid using a skin incision, the surgery uniformly damages the nerves that supply the lower eyelid muscle responsible for holding the lower eyelid firmly against the eye. Additionally the scar tissues that develop following this surgery plus any skin the doctor is tempted to remove risk causing the lower eyelid to be pulled during the healing process.
Transconjunctival surgery developed about twenty-five years ago was the answer. Except that we noticed that despite this better approach, as patients healed (an this was also true for transcutaneous lower eyelid surgery) the lower eyelid looked hollow because the fat was hiding the tear trough groove at the top of the cheek. To address this issue, it is now common at the time of tranconjunctival lower eyelid surgery to rotate a living pedicle of lower eyelid fat into the tear trough hollow. This procedure is called an arcus marginalis release. It is possible that this is what your surgeon was describing.
Performing lower eyelid surgery and then grafting free fat form a second site to compensate for the volume removed does not make a whole lot of sense.

It does not make any sense at all.
When we do transconjunctival blepharoplasty, it is usually done to remove the excess fat. Why would you take out fat and then immediately put it back in?
Regards

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

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 fat removal and redraping is certainly an acceptable surgical modality for your situation based upon what you wrote in your question.  External or internal approach is fine.

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.