Total fat removal, fat trim w/ reposition, reposition only or removal and fat replacement - which lower bleph technique is best?

Those are a lot of options but you left out one: Fat repositioning with fat grafting.

You want to go to someone who feels comfortable with all of the above; that way you will get the approach that best fits you.

I most commonly perform fat repositioning and fat repositioning with fat grafting.

Fat removal with fat grafting is less common; I typically perform this in cases where either there’s not enough to fat reposition which is fairly uncommon with an experienced Oculoplastic surgeon who loves to reposition, or only in cases where the fat is not amenable to repositioning because of it’s consistency for example in a Thyroid Eye Disease patient. This option is also less optimal because now you’re relying only on fat grafting for volume augmentation and it’s not as predictable as fat repositioning. I typically see fat grafting as an adjunctive procedure here. I’ve been teaching other surgeons and performing fat grafting for many years and I can tell you less is more.

Fat removal only has a higher risk, of causing hollowness and unhappy patients.

Partial fat excision with repositioning is extremely subjective and it’s not common to have “too much” fat to reposition. Again typically I will recommend repositioning with the option for fat grafting because the fat bags themselves are not enough volume to give the best result.

If you has 5 different surgeons, you might get five different answers. Surgeon training may be a major reason for surgeon preference. If they were trained one way, that's the way they will be best at.

For reference, I used to remove fat and then add fat. I've since evolved my technique so that I will do fat repositioning primarily with individual variation (trim, additional fat grafting).

Unfortunately, you have not provided photographs or told us your age. Routinely, I perform fat transfer by repositioning it. The fat will often create a hollow on aged appearance. We would not remove fat and then replace fat as that would not make sense. I would need photographs to give you a more accurate answer.

Best Wishes,

Gary Horndeski, M.D.

If your problem is congenital bulging of fat pads in your under eyes, and if you have good lower eyelid tone without much lower eyelid wrinkling, depending on your examination, a transconjunctival lower eyelid blepharoplasty maybe a reasonable approach. Please consider we asking you a question with photographs. I hope this helps. Sincerely, Dr Joseph

We know that total removal of fat tends to lead to hollowing and an aged or unnatural appearance long term. It is true that fat injections and fat repositioning can be challenging to predict exactly. Typically there is some combination of removal and repositioning that is best.
It is very hard to answer this question well without photos.

Hello and thank you for your question. A formal evaluation would be needed to determine the best treatment. There are both surgical and non-surgical options to correct the lower eyelids, depending on the specific situation.

For less significant puffiness and sagging UNDER the eyes, or more mild improvement, there are nonsurgical treatment options: we often use Renuvion helium plasma radiofrequency (RF) energy to achieve incredible results and take years off of your appearance. Combining RF energy and cool helium plasma, the signs of aging (wrinkles, pigmentation, skin laxity) are improved in a ‘Nonsurgical Lower Eyelid Lift.' The focused heating tightens and peels the outer skin layer with extreme precision, leaving the surrounding area undamaged, smoothing and tightening the periorbital skin, and improving the overall skin quality around the eyes. It's an aggressive treatment, and the recovery time is longer than with other nonsurgical procedures, but the results can be life-changing.​

Surgery (a lower blepharoplasty with or without canthopexy/canthoplasty or orbicularis muscle suspension) is a great option for more significant improvement- for example if there are more severe lower eyelid bags / bulging present. Sometimes the surgery can also be used to intentionally adjust the shape and/or size of your eyes, or correct any asymmetries!

Dr. Donald Groves is an expert facial plastic surgeon that I work with, who specializes in these types of procedures. It is important that if you are considering surgery that you go to someone who is well trained and very experienced with these delicate operations to get the best results. I suggest getting a consultation with an experienced cosmetic dermatologist and facial sculpting expert, or an aesthetic facial plastic surgeon like Dr. Groves; we are both located right here in Los Angeles.

Best,
Dr. Emer

It's important that you post a full set of eyelid pictures, including your midface to understand what bothers you, and what your current anatomy looks like. In our practice, we do not do fat replacement or repositioning on the lower lids. Occasionally will do a fat repositioning on the upper lids when necessary. We remove the puffy fat bags on the lower lids through a trans-conjunctival approach. If there's skin, then consider a pinch technique to remove skin, but those are usually on patients over 50 years of age

This is a highly complex area that is inherently challenging to assess and treat.
There are often two volume changes that happen immediately adjacent to each other in typical facial aging.
I typically differentiate if bulging of the lower eyelid fat pads is the primary problem or if it’s secondary in relationship to loss of upper midface volume or tear trough volume loss,
Equality assessment should determine which of the two is more important and how they should be treated.
Each plastic surgeon will have their own experience and skill set that they will rely upon.
What the surgeon said during your consultation has been consistent with my experience.
For most patients who need both treatments, I generally steer towards a trans conjunctival lower eyelid, blepharoplasty with volume restoration using fillers.
Best,
Mats Hagstrom MD