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.