What should be done for the lower bags and darkness? Relocation, removal and fat transfer? (photos)

I've really tried to do my homework on the procedures and all it has done is confuse me and scare me. I've seen 3 surgeons that have good reviews and they all said I should do different things. According to what I have read off of this website I should do what is best for best for my face anatomy. Looking at my photos should I do fat transfer with removal of fat pads or should I do fat relocating? And why? Which one will have the best results? Please help!!

Doctor Answers 5

Why fat transfers under the eyes are not advised, and performing lower eyelid surgery performed in context with the whole face

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I've also personally answered your question on YouTube under the title "The Best Treatment for Eye Bags, and Why Fat Transfer Under Eyes is Not Advised".

I’ve been in practice for 20 years and I am a specialist in oculofacial plastic surgery, doing a lot of eyelids and facelifts. Facial aging is something that I spend a lot of time on, and I focus on helping people understand the elements of the facial aging process, and how well a particular plan impacts it.

From your photos, you clearly demonstrate lower eyelid fat prolapse, but I point out to my patients who come in for eyelid consultation to also look at the adjacent area called the eyelid-cheek junction, as well as the area of the cheek called the submalar area. When you have bags under your eyes, it is often the dominant feature and it really affects the overall appearance of your face. When people have an eyelid procedure to address the fat pockets, they sometimes think that they look hollow or sad. This is because the adjacent areas of the face have also aged and because they weren’t dominant, the focus was not there.

As a specialist, I can tell you that in my experience, fat transfer to the lower eyelids is not advisable. I see patients from all over the world who have had fat transfer and they end up with irregularities and lumps. They try to build up and restore the fat that’s been lost and then try to camouflage the fat pockets. However, there are several defects in that idea. The fat that is under the eye has prolapsed forward like a hernia, so as herniated fat it has to be addressed in some way to restore it in its proper position. MRI studies have shown that people with fat prolapse actually have more fat, meaning they have an enlargement or an increase of fat. Thus, it’s justifiable to do procedures to reduce or remove the fat.

Moving fat from the orbit or the space may make sense, but a lot of people who get fat transposition will not have a good result. They will actually have chronic swelling in the eyelid-cheek junction. In my practice, I do some fat transposition but with the majority of the patients I do fat reduction because it is logical to reduce fat that is herniated past the rim and to get that type of contour. Concerns about hollowing and things like that are always addressed. Because cosmetic surgery is an art, doctors will have different opinions on how to do the procedures. Every doctor comes to the table with their aesthetic sense, their experience and technical abilities. When it comes to medical care and surgical care, it is really more of a gestalt of how you feel in terms of your comfort level with the doctor and their style that’s demonstrated by looking at before and after results. At the end, it’s always about trust and comfort.

As far as resection versus transposition, I think a lot of very good surgeons do a combination depending on what they see or whatever is appropriate for the patient. Cosmetic surgery is ideally about customization. Some doctors like to do things a certain way and they’ll always do it the same way. Very often, those are the doctors that get themselves in trouble because a certain percentage of patients don’t have an anticipated or ideal outcome.

I think meeting with doctors who have a lot of experience with eyelid surgery, particularly as a specialty, will probably help you make that decision. I think at this point, you are someone who has a little bit of information overload and you just don’t know what to do. You should understand that it’s your decision to find the doctor that resonates with you. I hope that was helpful, I wish you the best of luck, and thank you for your question.

New York Oculoplastic Surgeon
4.4 out of 5 stars 80 reviews

Improving eye bags and sags

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I have heard that story quite alot, about getting multiple treatment options  and being left confused.  That is partly the art of medicine and partly that there truly are many options that would successfully achieve your goals.  I tend to be more conservative and prefer the least amount of surgery to get the the best and most lasting and natural results.  I do quite a lot of consults for patient who look like you and would suggest an upper and lower lid laser blepharoplasty.  That is where a laser is used instead of a scalpel to cut, which results in much less bruising and swelling and less downtime. My partner and I prefer the laser to the scalpel for these reasons and it compliments our more conservative approach. The extra (carefully measured) skin is gently trimmed off from the upper lids and the extra/herniated fat is trimmed from the inside of the lower lid.  I trim most of the fat pad but not all, so risk of hollowing is minimized.  In addition, hyaluronic acid filler is very safe and may be easily used to prevent hollowing or a tear trough groove.  While some surgeons are quite skilled at fat transfer to the face and argue differently, I have seen more risks and complications from it over the years, and prefer the new, safe hyaluronic acid fillers to fat to treat hollowing.  In the end, each physician will have their comforts and preferences based on their experience.  Good luck with your choice.

Karen Stolman, MD
Sandy Dermatologic Surgeon

Treatment of lower eyelid bags and darkness

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There is no single best treatment for lower eyelid bags and darkness.  Options range from a topical product known as Neotensil (it does not have any permanent effects) to injectable fillers to various approaches to surgery.  If surgery is the way you prefer to go, I would find a surgeon with a good reputation whom you trust and feel comfortable with.  Aesthetic surgery is both an art and a science; what works well for 1 surgeon may not work as well for another and vice versa.  I agree that you should be treated by a surgeon who performs a large volume of eyelid surgery and has specialized training in this area.  You should also ask the surgeons about the risks of the procedures they recommend.  Good luck!

Brian Biesman, MD
Nashville Oculoplastic Surgeon
4.8 out of 5 stars 43 reviews

Blepharoplasty with arcus release,fat removal and fat grafting may be your best option

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Fat removal is needed to lessen the fullness of the bags beneath your lower eyelids.  However the deep depression beneath the eye bags requires an arcus marginalis release and fat grafting or fat transfer to plump this depression and redrape the eyelid skin.

This is a very straightforward, modern and advanced approach.  Please consult a board certified plastic surgeon who is very experienced in eyelid surgery and utilizes modern techniques.

For more information on eyelid surgery please read the following link:

Lower eyelid fat

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The procedure that is right for you depends on what you want.  From the looks of your pictures, the lower eyelid bags could be camoflagued with filler as a first step if surgery is not something you want at the time.
Fat repositioning is my preferred option for patients with prominent lower eyelid fat bags and tear troughs.  Removal, especially in patients without high cheek bones, will contribute to a hollow, aged appearance with time and is something I try to avoid.
Hope this helps,

Jason J. Hall, MD, FACS
Knoxville Plastic Surgeon
5.0 out of 5 stars 12 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.