Key points
- Under-eye fat repositioning is surgery that removes or moves bulging fat through the conjunctiva on the inside of the lower eyelid to soften the tear trough [1].
- It is mainly considered when the eyelid is not very lax and fat is bulging, or when there is little excess skin [2, 3].
- A review of 20 studies concluded that fat repositioning gives longer-lasting results but carries greater surgical risk than fillers [3].
- There are reports that recovery and risks can differ depending on the tissue layer where the fat is placed and how it is secured [3].
- The causes of under-eye aging differ from person to person, so the right method should be chosen after an accurate examination [4].
What is under-eye fat repositioning?
Under-eye fat repositioning treats under-eye fat through the transconjunctival approach, which uses an incision in the conjunctiva on the inside of the lower eyelid. Through this approach, bulging fat can be removed, or it can be moved to soften a tear trough deformity [1].
Where the focus used to be on taking out bulging fat, the thinking is described as having shifted toward preserving the shape and contour of the eyelid and cheek and keeping volume around the eyes [1]. The key to this surgery is moving the fat into hollow areas instead of discarding it, creating a smooth transition between the eyelid and the cheek [2]. Other reviews confirm this trend of moving fat to correct under-eye hollowness in addition to the traditional approach of trimming it [5].
Who is it considered for?
When the lower eyelid is barely lax and the fat around the eye is bulging, the transconjunctival approach is described as the first option to consider [2]. Other reviews also considered it suitable for patients with little excess skin [3], and noted that an approach through the skin is used when skin needs to be removed [5].
Bulging fat is not the only issue to look for in the lower eyelid. Sagging in the cheekbone area, tear trough deformity, forward-bulging fat (pseudoherniated fat), eyelid laxity, changes in skin texture, excess skin (dermatochalasis), and drooping pouches over the cheekbone (festoons) all need to be checked, and depending on the condition, other methods may be needed, such as an approach through the skin, an orbicularis sling, outer-corner fixation, skin removal, or skin resurfacing treatments [4].
Where the fat is placed and how it is secured
Studies differ on which layer the moved fat is placed in and how it is secured. According to a 2024 review of 20 studies, placing the fat on top of the membrane covering the bone (the supraperiosteal plane) allowed a faster operation; there was postoperative swelling and temporary contour irregularity, but the final cosmetic result did not differ from other layers [3].
Securing the fat from the inside (internal fixation) was found to reduce the risk of the fat moving back to its original position and of skin scarring, but it carries a risk that the fat may not settle exactly where intended [3].
These findings come from a narrative review, so they are hard to treat as evidence that rigorously compares the methods [3]. Which layer and fixation method to use is decided by the surgeon's judgment and the condition of your under-eye area.
How does it compare with fillers?
Besides surgery, hyaluronic acid filler is also used to correct the tear trough. The same review concluded that fat repositioning gives long-lasting results but carries greater surgical risk than fillers [3]. Fillers show results right away and are less invasive, but need to be repeated over time, and the review notes that using a blunt cannula can reduce the risk of blocking a blood vessel [3].
The authors concluded that both methods are effective: fat repositioning may suit people willing to undergo surgery for longer-lasting correction, while fillers may suit those who want a nonsurgical treatment with adjustable, shorter-term results [3]. Each has pros and cons, so the choice should match your own goals and condition [3].
Recovery and risks
Swelling and temporary contour irregularity can appear after surgery [3], so it is best to monitor your progress and follow your care team's instructions.
Reported risks to check include the moved fat returning to its original position, the fat settling somewhere other than expected, and skin scarring depending on the fixation method [3]. Because this is surgery, you should also keep in mind that it carries greater risk than fillers [3]. For lower eyelid surgery, it is stressed that anatomical knowledge, an accurate assessment before surgery, and careful technique determine the outcome [4].
What to ask during your consultation
The goal of lower eyelid surgery is described as making the under-eye area look younger while keeping a natural appearance that does not look operated on [4]. Under-eye aging is a combination of changes in the skin, fat, muscle, midface soft tissue, and tear trough, overlapping to a different degree in each person [6], so it is important to first identify the causes in your own under-eye area.
- Which is the main issue: bulging fat, hollowness, or sagging skin
- How much excess skin you have and how firm your lower eyelid is
- Whether fat will be removed, moved, or both
- The layer where the fat will be placed and how it will be secured
- How it differs from nonsurgical options such as fillers, plus recovery time and risks
Frequently asked questions
- Does under-eye fat repositioning involve a skin incision?
- The transconjunctival approach treats the fat through the conjunctiva on the inside of the lower eyelid [1]. However, there are reports that the risk of skin scarring can vary with the method used to secure the fat [3], and if there is a lot of sagging skin, an incision on the skin may be needed [5].
- Which is better, fillers or surgery?
- It is hard to say that either one is better for everyone. According to the review, fat repositioning lasts longer but carries greater surgical risk, while fillers work right away but need to be repeated at regular intervals [3]. It is best to discuss this with a specialist, taking into account how long you want results to last, how you feel about surgery, and the structure of your under-eye area.
References
- Davison SP, Iorio ML, Oh C. Transconjunctival lower lid blepharoplasty with and without fat repositioning. Clin Plast Surg. 2015.PubMed 25440740DOI
- Pack S, Quereshy FA, Altay MA, et al. Transconjunctival Lower Blepharoplasty. Atlas Oral Maxillofac Surg Clin North Am. 2016.PubMed 27499473DOI
- Christodoulou S, Tzamalis A, Tsinopoulos I, et al. Surgical and Non-Surgical Approach for Tear Trough Correction: Fat Repositioning Versus Hyaluronic Acid Fillers. J Pers Med. 2024.PubMed 39590588DOI
- Branham GH. Lower Eyelid Blepharoplasty. Facial Plast Surg Clin North Am. 2016.PubMed 27105798DOI
- Bhattacharjee K, Ghosh S, Ugradar S, et al. Lower eyelid blepharoplasty: An overview. Indian J Ophthalmol. 2020.PubMed 32971612DOI
- Jacono AA. Transcutaneous Blepharoplasty with Volume Preservation: Indications, Advantages, Technique, Contraindications, and Alternatives. Facial Plast Surg Clin North Am. 2021.PubMed 33906757DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
