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Lower Eyelid Blepharoplasty: Comparing Fat Removal, Fat Repositioning, and Fat Transfer

Lower eyelid blepharoplasty remains one of the most technically challenging procedures in facial rejuvenation. While upper eyelid surgery primarily addresses excess skin, lower eyelid surgery focuses on the delicate balance between volume, contour, and support. The primary anatomic concern is the protrusion of orbital fat—often perceived as “bags under the eyes”—combined with skin laxity, lid malposition, and midface deflation. 

Over the last two decades, three main surgical philosophies have emerged for addressing lower eyelid aging:

  1. Fat removal (traditional blepharoplasty)

  2. Fat repositioning (septal reset or arcus marginalis release)

  3. Fat transfer (autologous microfat or nanofat grafting)

 

Each approach has unique advantages, limitations, and aesthetic implications. Selecting the correct technique depends on the patient’s anatomy, degree of fat prolapse, skin tone, and goals for rejuvenation.

 

Fat Removal (Traditional Lower Blepharoplasty)

Overview

The classic approach involves transconjunctival or transcutaneous excision of prolapsed orbital fat pads—typically medial, central, and lateral compartments. The goal is to flatten the herniated fat contour and create a smoother lid-cheek transition.

Pros

  1. Proven and predictable:
    Fat removal has the longest clinical track record, with decades of consistent results. It effectively eliminates “puffy” lower lids due to true fat herniation.

  2. Simpler technique:
    Compared to repositioning or transfer, fat removal is technically straightforward and can be performed under local anesthesia with minimal downtime.

  3. Ideal for young or full-faced patients:
    In patients with good skin tone and midface volume, reducing excess fat restores definition without causing hollowness.

  4. Fast recovery:
    Swelling and bruising are generally mild to moderate and resolve within 1–2 weeks.

 

Cons

  1. Risk of hollowing:
    Over-resection of fat can create a “skeletonized” or sunken appearance, especially in thin or older patients with midface deflation.

  2. Tear trough deformity unaddressed:
    Removing fat does not correct volume loss in the nasojugal groove or infraorbital hollow, which may persist or worsen postoperatively.

  3. Limited rejuvenation for skin laxity:
    Fat removal does not address wrinkled or crepey lower eyelid skin, which may require adjunctive laser resurfacing or skin pinch excision.

  4. Irreversibility:
    Once removed, fat cannot be restored naturally; secondary correction often requires fat grafting or filler placement.

 

Ideal Candidates

  • Younger patients (30s–40s)

  • Mild to moderate fat prolapse

  • Strong orbital septum and skin tone

  • No significant tear trough hollowing

 

Fat Repositioning (Arcus Marginalis Release / Septal Reset)

 

Overview

Fat repositioning involves mobilizing prolapsed orbital fat and re-draping it over the infraorbital rim, rather than excising it. The technique aims to fill the tear trough and lid–cheek junction, blending the lower eyelid with the midface.

This approach preserves existing volume and uses it as a natural filler, correcting both protrusion and hollowing in one maneuver.

 

Pros

  1. Natural, blended contour:
    By redistributing orbital fat, surgeons can smooth the lid–cheek transition, reducing the demarcation between the lower eyelid and midface.

  2. Volume preservation:
    Retaining fat helps prevent postoperative hollowing—a common issue in traditional fat removal.

  3. Long-lasting results:
    Repositioned fat integrates naturally and maintains volume for years, unlike fillers or grafts that may resorb.

  4. Comprehensive correction:
    Addresses both protrusion and depression simultaneously, particularly in patients with visible tear troughs and midface deflation.

 

Cons

  1. Technically demanding:
    Requires meticulous dissection and precise fixation of the fat pedicle to the periosteum below the infraorbital rim. Inexperienced execution can lead to irregularities or asymmetry.

  2. Longer recovery:
    Swelling and bruising are often more pronounced and can last 2–3 weeks.

  3. Potential complications:

    • Overcorrection or lumpiness from misplaced fat

    • Under-correction if insufficient fat is mobilized

    • Rare tethering or scarring causing lower lid retraction

    • double vision from adhesion to inferior oblique muscle

  4. Not ideal for severe skin laxity:
    Repositioning addresses contour, but skin excess still requires adjunctive resurfacing or skin pinch excision.

 

Ideal Candidates

  • Middle-aged patients (40s–60s)

  • Fat prolapse with tear trough hollowing

  • Mild to moderate skin laxity

  • Desire for natural, blended rejuvenation rather than flatness

 

Fat Transfer (Autologous Fat Grafting)

 

Overview

 

Fat transfer—also called autologous microfat or nanofat grafting—involves harvesting fat from another site (typically the abdomen or thigh) and injecting it strategically under the lower eyelid and tear trough. It may be performed as a standalone procedure or as an adjunct to traditional blepharoplasty.

 

Pros

  1. Customizable volume restoration:
    Fat grafting allows precise augmentation of the lower eyelid–cheek junction, midface, and nasojugal groove.

  2. Minimally invasive:
    Can be done with small cannulas, under local anesthesia, and with little incision-based trauma.

  3. Biologic benefits:
    Fat contains adipose-derived stem cells that can improve skin texture, thickness, and quality.

  4. Complementary with surgery:
    Fat transfer is useful in revision blepharoplasty or post-surgical hollowing to restore natural volume.

 

Cons

  1. Variable fat survival:
    Resorption rates range from 30%–50%, and asymmetry may occur if graft survival is uneven.

  2. Risk of lumpiness or irregularity:
    Overfilling or uneven injection planes can cause contour irregularities, particularly under thin lower eyelid skin.

  3. Technically sensitive:
    Requires careful microinjection with blunt cannulas to avoid vascular compromise or nodularity.

  4. Less effective for significant herniated fat:
    Fat transfer does not address true orbital fat prolapse; it is better for volume addition than reduction.

  5. Vision loss from fat injection into artery - rare but potential complication. 

  6. Possible need for touch-ups:
    A secondary grafting session may be required 6–12 months later to refine volume symmetry.

 

Ideal Candidates

Patients with hollow or sunken lower eyelids

Prior fat removal or over-resection

Mild to moderate tear trough depression

Desire for nonsurgical or minimally invasive correction

 

Choosing the Right Technique

Selecting the optimal lower eyelid approach depends on four anatomical factors:

 

Fat Prolapse Severity:


Prominent herniation favors removal or repositioning; minimal herniation with hollowing favors fat transfer.

 

Skin Quality and Elasticity:


Fine wrinkles or crepey skin benefit from adjunctive resurfacing (CO₂ laser or chemical peel).

 

Midface Volume and Support:


Patients with midface descent benefit from repositioning or concurrent midface lift to maintain harmony.

 

Patient Age and Goals:

Younger patients often prefer transconjunctival fat removal for minimal downtime.

Middle-aged patients with visible troughs benefit from repositioning.

Older or post-surgical patients may require fat transfer to restore a youthful contour.

 

Dr Thiagarajah reviews the goals with each patient to determine the best plan for each person.

 

Complications and Considerations

 

Common to all techniques:

Swelling, bruising, transient numbness

Temporary chemosis or conjunctival swelling

 

Technique-specific risks:

Fat removal: hollowness, lower lid retraction, scleral show

Repositioning: irregular contour, tethering, asymmetry, double vision

Fat transfer: overfilling, oil cysts, partial graft loss, vision loss

 

Proper preoperative planning and conservative execution are key to achieving natural, youthful results without distortion of the eyelid shape.

Future Directions

Advances in eyelid rejuvenation are trending toward volume preservation and redistribution rather than reduction. Hybrid approaches—such as selective fat removal with limited repositioning and microfat grafting—offer the best of all worlds: contour refinement, volume maintenance, and tissue rejuvenation. 

Emerging techniques, such as nanofat injections for skin quality and platelet-rich plasma (PRP) adjuncts, may further enhance healing and aesthetic outcomes.

 

 

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Upper and Lower Blepharoplasty before and after

Medically reviewed by Chris Thiagarajah, MD

(ASOPRS) — Oculoplastic Surgeon, Denver Eyelid Specialists.

Published: updated regularly

• Last reviewed: 9/15/2025

Locations

 

Offices
 

8301 E Prentice Ave

Suite 403

Greenwood Village CO 80111

Vail Vision

1140 Edwards Village Blvd Edwards CO​​​

Oregon Trail Eye

329 W 40th St

Scottsbluff, NE 69361

​Surgery Centers

Park Avenue Surgery Center

1800 Emerson St Suite 220

Denver CO 80218

Cherry Hills Surgery Center

3535 S Lafayette St

Englewood, CO 80113 

Our Hours

Monday        8:00 AM — 5:00 PM

Tuesday       8:00 AM — 5:00 PM

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Saturday      Closed

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“Dr. Chris Thiagarajah is proud to serve patients throughout Denver, Cherry Creek, Greenwood Village, and the greater Denver Tech Center area with expert  eyelid surgery.

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