Under-eye fat repositioning or lower blepharoplasty: which one do you need?

Surgery for under-eye bags usually means one of two operations: fat repositioning or lower blepharoplasty. Both treat the bags. Lower blepharoplasty can do more, but it leaves a scar under the lashes. Here is how they differ and how we choose between them.

Inside the lid or under the lashes

Fat repositioning is done from inside the lower lid, so it leaves no scar on the skin. It works mainly on the fat. We release the ligament along the tear trough to make room for the fat, then set it in place.

Lower blepharoplasty is done through a cut just under the lash line, so it leaves a scar there. The scar is usually hard to see once it matures, but it does not go away. The operation moves the fat just as repositioning does, but it also works on the skin and the muscle underneath. When needed, it can support the lower lid at its outer corner or lift the cheek.

When the skin is still firm

Repositioning is the usual choice when the lower lid is not loose and the bag is fat pushing forward (Pack 2016, PMID 27499473). The fat is moved from the bag down into the groove below it. That blends the lower lid smoothly into the cheek. The skin and muscle are left alone, so the lid is less likely to turn outward afterward.

When the skin or cheek sags

Lower blepharoplasty is the better fit here because repositioning alone rarely does enough. Loose skin is trimmed, but only as much as the lower lid can spare (Cakmak 2021, PMID 33634449). If the cheek has dropped, we lift it through the same cut (Branham 2016, PMID 27105798). This step is often called a midface lift.

Both operations are well established, so we decide case by case after examining you. For more on why we keep the fat, see Under-eye bags: why we reposition the fat instead of taking it out.

References

1. Pack S, et al. (2016). Transconjunctival lower blepharoplasty. Atlas Oral Maxillofac Surg Clin North Am. PMID 27499473 (opens in new window).
2. Cakmak O, Emre IE. (2021). An update on subciliary lower eyelid blepharoplasty. Facial Plast Surg. PMID 33634449 (opens in new window).
3. Branham GH. (2016). Lower eyelid blepharoplasty. Facial Plast Surg Clin North Am. PMID 27105798 (opens in new window).