Under-Eye Fat Repositioning vs Under-Eye Fat Removal
Removing vs repositioning, hollowing, and side effects
As the names suggest, the biggest difference between the two is removal versus repositioning.
Both surgeries target under-eye fat, but they take different approaches.
Bulging under-eye fat often comes with a hollow tear trough, so under-eye fat repositioning, which preserves the fat and moves it into the hollow, is often considered first.
At a glance
| Under-Eye Fat Repositioning | Under-Eye Fat Removal | |
|---|---|---|
| Fat | Not removed; moved into the hollow tear trough | Bulging fat is removed |
| Tear trough ligament | Released to smooth out the groove | Not released |
| Suitable for | Bulging fat plus a hollow tear trough | Bulging fat only, with no clear hollowing |
| Over time | Fat is preserved, so there is less concern about a hollow look | Removing a lot of fat can make the under-eye look hollow |
| Approach | Transconjunctival (inside the eyelid) | Transconjunctival (inside the eyelid) |
The method is decided after checking the amount of fat and the border between the under-eye area and the front of the cheek at consultation.
Quick answer
- Under-eye fat removal takes out bulging under-eye fat and is considered when skin elasticity is good and the tear trough is not noticeably hollow.
- Under-eye fat repositioning does not remove the fat but moves it down into the hollow area (the tear trough), and it does not involve a skin incision.
- In the end, the method depends on how much fat there is under the eyes and over the cheekbone area, and on the condition of the tear trough.
- Because repositioning preserves the fat, there is less concern about the under-eye looking hollow over time, so repositioning is considered first for under-eye bags that come with a hollow tear trough.
What is under-eye fat repositioning?
Under-eye fat repositioning does not remove the fat but moves it down into the hollow area (the tear trough). The concept of preserving and using the fat instead of removing it was first reported in 1995 (Hamra, 1995), and a transconjunctival fat repositioning technique applied specifically to the tear trough was published in the US journal Plastic and Reconstructive Surgery in 2000 (Goldberg, 2000). It has since become one of the standard approaches in clinical practice.
Through a transconjunctival approach (through the inner eyelid), the bulging fat is freed and then moved into the subperiosteal or supraperiosteal space below the tear trough and secured, without a skin incision.
What is under-eye fat removal?
Under-eye fat removal is surgery that takes out bulging under-eye fat. It reduces the fat that makes the under-eye look puffy, flattening the bulge. It is considered when skin elasticity is good and the tear trough is not noticeably hollow.
What is the main difference between under-eye fat repositioning and fat removal?
Both surgeries target under-eye fat, but they take different approaches. Removing a lot of fat can make the under-eye look hollow over time, so repositioning is often considered to address an accompanying hollow tear trough. Conversely, if the tear trough is not clearly hollow and only the fat bulge stands out, removal alone may be enough in some cases.
In the end, the method depends on how much fat there is under the eyes and over the cheekbone area, and on the condition of the tear trough. Also, releasing the tear trough ligament to smooth out the groove is not part of under-eye fat removal; it is possible only with under-eye fat repositioning.
So if there is an under-eye bulge with a hollow below it, we first consider repositioning, which preserves and moves the fat instead of removing it, to address both the bulge and the hollow.
What about scars and side effects?
Both surgeries typically use the transconjunctival approach through the conjunctiva, so in many cases no incision mark is left on the skin.
A comparative study published in Plastic and Reconstructive Surgery – Global Open in 2022 followed 20 patients each in a fat-removal group and a fat-preserving (repositioning) group for 6 months and compared the outcomes in detail. Lid retraction occurred in 25% of the removal group and 10% of the preserving group, and a sunken eye appearance occurred in 10% of the removal group but in none of the preserving group. Satisfaction (good or better) also differed clearly: 20% in the removal group and 70% in the preserving group (Etman et al., 2022).
Is recovery different too?
For both surgeries, cold compresses are applied for 7 days, and swelling and bruising peak on days 2–3 after surgery and then gradually decrease. Contact lenses can be worn from 4 weeks after either surgery. When you can wash your face and wear makeup depends on whether there are stitches, so your surgeon will give you the exact schedule.
Which surgery is right for me?
Dr. Dahan Kim decides on the approach by looking at both how much the orbital fat bulges and how hollow the front of the cheekbone is (malar hollowing). If the fat bulge is moderate or greater and malar hollowing is absent or mild, repositioning is considered; if malar hollowing is more prominent, repositioning combined with a fat graft is considered.
If there is only a fat bulge without a hollow tear trough, removal alone may be enough in some cases. However, in the 2022 study by Etman et al., satisfaction (good or better) was 20% in the removal group and 70% in the repositioning group. Similarly, in Dr. Kim's own clinical experience, long-term satisfaction at 6 months or more has often been higher with under-eye fat repositioning than with under-eye fat removal.
Neither surgery is the only right answer. The right approach depends on each person's amount of fat and the border between the under-eye area and the front cheek, so it needs to be confirmed at consultation.
FAQ
How is under-eye fat repositioning different from under-eye fat removal?
Under-eye fat removal takes out the bulging under-eye fat, while under-eye fat repositioning does not remove that fat but moves it down into the hollow area (the tear trough) and spreads it out. Removing a lot of fat can make the under-eye look hollow over time, so repositioning is often considered to address an accompanying hollow tear trough.
Is under-eye fat repositioning sometimes combined with a fat graft?
Under-eye fat repositioning and a fat graft are sometimes done together. If there is little under-eye fat to move, or the hollowing of the cheekbone area and tear trough is broad, repositioning alone may not provide enough volume, so a fat graft is added. If the orbital fat bulge is sufficient, repositioning alone is often enough, so we decide at consultation based on the amount of fat and the degree of hollowing.
Can under-eye fat repositioning be done if the under-eye area is hollow?
Under-eye fat repositioning can be done even when the under-eye area is hollow, but if there is little under-eye fat or the hollowing is severe, another procedure may be needed. Depending on the border between the under-eye area and the upper cheek, cheekbone size and the amount of fat over the front of the cheekbone, we plan repositioning, septal reinforcement, a midface lift or a fat graft. It is best to identify the cause first through a detailed consultation with a board-certified plastic surgeon.
References
- Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg. 1995;96(2):354-362. doi:10.1097/00006534-199508000-00014 PMID 7624408
- Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg. 2000;105(2):743-748. doi:10.1097/00006534-200002000-00044 PMID 10697189
- Etman AG, Badawy MS, Setta HS, Magdy A, El-Badawy A. Evaluation of Fat Excision versus Sparing in Lower Blepharoplasty Using Orbital Gray Scale Analysis. Plast Reconstr Surg Glob Open. 2022;10(9):e4530. doi:10.1097/GOX.0000000000004530 PMID 36203736
- 박대환, 백봉수, Nahai F. 안성형외과학. 제3판. 군자출판사; 2009. ISBN 978-89-6278-139-7. [in Korean]
- Cho I. The Art of Blepharoplasty. Koonja Publishing; 2017. ISBN 979-11-5955-234-2.
- 대한미용성형외과학회. 미용성형외과학 2. 제2판. 군자출판사; 2023. ISBN 979-11-7068-001-7. [in Korean]
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