Do I Really Need to Remove Under-Eye Fat? The Secret to Lower Blepharoplasty Without Sunken Under-Eyes: 'Fat Preservation Technique'

Many people, both older adults and younger individuals, often have excessively protruding under-eye fat. When under-eye fat is excessive, it can resemble dark circles, making one look tired and older.

There is much discussion about how to treat this bulging fat. Some methods involve removing under-eye fat, while others suggest repositioning it. Under-eye fat repositioning is a relative concept to under-eye fat removal, meaning the surgery aims to preserve the fat as much as possible rather than eliminating it.

Today, I’d like to introduce a plastic surgery paper that discusses how to manage under-eye fat during lower blepharoplasty and the methods for under-eye fat repositioning. The author I’m introducing today, B.C. Mendelson, has made outstanding contributions in the field of anti-aging, particularly in face lifting.

2001 Sep;21(5):450-9.

Fat preservation technique of lower-lid blepharoplasty

B C Mendelson

This paper discusses the fat preservation technique in lower eyelid blepharoplasty. Unlike traditional fat removal methods, it thoroughly explains the surgical technique for repositioning bulging lower eyelid fat and reinforcing the orbital septum to restore a youthful eye appearance, along with its anatomical basis and surgical procedure. This technique focuses on increasing the predictability of surgical outcomes and reducing recurrence and complications.

Lower blepharoplasty: Is there a new way to preserve fat?

1. Under-eye fat: Do we really have to remove it? A new approach to lower blepharoplasty!

Lower blepharoplasty is often thought of as a surgery to remove under-eye fat. However, it’s not always necessary to remove all the fat. The author’s lower blepharoplasty technique, instead of simply removing the bulging under-eye fat, repositions it back to its original place. This can improve the structural problems of the eyelid, making one look younger.

This method doesn’t just flatten the under-eye area. It strengthens the supporting structures of the eyelid to prevent the fat from protruding again. While older lower blepharoplasty techniques simply involved cutting out fat and pulling the skin, the fat preservation technique focuses on restoring the eyelid’s structure, which has changed due to aging, to its original state. If performed correctly, it can avoid problems such as the eyelid being pulled down or the fat bulging again.

2. The secret to youthful eyes: Is it hidden in the eyelid structure?

Figure 1 shows the eyelids of young people. Young eyelids appear shorter vertically and have a concave under-eye area. The part connecting the lower eyelid to the anterior cheek begins relatively high, just above the cheekbone.

However, as shown in Figure 2, problems arise with age or congenital weakening of the eyelids. As the fibrous tissue supporting the fat within the eyelid weakens, the fat pushes forward. This causes the lower eyelid to bulge, making the under-eye fat particularly prominent. When the cheek sags and the area below the cheekbone appears sunken, the under-eye fat feels even more prominent.

3. Capsulopalpebral fascia repair: What exactly is it?

The term ‘capsulopalpebral fascia repair’ might sound a bit difficult, right? This is a surgery that strengthens an important structure located behind the eyelid. The capsulopalpebral fascia plays a crucial role in eyelid movement and shape, similar to the levator muscle of the upper eyelid. This fascia is connected to a structure called the orbital septum of the lower eyelid, as shown in Figure 3.

The orbital septum acts as a barrier, preventing the fat inside the eyelid from pushing forward. The capsulopalpebral fascia reinforces the upper part of the orbital septum, making it stronger. However, with age, the lower part of this orbital septum weakens, causing the fat to bulge forward. Capsulopalpebral fascia repair, as shown in Figure 4, is a surgery that strengthens precisely this weakened lower part of the orbital septum. By pulling and fixing the capsulopalpebral fascia and orbital septum down to the lower cheekbone rim during lower blepharoplasty, the weakened area is reinforced. This makes the entire supporting structure of the eyelid as strong as if it were augmented by the capsulopalpebral fascia after surgery.

4. Fat preservation technique: How is the surgery performed?

How is lower blepharoplasty using the fat preservation technique performed? First, the under-eye skin and muscle are dissected to create a flap. This flap is lowered to the cheekbone rim, exposing the orbital septum. At this point, the underside of the eyelid muscle may be adhered to the orbital septum, and it must be carefully separated to avoid damaging the orbital septum. It is crucial to accurately locate the capsulopalpebral fascia; pulling the eyelid margin upwards makes this fascia taut and easier to find. By pulling the bulging under-eye area downwards and separating the upper and lower parts of the orbital septum, the junction where the capsulopalpebral fascia and orbital septum meet appears as a white line, which is then identified.

Now it’s time to reposition the bulging fat inwards. As shown in Figure 5, fat can be repositioned without opening the orbital septum. Sutures are used to fix the capsulopalpebral fascia to the periosteum on the cheekbone rim. Care must be taken not to damage the under-eye arterial branches with the needle. The important point is to precisely place the sutures at the exact junction where the capsulopalpebral fascia and orbital septum meet. If the sutures are placed too high, there is a risk of the eyelid shortening and everting. When the fat is pushed inwards, the internal pressure of the eye increases, which can make the fat in other un-fixed areas appear more prominent.

During surgery, it’s important to check if the fat pressure is appropriate. If the pressure is too high, the operated area can bulge again, increasing the likelihood of recurrence. If the pressure is too high, some fat may need to be removed. As shown in Figures 6 and 7, especially the outer fat of the eye is only partially removed if necessary, and several sutures are used to tie up the loosened parts. It’s important to place the sutures diagonally to create a new eyelid contour. This naturally creates a concave area and a slightly bulging area, similar to a youthful eyelid. Before the surgery ends, tests should be performed to ensure the eyelid moves well and the surgical area is not overly tight. The eyelid margin is gently pulled, and pressure is applied to the upper eyelid to increase intraocular pressure, checking that the surgical area does not bulge excessively. If the surgery is performed correctly, there will be no restriction in eyelid movement. Finally, the separated skin and muscle are put back in place and sutured, completing the surgery.

5. Who is suitable for the fat preservation technique?

This fat preservation technique is not suitable for everyone. The ideal candidate for this surgery is a relatively young patient, specifically under 50 years old. Younger patients often have bulging under-eye fat but not severe overall facial aging. In such cases, removing all the fat can, in the long term, make the under-eye area look hollow or older, so preserving the fat is preferable.

However, one caveat is that it may not be suitable for patients with underdeveloped cheekbones. If the cheekbones are small, fixing the under-eye fat inwards can cause the eyelid to appear pulled down. Additionally, this surgery alone may not address overall aging issues around the eyelids. If there is severe skin laxity or wrinkles around the eyelids and cheeks, it may need to be considered in conjunction with a facelift or other lifting procedures. It’s important to remember that this surgery is most effective for patients with mild laxity around the eyelids.

6. Fat preservation technique: Is it really effective?

Is the fat preservation technique really effective? Looking at the surgical results, it’s clear that the eyelids have become very natural and aesthetically pleasing. By strengthening the supporting structures of the eyelid and appropriately preserving fat, an elegant under-eye contour is achieved. Photos taken 5 and 8 years after surgery show almost no signs of the sunken under-eye appearance that can occur when fat is excessively removed.

Especially in younger patients, it has been observed that the problem of under-eye fat bulging again rarely occurs even 5 or 10 years after surgery. This is because the fat within the eyelid is maintained under appropriate pressure through capsulopalpebral fascia repair. Of course, if the fat is too prominent, some fat may need to be removed, but preserving the fat yields better results than removing all fat using standard methods. Using the correct surgical technique can achieve good results without interfering with eyelid movement or causing eyelid shortening.

7. Conclusion

Advantages of fat preservation: Preserving fat is better than completely removing it.

Use of precise methods: Correct use of the capsulopalpebral fascia and orbital septum can achieve aesthetically pleasing results without causing eyelid mobility issues or vertical shortening.

Source: Aesthetic Surgery Journal, September/October 2001.

Frequently Asked Questions

Do I always need to remove under-eye fat?

No, it is not always necessary to remove all the fat. The fat preservation technique in lower blepharoplasty improves structural problems of the eyelid by repositioning the bulging under-eye fat back to its original place instead of simply removing it.

What is the fat preservation technique?

The fat preservation technique is a lower blepharoplasty method that, instead of removing bulging under-eye fat, repositions it and strengthens the weakened orbital septum through capsulopalpebral fascia repair, thereby reinforcing the supporting structure of the eyelid.

Who is suitable for the fat preservation technique?

The fat preservation technique is most ideal for relatively young patients, i.e., those under 50 years old. It is suitable for cases where under-eye fat is prominent but overall facial aging is not severe, and it can prevent the under-eye area from looking hollow in the long term.

What are the advantages of the fat preservation technique?

The fat preservation technique strengthens the supporting structures of the eyelid and appropriately preserves fat to create a natural and elegant under-eye contour. There is almost no under-eye hollowing or fat recurrence after surgery, and good results can be achieved without restricting eyelid movement.

What is capsulopalpebral fascia repair?

Capsulopalpebral fascia repair is a surgery that strengthens the capsulopalpebral fascia, an important structure located behind the eyelid. It reinforces the weakened lower part of the orbital septum to support the fat and prevent it from pushing forward.

Can under-eye fat bulge again after the fat preservation technique?

No, the fat preservation technique reduces the likelihood of recurrence. Especially in younger patients, it is reported that the problem of under-eye fat bulging again rarely occurs even 5 or 10 years after surgery. This is because the fat is maintained under appropriate pressure through capsulopalpebral fascia repair.