Non-surgical Under-eye dark circles removal—does the under-eye area flatten just by removing fat?

Non-surgical Under-eye dark circles removal (transconjunctival fat removal) is a procedure that removes fat causing under-eye puffiness through the mucous membrane on the inside of the eyelid, without creating a skin incision. While swelling can be reduced without scarring the skin, skin sagging and the hollowness beneath the puffiness (tear trough) cannot be corrected by fat removal alone[1][2]. It suits those with minimal excess skin and prominent puffiness as the main concern[3].

Why does removing fat reduce under-eye puffiness?

The puffiness is actually fat surrounding the eyeball that has been pushed forward. Textbooks typically describe that the standard approach to remove this protruding fat is to enter from the inside of the eyelid without cutting the skin[4]. This is because it leaves no scar on the skin side and carries minimal risk of eyelid eversion (ectropion), a complication where the eyelid turns outward[5]. Reports focusing on middle-aged and older men also note that the transconjunctival approach is becoming the first choice due to hidden scarring and fewer complications[5].

What remains after removing only fat?

What remains is skin sagging and hollowness. Textbooks identify the weaknesses of this procedure as incomplete fat removal and inability to correct fine lines on the surface[1]. Furthermore, reports indicate that the conventional fat-removal-only method not only fails to correct the groove beneath the puffiness but may also make under-eye hollowness more noticeable[2]. For patients with both puffiness and hollowness, methods involving repositioning some fat toward the hollow area or adding volume are considered[2].

Who is a good candidate, and for whom is it insufficient?

It suits those with minimal excess skin and clearly defined fat puffiness. Reviews indicate that the transconjunctival approach works well for younger patients without excess skin, while patients requiring skin excision undergo surgery from the skin side[3]. Research examining age effects found that patients under 50 rated improvement in puffiness and sagging more highly than those 50 and older[6]. The same study also showed that satisfaction regarding sagging tends to decline beyond the late 40s[6].

How long does swelling persist after surgery?

Swelling occurs in all patients and typically subsides over several weeks. A study following 97 patients reported that temporary lower-eyelid swelling was observed in all cases and settled within 8 weeks[7]. The same study found conjunctival edema (white of the eye swelling) in 2.1% and temporary cheek numbness in 3.1%, resolving within 2 and 3 weeks, respectively[7]. No major complications occurred[7].

However, these results come from a retrospective review of surgery by a single surgeon, with a mean follow-up period of 8.2 months[7]. Since swelling resolution varies among individuals, it is practical to allow extra time if scheduling surgery before an important event.

What are the possible complications and common complaints?

The most common complaint is "incomplete removal." A study examining complaints about eyelid surgery over 7 years found that incomplete removal of under-eye puffiness was the most frequent complaint regarding lower-eyelid surgery[8]. A systematic review of lower-eyelid surgery overall found no reports of major complications affecting the eyes or vision, and noted that most aesthetic and functional issues were resolved through observation or revision surgery[9]. Removing too much causes hollowness, while incomplete removal leaves puffiness, so the decision about how much to remove determines the outcome[2][7].

What should I ask about during the consultation?

You should confirm whether your under-eye dark circles are primarily puffiness or also involve hollowness and sagging. If puffiness alone, fat removal surgery may be sufficient, but if hollowness is present, also asking about fat repositioning or volume-adding methods will help with decision-making[2]. If excess skin is identified, alternative methods such as skin-side surgery become options[3].

The under-eye condition often differs between the two sides. During consultation, it is recommended to have each side examined separately and ask how the approach to removing and preserving fat applies to your specific under-eye area.