Fat removal only, or relocate/add fat? How to choose based on under-eye hollowing

If there is only puffiness under the eyes, fat removal ("fat removal") is sufficient. If there is also hollowing (tear trough) below the puffiness, the options are either relocating fat to the groove without removing it, or adding fat from another body area.[1][2]. High-quality research directly comparing which is superior does not yet exist, and the choice is determined by the shape of the under-eye area.[3].

What are the 3 methods and how do they differ?

Fat removal is surgery to remove fat; fat transfer is surgery to relocate fat into the groove without removing it; fat injection is surgery to place fat harvested from the thigh or abdomen into the groove. Review articles note that in recent years, in addition to conventional fat removal, the trend is a method that relocates orbital fat toward the groove to correct hollowing.[1]. Both fat transfer and fat injection methods share the point of eliminating puffiness while filling the groove simultaneously, and both are reported to have advantages and disadvantages.[3].

When is fat removal alone sufficient for under-eye treatment?

When there is minimal excess skin, puffiness is the main concern, and there is no hollowing below it. Textbooks state that fat removal is suited for patients with minimal skin laxity, and its weakness is that fat may be left behind and surface wrinkles cannot be corrected.[4]. Conversely, it has been reported that performing fat removal surgery alone on patients with hollowing does not correct the groove and may make the under-eye area appear sunken.[2].

Where is the difficulty in fat transfer methods?

The difficulty lies in keeping the fat in the correct position within a narrow surgical field. After detaching the ligaments of the groove from behind the eyelid, precise placement of fat is reported to be difficult due to limited visibility, and techniques using guide needles to facilitate placement have been published.[5]. In this report following 26 patients for 6 months, there were no cases of infection, ectropion, orbital hemorrhage, or vision loss. One patient had mild asymmetry, and 2 patients had temporary diplopia (double vision), which resolved within one week.[5].

The fixation method also influences outcomes. In a study comparing 127 patients, the group in which transferred fat was secured with sutures on the skin side showed strong skin discoloration in 42.85%, whereas the group using adhesive (fibrin glue) without sutures had 0% incidence.[6]. Severe bruising also decreased from 71.42% to 36.36%.[6]. This is a retrospective study, and which fixation method is used depends on the facility.

For whom is the fat addition method suited?

It is suited for patients with deep grooves and insufficient relocatable fat. In a report combining fat removal with fine fat injection (nanofat) in young Chinese patients, 41.0% answered "very satisfied," 54.6% answered "satisfied," and satisfaction was low in 4.4%.[3]. Complications included temporary scleral injection in 2.7%, insufficient groove filling in 2.7%, and increased fine wrinkles in 5.5%.[3]. The amount of injected fat that remains was not measured, and the authors themselves wrote that direct comparison with fat transfer methods is needed.[3].

Are there methods other than surgery?

For patients with shallow grooves, filling the groove with injectable agents and intradermal injection of botulinum toxin are also reported. Hyaluronic acid lasts long without surgery, but is not permanent.[7]. In a study of 42 patients with mild grooves injected with botulinum toxin, indices for grooves and fine wrinkles improved, but this was not a direct comparison with surgery.[8]. For patients with large puffiness, injection may not conceal it even if the groove is filled; asking during consultation about the differences from surgery can reduce confusion.

How do I identify my own under-eye condition?

The classification axes are three: puffiness, hollowing, and excess skin. If only puffiness is present, fat removal; if both puffiness and hollowing exist, fat transfer or addition methods; if there is excessive skin, surgery from the skin side—this is the framework in review articles and textbooks.[1][4]. However, if fat transfer methods are applied as-is to patients with excessive fat, the cheeks may swell too much, and adjustments involving partial removal during transfer have also been reported.[9].

During consultation, ask which type your condition is closest to and how the amount of fat to remove and relocate will be determined. If the answer is tailored to your specific under-eye condition rather than general, it becomes easier to decide with confidence.