Under-eye fat repositioning: Why is under-eye fat repositioned instead of being removed?

 

Hello! I am Dr. Sung-Cheol Chu, the representative director of D-Day Plastic Surgery Clinic.

 

During consultations for lower eyelid fat repositioning, there is a question patients frequently ask: "My under-eye area is bulging out; isn't removing just the fat enough?"

 

In the past, methods to remove bulging under-eye fat were widely used. However, what determines under-eye aging and one's impression is not simply a matter of having 'a lot or a little fat.'

 

As the fat under the eyes protrudes forward, a sunken area known as the tear trough may exist beneath it. When these two features appear together, the area above is bulging while the area immediately below is sunken, creating a shadow that can make one look tired and older than their actual age.

 

Related research also explained that as cheek tissue descends and orbital fat protrudes simultaneously with aging, a tear trough can form along the lower orbital margin. The research team introduced a method to smooth the contour between the lower eyelid and the cheek by relocating the protruding fat to the sunken area rather than simply removing it.

 

Therefore, modern under-eye surgery is evolving from a mere "fat removal procedure" to a "surgery that reconstructs the volume and contour of the under-eye area." Today, I will explain under-eye fat repositioning surgery.

 

1️⃣ What causes the under-eye area to puff out?

This is because orbital fat protrudes forward due to aging and anatomical changes.

 

Beneath our eyes, there is orbital fat that protects the eyeball. When we are young, this fat is maintained relatively stably by surrounding tissues, but as aging and anatomical changes progress, the fat under the eyes can protrude forward, making the area under the eyes appear puffy.

 

If the tear trough also deepens, a continuous sequence of bulging, boundary, and sunken areas appears under the eyes. Therefore, some people may develop shadows under their eyes that make them look like dark circles, even though their actual pigmentation is not severe.

 

🔹 Key Principle — Research on lower blepharoplasty also indicates that aging under the eyes is not just a problem of fat protrusion alone Skin laxity, fat protrusion, eyelid position, tear trough, orbital margin and midface shape It explains that it must be evaluated together.

 

2️⃣ Is under-eye fat repositioning a surgery that unconditionally removes fat?

No. It is a surgery that uses fat from the protruding area to fill in the sunken area.

 

To put the essence of under-eye fat repositioning simply, it is a surgery that uses fat from protruding areas to fill in sunken areas.

 

During surgery, the protruding orbital fat is identified, and the structure forming the tear trough is dissected to the necessary extent. The fat is then relocated to the tear trough or below the orbital margin to alleviate the height difference between the lower eyelid and the anterior cheek.

 

🔸 Actual Example — Under-eye fat protrusion ↓, tear trough hollowness ↑ → The goal is to soften the boundary extending from the under-eyes to the cheeks.

 

Early studies on fat redistribution also describe the method of moving orbital fat beyond the lower orbital margin as a way to correct the tear trough while maintaining the under-eye contour.

 

 

3️⃣ Then why not remove all the fat?

This is because the area around the eyes naturally requires appropriate volume.

 

This is the most important part to understand under-eye fat repositioning. If a large amount of bulging fat is removed, the area under the eyes may appear flat in the short term.

 

However, the area around the eyes naturally requires appropriate volume. If fat is excessively removed without considering the patient's anatomical condition, the area under the eyes may appear sunken, or the boundary between the lower eyelid and the cheek may be emphasized.

 

For this reason, in recent lower eyelid surgeries, the concept of redistributing fat while preserving necessary volume, rather than unconditionally removing it, is being treated as important.

 

However, this does not mean that fat must never be removed. In cases of very severe fat protrusion, it may be necessary to adjust the amount of fat along with redistribution. In fact, recent studies explain that while lower eyelid surgery has evolved from simple fat excision to a focus on fat preservation and redistribution, selective fat excision may still be required in cases of severe fat protrusion.

 

Ultimately, the core issue is not the dichotomy of removal versus redeployment, but, Moving and adjusting, leaving only what is necessary for the patient no see.

 

4️⃣ In what cases can under-eye fat repositioning be considered?

This is a case where fat protrusion and tear troughs are present together, but skin sagging is not severe.

 

Typical examples are as follows.

 

🔹 Cases where under-eye fat bulges forward
🔹 Cases where deep tear troughs cause shadows to form under the eyes
🔹 When the area under the eyes is puffy and the area immediately below it appears sunken
🔹 Cases where skin sagging is not severe but you look tired due to under-eye fat
🔹 When the boundary between the under-eye area and the front of the cheek is distinct

 

A transconjunctival approach may be considered, particularly in relatively young patients with mild skin sagging. This method is characterized by the ability to reposition fat without creating an external incision in the skin, as it accesses the fat through the conjunctiva on the inner side of the lower eyelid.

 

However, not all under-eye problems can be solved with under-eye fat repositioning alone.

 

 

5️⃣ Would it be a different story if the skin under the eyes is significantly sagging?

Yes. If skin sagging is present, lower blepharoplasty may be more suitable.

 

This is one of the most common misconceptions when looking into lower eyelid fat repositioning. Just because the area under the eyes is bulging does not mean that everyone needs to undergo fat repositioning through the conjunctiva.

 

If skin elasticity is sufficient and there is not much sagging, good results can be expected with fat redistribution alone; however, if the skin is significantly loose or accompanied by relaxation of the orbicularis oculi muscle and reduced support of the lower eyelid, lower blepharoplasty, which adjusts both the skin and muscles, may be more suitable.

 

Studies on lower blepharoplasty also emphasize that the surgical method must be determined by comprehensively considering skin laxity, fat protrusion, the position of the lower eyelid, and the anatomical conditions of the tear trough and mid-face.

 

Therefore, rather than the question "From what age should I get under-eye fat repositioning?" "Is the cause of my under-eye problem fat, sagging skin, or tear troughs?" It is important to check this first. This is because anatomical condition is more important than age itself in determining the surgical method.

 

 

6️⃣ Is repositioning possible even if I don't have much under-eye fat?

It may be possible if there are palpable fat pads, but an individual evaluation is required.

 

There is an interesting study. A study published in Plastic and Reconstructive Surgery in 2024 evaluated whether tear troughs could be corrected using fat redistribution in patients with palpable fat pads, even in those with little to no fat protrusion.

 

Analysis of a total of 232 patients showed that tear trough deformation was resolved in more than 85% of cases according to the researchers' evaluation criteria, and the researchers reported that this method is applicable even to patients with little fat protrusion if an appropriate fat pad is present.

 

However, this study is based on Level IV evidence and is not a randomized controlled trial. Therefore, rather than generalizing that "anyone can have under-eye fat repositioned even without it," The patient's fat volume and tear trough structure must be evaluated individually. It is appropriate to understand this as a basis.

 

 

7️⃣ Is research on under-eye fat repositioning being conducted in Korea as well?

Yes. A domestic study comparing results based on fixation methods has been published.

 

In a 2020 study published in Aesthetic Plastic Surgery with participation from the Department of Plastic Surgery at Samsung Seoul Hospital, the clinical results of different fat fixation methods in suborbital fat repositioning through the conjunctiva were compared.

 

A total of 545 patients were evaluated, and in the group that received the newly proposed internal fixation method, 88.9% were graded 0 or I in the assessment of postoperative tear trough deformity. The researchers reported that the rates of reoperation and overall complications were lower with this fixation method compared to existing methods.

 

However, since this is also a study that evaluated specific surgical methods and fixation techniques, the figures should not be interpreted as the success rate of all lower eyelid fat repositioning surgeries.

 

8️⃣ Can there be side effects to under-eye fat repositioning?

Yes. Rather than viewing it as a simple surgery, it must be planned with the anatomical structure in mind.

 

You should not take lower eyelid fat repositioning lightly just because it is a relatively frequently performed surgery.

 

After lower eyelid surgery, in addition to temporary swelling and bruising, depending on the patient's condition and the surgical method, asymmetry under the eyes, overcorrection or undercorrection, hollowness under the eyes, residual tear trough, conjunctival edema or bleeding, paresthesia, dry eye symptoms, and changes in lower eyelid position may occur.

 

In related studies, undercorrection, transient conjunctival hemorrhage, eyelid numbness, and dry eyes have also been reported, and in these studies, these symptoms resolved spontaneously. Additionally, a systematic review of the safety of lower blepharoplasty published in 2025 analyzed 36 studies and reported an overall low complication profile; however, it also explained that proper surgical planning is important because there is a possibility of functional and cosmetic complications in lower blepharoplasty.

 

Therefore, rather than thinking of it as a "simple surgery with invisible scars" Surgery that meticulously handles the anatomical structure of the eyelids You need to understand that point.

 

 

💬 Frequently Asked Questions

 

Q1. What is the difference between under-eye fat repositioning and under-eye fat removal?

 

A1. Under-eye fat removal is a method that reduces bulging by removing a portion of protruding orbital fat, while under-eye fat repositioning is a method that alleviates the height difference under the eyes by moving the protruding fat toward the tear trough or sunken areas. Particularly in cases where under-eye fat protrusion and a tear trough are present together, excessive fat removal can actually make the area under the eyes appear sunken; therefore, a method of repositioning the fat while preserving it may be considered.

 

Q2. Does under-eye fat repositioning improve dark circles?

 

A2. It depends on the cause of the dark circles. If the dark circles are shadow-type caused by protruding under-eye fat and a sunken tear trough beneath it, fat repositioning can flatten the under-eye contour and alleviate the appearance of darkness. However, cases involving skin pigmentation or visible blood vessels may not be sufficiently improved by fat repositioning alone. Since tear troughs can appear alongside under-eye fat protrusion or independently, it is important to identify the underlying cause first.

 

Q3. Can anyone with bulging under their eyes receive under-eye fat repositioning?

 

A3. That is not the case. You must examine not only fat protrusion but also tear trough depth, skin sagging, eyelid elasticity, and lower eyelid support. In particular, if the skin is significantly sagging, fat repositioning alone may not be sufficient, and procedures such as blepharoplasty to adjust the skin may be necessary. Several related studies also explain that while a conjunctival approach can be considered when there is minimal excess skin and fat protrusion is the primary issue, a different approach is required for patients who need skin excision.

 

Q4. Is the effect of under-eye fat repositioning permanent? Can the fat protrude again?

 

A4. While the surgically repositioned fat and corrected lower eyelid contour can be maintained for a long time, it cannot be assumed that the current appearance will remain the same for a lifetime. Even after surgery, natural aging continues in the tissues surrounding the eyes, such as the skin and ligaments, and changes in these supporting structures can affect orbital fat protrusion and changes in the lower eyelid contour. Recent related studies also explain that degenerative changes in the lower eyelid's supporting structures due to aging are involved in orbital fat prolapse.

 

Q5. Are there any side effects to under-eye fat repositioning?

 

A5. Yes. In addition to swelling and bruising, issues such as undercorrection, overcorrection, irregular contours, asymmetry, hollowness under the eyes, bleeding, and changes in eyelid position may occur. Various complications have been reported in related studies, and sufficient consultation with a specialist is crucial to minimize or reduce side effects. Therefore, it is appropriate to understand lower eyelid fat repositioning not merely as a "simple surgery to move fat," but as a procedure that requires planning while considering the complex anatomical structure of the lower eyelid.

 

🎯 Conclusion

 

Good under-eye fat repositioning is not determined by 'how much is removed'.

 

The purpose of under-eye fat repositioning is not simply to eliminate under-eye fat. The key is to reduce the height difference between the bulging and sunken areas and to create a more natural contour extending from the lower eyelid to the front of the cheek.

 

Therefore, before surgery, you must distinguish at least the following three things.

 

🔹 First, how much the fat is protruding
🔹 Second, how deep is the tear trough?
🔹 Third, is the skin and lower eyelid elastic?

 

The same surgery cannot be applied to people with a lot of under-eye fat but good skin elasticity, people with little fat but deep tear troughs, or people with accompanying sagging skin and muscles.

 

In fact, even in the literature on lower eyelid surgery, there is still a lack of clear consensus on which single surgical technique is most superior depending on the patient's age or race, and limitations are pointed out regarding the need to select a surgical method tailored to various anatomical conditions.

 

So in the consultation room, rather than asking "How much under-eye fat do you remove?" "Which is the bigger problem under my eyes, fat protrusion or tear troughs?" It would be better if you asked like this. The key point is that lower eyelid fat repositioning is not a surgery to remove fat, but one to restore balance to the area under the eyes. 💖

 

📚 References

1. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plastic Surgery. 1999.

2. Grant JR, Laferriere KA. Periocular rejuvenation: lower eyelid blepharoplasty with fat repositioning and the suborbicularis oculi fat. Facial Plastic Surgery Clinics of North America. 2010.

3. Chang CH, Bae J, Cha MK, Bang SI, Lee KT. Internal Fixation Method Using EZ-Tcon for Transconjunctival Fat Repositioning: Clinical Outcomes and Efficacy. Aesthetic Plastic Surgery. 2020.

4. Chen J, et al. Transconjunctival Fat Repositioning Blepharoplasty: Is Excess Fat Herniation a Prerequisite? Plastic and Reconstructive Surgery. 2024.

5. Lower eyelid blepharoplasty: An overview. Indian Journal of Ophthalmology. 2020.

6. Safety and Complications in Lower Eyelid Blepharoplasty: A Systematic Review. 2025.

 

D-Day Plastic Surgery Clinic

Chief Director Chu Seong-cheol

Plastic surgeon at Catholic University Seoul St. Mary's Hospital
Former Director of Soon Plus Plastic Surgery Clinic
Former Director of Wonjin Plastic Surgery Clinic
Former Director of Iwell Plastic Surgery Clinic
Former Director of Ruby Plastic Surgery Clinic
Current Chief Director of D-Day Plastic Surgery Clinic
Member of the Korean Society of Plastic and Reconstructive Surgeons
Member of the Korean Society of Aesthetic Plastic Surgery
Member of the Korean Society of Craniofacial Plastic Surgery
Member of the Korean Society of Microsurgery
Member of the Korean Society of Surgery on the Hand
Member of the Ocular Surgery Research Group of the Korean Society of Plastic and Reconstructive Surgeons
Member of the Rhinoplasty Research Group of the Korean Society of Plastic and Reconstructive Surgeons
Member of the Liposuction Research Group of the Korean Society of Plastic and Reconstructive Surgeons