Lower Blepharoplasty vs Under-Eye Fat Repositioning: What's the Difference, and When Should You Have It?

Hello, I'm Dr. Yoosuk Chung, Director of TheLINE Plastic Surgery.

When the area under the eyes starts to bulge and a groove deepens beneath it, many people think, "The fat has increased, so it just needs to come out." But lower blepharoplasty today is not surgery that removes fat. It is surgery that preserves the fat and moves it. Today I'd like to explain how lower blepharoplasty relates to under-eye fat repositioning, how the choice between a transconjunctival and a skin incision is made, and why it is so often done together with a facelift.

Lower blepharoplasty is a topic I have presented on at academic meetings several times. At the 11th Congress of Asia Anti-Aging Medicine in 2018, I presented "Lower Blepharoplasty with Low Risk," and at the 2020 Asia Forum for Aesthetic Surgery & Medicine, I presented "The Effect of Lower Blepharoplasty on Mid Facelift."

What Exactly Is Lower Blepharoplasty?

Anatomically, the upper eyelid is called the upper lid and the eyelid below is the lower lid, so any surgery related to the lower eyelid is lower blepharoplasty. In everyday use, however, lower blepharoplasty refers to surgery that corrects the deep groove, bulging fat, and sagging skin that come with aging, to give a brighter look.

Why Does Under-Eye Fat Bulge Out?

In the past, because the area under the eyes bulged, it was assumed the fat had increased, and a lot of it was removed. But in my experience in surgery, this fat (orbital fat) has in most cases not increased so much as been pushed out. The structures that hold the fat back like a dam weaken and loosen with age, and the fat pushes out through the gap. Since the fat hasn't increased but has been pushed out, it is important to preserve that fat.

Research offers a similar explanation. A 2018 study analyzing CT scans of 265 patients reported that the density of orbital fat drops markedly with age. It interpreted the apparent increase in fat not as fat cells multiplying or growing, but as existing fat spreading out to fill a bony orbit that enlarges with age. It also concluded that the lower orbital rim descends and stretches the lower eyelid, and together with an eyelid that weakens with age, this pushes the fat forward[1].

What Is the Difference Between Lower Blepharoplasty and Under-Eye Fat Repositioning?

Lower blepharoplasty brightens the whole under-eye area, and the method used most within it is under-eye fat repositioning. They are not two different surgeries. One is the broad category and the other is a method within it.

Under-eye fat repositioning does not discard the bulging fat. It spreads the fat downward to fill the deep groove. This smooths out both the bulge and the shadowed groove, and the weakened membrane is reinforced at the same time. The research is moving in the same direction. A 2025 systematic review concluded that the traditional approach of excising fat is giving way to preserving and repositioning it. It also noted that removing fat alone eventually leaves the eyes looking hollow, which the authors described as aging caused by surgery[2].

How Do You Choose Between a Transconjunctival and a Skin Incision?

There is no recommended age. If under-eye fat is the problem, it can be done even in your 20s. The deciding factor is not age but how much the skin has sagged.

People in their 20s and 30s usually have little skin laxity, so rather than cutting the skin, I go in through the conjunctiva inside the eyelid and address only the fat. From the 50s and 60s, when there is sagging, I mainly use a skin incision. These days, though, perhaps because many people take good care of their health, quite a few people in their 40s and 50s have no skin laxity. In those cases, regardless of age, the transconjunctival approach can also give good results.

A 2025 systematic review of 24 studies and 3,623 patients reached the same conclusion. Both the transconjunctival and skin incision approaches achieved fat removal or repositioning safely and effectively, with no significant difference in outcomes. It concluded that the transconjunctival approach is better suited to younger patients who don't need skin removed[2].

What Are the Side Effects of Lower Blepharoplasty?

The most serious side effect is ectropion, where the eyelid turns outward. A little more of the inner lining showing temporarily after surgery is hard to call a side effect, because it improves with time. The problem is severe ectropion, where the eyelid pulls away from the eyeball and the inner lining is fully exposed, causing vision to drop or making daily life difficult. That is why, in skin-incision lower blepharoplasty, the orbicularis muscle is anchored to the orbit to keep the eyelid from turning out after surgery.

Next is asymmetry. The fat has to be spread well for a good result, but one side may spread well while the other is undercorrected, leaving a groove and some bulging. Last is scarring. Because the closure is done delicately, scars are usually not very noticeable, but occasionally someone forms scars more readily than others.

Here is what the research numbers show. In a 2024 meta-analysis of 33 studies and 4,671 patients who had the under-eye area corrected with fat repositioning or fat grafting, the overall complication rate was 11.2%, unsatisfactory correction or contour irregularity 6.2%, and reoperation 2.4%[3]. In a study of 1,152 Asian patients who had fat-repositioning lower blepharoplasty over 18 years, 7 (0.6%) developed ectropion, all in the skin incision group, and all were treated with lateral canthal fixation[4].

What Procedures Are Done Together with Lower Blepharoplasty?

The procedure most often done together is a facelift. When I perform a facelift, I almost always do lower blepharoplasty at the same time. That way the face is lifted and the under-eye area becomes clean as well, for a better result. How a facelift lifts a sagging face is explained in "Facelift vs Thread Lift: What's the Difference, and How Long Does a Facelift Last?"

The reason the lower eyelid and facial sagging need to be looked at together lies in anatomy: right below the under-eye area is the front of the cheek, the midface. The 2025 systematic review concluded that skin-incision lower blepharoplasty allows a midface lift to be performed at the same time as lateral canthal fixation, and that it is better suited to older patients whose eyelids need tightening and anchoring[2]. This is also why I presented on midface lifting through lower blepharoplasty at the 2020 meeting.

Older patients often have lateral canthal fixation at the same time. Even without previous surgery, some people's eyelids have weakened enough that they are already slightly turned out. In those cases, I fix the lateral canthus, or trim a little of the stretched eyelid tissue to shorten it and then anchor it, a lateral canthoplasty. The 2025 systematic review also noted that tightening the lateral canthus and supporting the lower eyelid muscle has become essentially standard in skin-incision lower blepharoplasty, and that as a result eyelid malposition has dropped to about 0.4% with both the transconjunctival and skin incision approaches[2].

A forehead lift is also a good combination. Some people find the under-eye area is now clean, but double eyelid surgery feels like too much, and the outer corner of the eye still looks heavy. Lifting the forehead slightly in that case can make the outer corner of the eye look more open.

What Is It Like When a Plastic Surgeon Has Lower Blepharoplasty?

Not long ago, Dr. Jaeho Cho had lower blepharoplasty with me. Here is what he said when he was almost three weeks out from surgery.

"At first I went back and forth over whether to have an incision, whether to have lower blepharoplasty at all. Staff members who'd had it said it was great, so I went ahead, but right after surgery I completely regretted it. My eyes were puffed up and my face was swollen too. But after about five days the swelling went down, and when the eye bags that had been bulging out were all gone, I thanked the staff member who'd told me I absolutely had to do it."

Dr. Cho also struggled with whether to just spread the fat through the conjunctiva or also remove the excess skin. A staff member in the operating room told him, "If the outer skin has sagged, you should have it cleanly removed. If you only go in from the inside, you'll end up having surgery twice anyway." He took that advice and chose the skin incision, and says it was a very good decision.

"I'm actually very easily scared. I asked Dr. Chung over and over. I always tried to understand how anxious patients feel, but once I was the one having it, I had so many more questions, and I came to understand patients much better. Still, if you have eye bags, there's no need to hesitate. Having it done early, when the sagging is moderate, gives better results and better long-term effects."

Lower blepharoplasty is a relatively simple surgery, but it turns a tired-looking face fresh, so it helps a great deal in improving the overall impression of the face. The fat is spread precisely from the inside, and only as much excess skin as needed is removed before closing. That is why it is one of the surgeries with the highest satisfaction.

Individual Differences and Precautions

• How far the fat has been pushed out, how deep the groove is, and how much the skin sags differ from person to person. Even at the same age, some people suit the transconjunctival approach and others a skin incision.
• Researchers explain why under-eye fat bulges in somewhat different ways, and the CT study above[1] represents one of those views.
• The complication rates[3][4] are pooled figures from many clinics and techniques. Your own risk can only be known by examining your eyelid support and skin in person.
• Recovery time and post-operative precautions will be covered separately in the next article.

Three Key Takeaways

1. Lower blepharoplasty covers all lower eyelid surgery, and the method used most within it is under-eye fat repositioning, which moves the fat into the groove instead of discarding it.
2. The choice between a transconjunctival and a skin incision depends on skin laxity, not age, and research shows both can achieve fat repositioning safely[2].
3. Combining a facelift with lower blepharoplasty addresses both the face and the under-eye area, for a better result.

Whether the transconjunctival approach is enough for your under-eye area, whether you need a skin incision, or whether it should be planned together with a facelift can only be judged by an in-person examination. Please visit us for a consultation for an accurate assessment.

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By Dr. Yoosuk Chung (Board-Certified Plastic Surgeon)

--- Sources

1. Kim J, Park SW, Choi J, Jeong W, Lee S. Ageing of the bony orbit is a major cause of age-related intraorbital fat herniation. J Plast Reconstr Aesthet Surg. 2018;71(5):658–664. DOI 10.1016/j.bjps.2017.11.029

2. Atiyeh B, Chrabieh E, Makkawi K, Beaineh P, Issa O, Emsieh S. Transconjunctival or Transcutaneous Approach for Fat-preserving Lower Lid Blepharoplasty? Plast Reconstr Surg Glob Open. 2025;13:e7345. PMC12708136

3. Complications of Fat Grafting and Repositioning for Correction of Lower Eyelid Pouch With Tear Trough Deformity or Lid-Cheek Junction: A Systematic Review. Ann Plast Surg. 2024;93(3):e9–e25. PubMed 39158343

4. Cheng AM, Chuang AY, Wei YH, Sibia SS, Liao SL. Supraperiosteal fat repositioning with midface lift in lower eyelid blepharoplasty: an 18-year experience. Graefes Arch Clin Exp Ophthalmol. 2024;262(7):2291–2298. PubMed 38353810

This article summarizes common questions about lower blepharoplasty, based on Dr. Yoosuk Chung's clinical experience and papers published in academic journals. Please confirm your own condition through an examination by a specialist.