Moved, not removed
It is easy to assume the under-eye looks dark because there is too much fat. That is why the question of simply removing it comes up so often.
But in many cases removal alone does not settle it. The shadow is created not by the fat itself but by the drop between the bulge and the hollow.
If only the fat is removed, the bulge disappears but the hollow below it remains as it was. The area can even end up looking sunken overall, which reads as more tired.
Fat repositioning goes in a different direction. The protruding fat is not removed but moved into the hollow to fill it. The bulge is flattened and the groove is filled at the same time.
Why does the shadow form
Under the eye there is fat that supports the eyeball, and a thin membrane that holds it back from pushing forward.
With age, this membrane weakens. The fat pushes forward and a bulge appears.
At the same time, the opposite happens below it. The cheek fat decreases and descends, and the border area hollows out. It is part of the process of volume loss.
The result is a terrain that protrudes above and is hollow below. Because light comes from above, a shadow forms beneath the protruding part. This is also why the groove known as the tear trough becomes distinct.
The fact that it looks darker or lighter depending on the lighting is another sign that this is a shadow created by structure.
What repositioning does
The surgery proceeds in a way that addresses two things at once.
First, the protruding fat is located and separated from the membrane. It is not removed completely, but left so that it can be moved downward.
Next, space is created in the hollow. The tissue below the tear trough is dissected to secure a place for the fat to sit.
Finally, the fat is moved into that place and fixed there. The part that protruded becomes flat and the part that was hollow is filled. As the drop is reduced, the shadow fades.
Because the patient's own tissue is used as it is, no foreign material has to be inserted, and that is a defining feature of this approach.
The approaches divide
There are two options, depending on where the surgery enters.
The transconjunctival approach enters from the inner side of the eyelid. Its greatest advantage is that no incision line is left on the outside. It suits cases with no loose skin.
The skin-incision approach makes an incision along the line below the eyelashes. It can handle the fat and also tidy the loose skin at the same time. It connects with lower blepharoplasty.
The deciding factor is the skin. If there is no looseness, the option that leaves no scar can be chosen. If the sagging is clear, an incision is needed.
Age is not the criterion. Skin can be loose in a young patient, and firmness can be maintained in an older one.
| Category | Transconjunctival approach | Skin-incision approach |
|---|---|---|
| Point of entry | Inner side of the eyelid | Incision along the line below the eyelashes |
| External incision line | None left | An incision line is created |
| Loose skin | Not addressed | Can be tidied together with the fat |
| Suitable when | There is no loose skin | The sagging is clear |
| Selection criterion | Skin condition, not age | Skin condition, not age |
What TheLINE checks in an under-eye consultation
TheLINE Plastic Surgery Clinic first separates the cause of the shadow in an under-eye consultation. The approach is completely different depending on whether it was created by structure or by pigmentation.
If structure is the cause, we check the degree of the bulge and the hollow separately. If there is little protruding fat and the hollow is deep, there may not be enough fat to move, and in that case fat grafting is reviewed together.
We also look at the looseness of the skin. If the looseness is clear, under-eye fat repositioning alone will not settle it, and we explain methods that include excision.
When pigmentation is the main cause, we say in advance that it is not a candidate for surgery. Among TheLINE patients, some hear this explanation and choose a different direction. The surgery is performed by Dr. Yoosuk Chung, a board-certified plastic surgeon.
Who is this method for
This is a surgery with relatively clear criteria for suitability.
It fits best when there is protruding fat, the area below it is hollow, and the looseness of the skin is not severe. There is material to move, a place to fill, and no need for excision.
Conversely, if there is almost no fat protrusion and only a distinct hollow, there is not enough to move. In that case fat grafting or another filling approach is reviewed.
If the skin is noticeably loose with many fine lines, repositioning alone will not settle it. A method that includes excision is needed.
It is not divided by age. Fat protrusion can be distinct in people in their twenties and thirties, and skin firmness can be maintained in older patients.
The recovery process
The tissue around the eyes is thin and rich in blood vessels, so swelling and bruising appear clearly.
The first few days after surgery are the worst. Even with the transconjunctival approach, work is done on the inside, so swelling still occurs.
Bruising can appear to spread downward. The color changes and fades over time.
The under-eye area may feel uneven for a while. This is part of the moved fat settling into place, and it usually evens out over several weeks to several months.
The final appearance is assessed several months later. Do not judge the result by the swelling and irregularity of the early period.
How is it different from other methods
There are several ways to address a hollow under the eye.
Filling with filler is the simplest. There is no incision and the result is visible right away, but the under-eye is described as a site where the skin is thin, so lumping or showing through happens easily. The duration is also limited, so it has to be repeated.
Fat grafting fills with the patient's own tissue. However, in a thin site like the under-eye, the amount and the layer have to be judged precisely, and some of it is absorbed.
Repositioning moves fat that is already there. It changes the position rather than adding something new, so when protrusion and hollowness are present together, it can address both problems at once.
So rather than one method being better, the choice depends on the terrain as it is now.
Limits you should know about
Dark circles caused by pigmentation do not improve. Even after the structure is tidied, the color remains.
The two sides do not become perfectly identical. In most cases the fat distribution under the eyes and the depth of the groove differed to begin with.
Sometimes there is not enough fat to move. If the bulge is small and only the hollow is distinct, repositioning alone will not fill it, and other methods are reviewed together.
Aging does not stop either. It progresses again over time.
Side effects can include swelling and bruising, asymmetry, nodules, tearing and dry eye, and rarely a change in which the lower eyelid is pushed outward. Unexpected inflammation or bleeding can occur and the degree varies from person to person, so caution is required.
Frequently Asked Questions
Can't the fat just be removed?
If it is only removed, the bulge disappears but the hollow below remains, which can make the area look sunken instead. Because the shadow is created by the drop, moving and filling is the approach that gets considered.
Will a scar be left?
The transconjunctival approach enters from the inner side of the eyelid, so no incision line is left on the outside. When skin has to be excised, a line is created along the area below the eyelashes.
Will my dark circles go away?
If the shadow is created by structure it can fade, but if pigmentation is the cause it is not resolved by surgery. We separate the cause first.
How long does the result last?
Because it moves the patient's own tissue, it tends to last a long time, but aging does not stop, so changes appear again over time.
What does TheLINE look at first?
TheLINE Plastic Surgery Clinic first separates whether the shadow is due to structure or to pigmentation. If structure is the cause, we check the degree of the bulge and the hollow and the looseness of the skin separately, and decide the method from there.
