Doctor's Column

The most controversial topic in lower blepharoplasty is "fat removal" versus "under-eye fat repositioning." Some doctors say the fat must be removed, while others say it should never be removed. So, which is right?

Dr. Sung-hoon Kim of SH Plastic Surgery explains the differences and limitations of the two methods through actual patient cases and anatomical evidence,

as well as the necessity of the fundamental solution: under-eye fat repositioning + orbital septum reinforcement + midface (front cheek) lifting.

Face Designer, Dr. Sung-Hoon Kim, Director of SH Plastic Surgery

"Doctor, one clinic told me that I definitely need to remove the fat, while another clinic said I should never remove it. What on earth is the right answer?"

These were the words of a female patient in her early 40s who visited the consultation room because of bulging under her eyes.

A few years ago, the area under her eyes began to protrude noticeably, and people around her started commenting that it looked dark like dark circles, even with makeup on.

At first, she brushed it off thinking it was just fatigue, but after constantly seeing herself look tired in photos, she finally decided to seek a consultation.

The problem was that every hospital gave a completely different explanation.

One clinic said, "The protruding fat is the problem, so it must all be removed," while another clinic said, "You should never remove fat; you must reposition it."

From the patient's perspective, it was bound to be confusing.

She had no way of knowing what was right, or which method was the safest and most effective.

I first explained to the patient step by step why lower eyelid fat bulges out, and why it shouldn't be judged simply based on the fat itself. The under-eye area doesn't protrude simply because there is "too much fat."

As the orbital septum that holds the fat stretches, it fails to provide support, and the fat pushes forward through that gap.

In addition, as the fat in the anterior cheek sags and loses volume, the bulging and hollow areas are revealed simultaneously, creating an even more fatigued and aged impression.

This patient had also heard about the experience of a friend who previously underwent fat removal surgery.

She said she was terrified by the story: "It looked fine at first, but over time, the eyes became hollowed out, making them look even more tired."

Conversely, in the case of an acquaintance who underwent fat repositioning, she heard a review saying that it looked good at first, but was disappointing because it didn't dramatically change their overall impression.

So I told her:

"Doing only fat removal or only fat repositioning leaves you 2% short. Ultimately, the key lies not just in handling the fat well, but in a comprehensive approach that reinforces the septum and lifts the midface."

After hearing my explanation, this patient showed a sense of relief, saying, "It feels like the puzzle pieces have finally come together."

Today, just like in this case, I will discuss the differences and limitations of fat removal and under-eye fat repositioning, which many people find confusing.

Why Under-Eye Fat Occurs

Many people ask, "Why does the area under my eyes keep looking bulging?"

Eye bags, or under-eye fat, do not simply occur due to aging.

They appear as a result of a combination of various factors.

First, as the muscles and tissues supporting the area around the eyes weaken, they can no longer hold the fat securely.

Consequently, the fat gradually pushes forward, resulting in a bulging appearance under the eyes.

The loss of skin elasticity and subsequent sagging that comes with aging also plays a role.

As the skin stretches, an area that looks like a small pouch is formed.

Another important factor is the fat pad that supports the eyeball.

When this fat is not in its proper place and protrudes forward, it creates a puffy, swollen appearance under the eyes.

On top of this, if fluid accumulates further due to lifestyle factors such as allergies or excessive salt intake, the swelling and puffiness worsen, making the under-eye fat appear far more prominent.

In other words, under-eye fat does not occur simply from "gaining weight," nor does it appear solely from "being tired."

It is best understood as a complex result influenced by muscles, the orbital septum, fat, skin, and even lifestyle habits.

Why lower eyelid under-eye fat protrudes

It is easy to understand if you look at the anatomical illustration by Dr. Siew from Singapore.

Stretched orbital septum – The septum, which originally prevented the fat from protruding forward, stretches and loses its function.

Protrusion of orbital fat – As the septum weakens, fat pushes forward.

Sagging of anterior cheek fat – As the anterior cheek hollows, both under-eye hollowing and nasolabial folds worsen simultaneously.

In other words, it is not simply an issue with fat alone, but requires addressing complex structural changes where the septum, fat, and anterior cheek are all simultaneously involved.

Fat repositioning + Septal reinforcement + Anterior cheek lifting (± Small amount of fat removal if necessary)

All of these must be performed to achieve improvement in the lower eyelid.

1. Under-eye fat removal

On the surface, the method seems simple.

Since the area under the eyes is bulging, it is easy to think that simply removing the causative fat is the answer.

In fact, in the past, this was the most commonly used method.

Immediately after surgery, the under-eye bags disappear and the appearance looks smooth, so patients are often satisfied initially.

However, over time, problems begin to surface.

The fat that protects and supports the eyeball is not merely a "useless lump."

It is an important structure that acts as a kind of cushion; when it is gone, the support around the eyes weakens.

As a result, the upper eyelids hollow, double eyelids become smaller, and a gaunt, tired appearance emerges where the bones appear prominent.

Furthermore, it can make aging appear accelerated.

In particular, the skin around the eyes, lacking fat, becomes thinner, causing blood vessels to show through and dark circles to worsen.

In other words, fat removal alone not only fails to resolve the fundamental problem, but can actually create new issues.

That is why I do not recommend methods that unnecessarily remove fat.

2. Under-eye fat repositioning

As explained above, fat removal alone not only fails to solve the root problem, but can also create new issues instead.

Due to these problems, rather than simply removing the fat, the method of shifting and repositioning it has been widely performed recently.

Instead of extracting the fat, it is a method where the protruding fat is spread and used to fill in the hollow tear trough.

Doing this reduces the bulging areas and fills in the sunken parts, making the under-eye area look much softer and smoother.

This is certainly a much better approach than fat removal.

However, this also has its limitations.

Even if the tear troughs are improved, the impression can still look tired if the front cheekbones are sunken.

In other words, while the under-eye area has been tidied up, it falls short of making the entire face look youthful.

This is where the feedback frequently given by patients comes from: "It’s a bit better, but I don’t feel like there's a definite difference."

Furthermore, fat repositioning alone cannot solve the problem of a stretched orbital septum.

The septum is a "wall"-like structure that holds the fat in place,

and if it is weakened, simply relocating the fat can lead to bulging again over time or result in an uneven texture.

In the end, while "fat repositioning" is certainly an advanced method compared to "fat removal,"

long-term satisfaction is bound to decline if correcting sunken front cheeks and reinforcing the septum are not performed together.

Reflections by Facial Designer Dr. Kim Seong-hoon

The lower eyelid is an area that cannot be simply defined by words like "bulging" or "sunken."

Because fat, septum, muscle, bone, and even the front cheekbones are all interconnected, taking the wrong approach can actually ruin one's appearance.

I always emphasize to my patients:

"There is no single right answer in surgery. One must comprehensively read the structure and condition of the face."

Removing fat unconditionally is not the answer, nor is simply repositioning it.

If the septum has weakened, it needs to be reinforced, and if the front cheeks are sunken, lifting is required.

Only when that balance is struck will a natural and long-lasting result emerge.

This is also why I use the title "Face Designer."

Design is not about forcibly creating something that isn't there, but the process of reviving the harmony that was originally present.

Lower blepharoplasty is not a surgery that merely makes one look young, but one that restores the natural vitality inherent to the face.

In fact, many patients say that after the surgery, they no longer hear people saying they "look tired."

Also, rather than saying "I look younger," they give feedback like "My face has brightened up" and "I have aged backward naturally."

This is not just a simple cosmetic change, but a restoration of facial expressions and impressions.

The lower eyelid is a position that represents the balance of the midface.

It may seem like a small change, but correcting this balance transforms the entire impression.

That is why I always design surgeries based on anatomical truth without exaggeration.

Considering each patient's face as a canvas, I work to bring out the original lines rather than forcibly layering colors over it.

Moving forward, rather than hearing that they "had plastic surgery,"

I will continue to work so that patients hear that they "don't look tired and look natural,"

I will uphold my philosophy as a face designer.

Sincerely, Sung-hoon Kim, Face Designer

FAQ

Q1. Can the fat not be completely removed?

A1. It is absolutely not recommended. Recurrence, hollow eyes, and accelerated aging may occur.

Q2. Isn't fat repositioning alone enough?

A2. It improves in the short term, but satisfaction drops because sunken front cheekbones are not resolved.

Q3. Is orbital septum reinforcement really necessary?

A3. Yes, reinforcement is essential because fat protrudes as the septum stretches.

Q4. Why is front cheekbone lifting necessary?

A4. If sunken front cheekbones are not corrected, an overall youthful impression cannot be achieved.

Q5. Are surgical scars very visible?

A5. The incision line is located right below the eyelashes and becomes almost invisible over time.

Q6. How long is the recovery period?

A6. Stitches are usually removed after one week, and swelling and bruising gradually disappear over 2 to 3 weeks.

Q7. Can I still undergo surgery if I have already had fillers or fat grafting?

A7. Yes, it is possible. It can be corrected even if it has become uneven due to previous procedures.

Q8. How difficult is revision surgery?

A8. The difficulty increases in cases of simple fat removal or overcorrection, but it is fully correctable.

Q9. Is this surgery possible regardless of age?

A9. It is possible for anyone in their 30s to 60s, and the approach is designed differently for each age group.

Q10. Are the results maintained in the long term?

A10. When fat repositioning, orbital septum reinforcement, and front cheekbone lifting are performed together, stable results are seen over the long term.

※ This post reveals actual before and after photos of the surgery to provide accurate information.

Please note that these photos were posted with the patient's consent, and bruising and swelling may vary and differ from person to person.