Was 2024 the year we reached peak filler? What goes up must come down, and after reaching dizzying, anatomy-distorting heights, everyone from injectors to the injected seem to be easing back on inserting volumizing gels into lips, cheeks, and under-eyes.
Filler fatigue is well documented: Plastic surgery societies have reported people are getting fewer injections than they were, and reversals are on the rise. In an annual survey of plastic surgeons, the American Academy of Facial Plastic and Reconstructive Surgery found that for 24% of survey respondents, looking unnatural is their patients’ biggest fear when considering a facial procedure. “Filler fatigue is now very common, with many patients being overfilled and not happy with the way they look,” says Dr. Robert Schwarcz, M.D., a New York City-based board certified oculoplastic surgeon.
That doesn’t change the fact that people still want a treatment that helps restore volume loss in the face — that’s why fat grafting, aka fat transfer, has gotten more popular, especially in the under-eye area. This procedure is performed by extracting or harvesting the body’s own fat from another area, such as the stomach or thighs, purifying it, and then injecting it into the under-eye region.
“I’m seeing an increase in the number of patients coming to me to discuss concerns around the under-eye,” says Schwarcz, noting that there’s been an increase in the number of lower blepharoplasties — a type of eye surgery that specifically addresses the overhang (or excess skin or fat) under the eyes, which can lead to a reduction in shadows and dark circles — paired with fat transfers. Even when performed solo, without an accompanying lower blepharoplasty, “it’s a procedure that gives a longer lasting and more satisfying natural result than filler,” says Schwarcz.
Considering how wildly popular fillers are for plumping the tear trough or infraorbital hollow under the eyes, it might seem out of left field to even suggest that they’ve been overprescribed for this use. But just because almost everyone has been getting filler in these areas doesn’t mean they should. The risk versus reward of placing filler under the eyes has been long debated by dermatologists and plastic surgeons.
“Fillers can be quite effective in treating the overall appearance of the undereye area if the patient is the ideal candidate, which can be very tricky to judge and best left to the discretion of an oculoplastic surgeon,” Schwarcz says.
He notes that the ideal candidate for filler should not have skin that is too thin, too large of a fat bag, or anatomic fluid accumulation of a fluid festoon (a swollen, hammock-like bag in the lower eyelid and cheek region). However, even when patients are carefully vetted before being injected, Schwarcz says there is still worry of filler migration (filler moving away from their injection site to other parts of the face). There’s also a worry that its hydrophilic nature can draw fluid and cause swelling.
As the risks of filler for the under-eye area are becoming more well documented, patients are open to alternatives, which, though more invasive, give longer-lasting results. Liz Gaelick, a 60-year-old professional organizer and homemaker based in New York, had been getting fillers every year since the age of 48 for the sunken hollows under her eyes. “But it got to a point that my dermatologist said it would not help me anymore and recommended surgery,” she says. “In 2023, I decided I couldn’t look at myself in the mirror anymore and makeup only made things worse.”
That’s when she called Schwarcz, who recommended a fat transfer. “It seemed like the answer to my under-eye issue,” Gaelick says. She says she sailed through the recovery process with no pain and minimal swelling. Today, a year out, she loves her results and how smooth her under-eye looks. “It accomplished what the fillers could not — it’s the best thing I have ever done for myself.”
While fat grafting is performed to inject lost volume in several areas of the face and body — including the cheeks, temples, lips, hands, breasts, and buttocks — patients like Gaelick are becoming more open to getting it done under the eyes, too. Most plastic surgeons have been deploying this technique for years in patients who undergo face lifts or lower blepharoplasties, and even as a standalone procedure to restore volume in that area.
“I have been administering under-eye fat injections for about 25 years, with two to three treatments in my practice per week,” says Dr. Yannis Alexandrides, M.D., a London-based plastic surgeon who is board-certified in Europe and the United States, and is the founder of 111SKIN. He’s a big proponent of the technique, in part because it doesn’t have to be repeated at regular intervals. “I prefer fat transfer to filler because it lasts much longer, and in some cases, can even last forever since it’s your own fat cells and the body accepts this more readily,” he says. He estimates that about 25% of his patients request it of their own accord, often after doing their own research, or seeing the excellent results on people they know.
Dr. David Shafer, M.D., a board-certified New York City-based plastic surgeon and founder of Shafer Clinic Fifth Avenue, also performs several fat transfers each week in the under-eye, either alone or as part of a facelift and surgical rejuvenation procedures, and is increasingly seeing more patients open to it. “Patients like the option of an all-natural procedure that does not involve foreign substances,” he says.
Dr. Jennifer Levine, M.D., a board-certified facial plastic surgeon in New York City, also finds her patients are interested in seeking options beyond the realm of fillers. “Patients are more interested in regenerative procedures,” she says. “Fat is regenerative because it contains stem cells, so it does improve skin quality.”
Fat wins out over fillers in many other areas too: Hyaluronic acid fillers are known to attract water molecules and promote swelling around the eyelids. “Fat does not do this, making it an ideal treatment for patients seeking a long-lasting, more natural-looking result,” says Alexandrides.
Additionally, risks of migration are minimal, says Schwarcz, so the fat injected in your under-eye area two years ago won’t slip down to give a swelling in the cheek. Fat patients will also skip the Tyndall effect, he says, a side effect of fillers that have been too superficially injected, leaving the skin with a blue tinge.
But before you run to make an appointment, know this: Fat transfer is a surgery, which means it’s not going to be just a quick visit to an injector’s office with no preparation or downtime. It’s a process that requires anesthesia or sedation, and a week of downtime with bruising and tenderness in the transplanted area, as well as the part of the body where the fat has been extracted from. There’s also a pre-procedure consultation with the surgeon, in which the professional will assess facial anatomy, discuss the patient’s medical history and their desired results.
“Pre-op, you will be carefully marked and will receive local anesthesia or sedation,” Shafer says. Once numbed, the surgeon will harvest (or liposuction) the fat from the other areas of the body by making a small incision with a thin cannula. The fat is carefully removed and purified so it can be injected under the eye in the same manner as under-eye filler. “The fat is spun in a centrifuge and the fat cells are further broken down to 1200 microns with a sizing adinizer (a device that cuts the fat down to the desired size). This process takes about five minutes during operation time,” Schwarcz says.
“Post-op, there may be temporary tenderness, swelling, or bruising,” says Shafer. “There’s a follow-up appointment a few days later, to check on the results, and any complications.” He recommends taking time off or working from home for several days to allow time for healing.
Here, too, the right patient selection is key. “Fat transfer is most effective for patients who have significant volume loss or hollowness in the under-eye area or are dealing with sunken eyes due to the natural aging process, genetics, or weight loss,” says Shafer. The age demographic for his patients who get this procedure is between 30 to 50.
Alexandrides prefers to do fat grafting on patients who have tear trough deformity. “This is a loss of volume under where the eyelid ends and creates a deep line,” he says. “This line needs support to diminish, which is when I use fat transfer injections, and it helps improve volume and hollowness in that area.”