Surgeons performed 120,755 eyelid surgeries in the United States in 2024. That made blepharoplasty the fifth most common cosmetic surgical procedure in the country, per the American Society of Plastic Surgeons. A quieter complaint travels alongside that volume: eyes that look tighter but also hollow, scooped out, unmistakably operated on.
Dr. Andrew Jacono, a dual board-certified facial plastic surgeon based in Manhattan, has built part of his reputation on avoiding that outcome. He is best known for developing the extended deep-plane facelift, and he applies the same logic to the eyes. Rebuild what has shifted. Don’t cut away what remains.
Removing Fat Creates the Hollow Stare
Standard blepharoplasty has long relied on excising the fat pads that bulge beneath the lower lids or crowd the upper ones. “It’s still common practice to remove the fat pad from around the eyes with traditional blepharoplasty,” Dr. Jacono told Dermatology Times. “With or without fat grafting, it still de-volumizes the eyes.”
Fat under the eye does more than cause puffiness. It cushions the orbital rim. Once that cushion is removed, the hollow beneath the eye, known as the tear trough, only deepens.
Moving Fat Instead of Discarding It
Dr. Andrew Jacono’s alternative is fat transposition. Rather than excising the pads that bulge beneath the lower lids, he releases them and repositions the tissue downward into the tear trough itself. His practice describes the logic plainly: instead of removing the fat bags under the eyes, which creates a hollowed-out, plastic, and “done” look, Jacono moves the orbital fat down into the trough. The bulge and the hollow get addressed in one motion, not two separate procedures.
The technique also sidesteps a limitation of free fat grafting, a subject he examined in the Aesthetic Surgery Journal. Fat injected from elsewhere in the body loses roughly 30% of its volume as the body reabsorbs it. That shrinkage is unpredictable and can leave results uneven years later. Fat that stays attached to its own blood supply, simply moved rather than harvested and reinjected, survives at a far higher rate because it never stops functioning as living tissue.
Matching the Incision to the Patient
The New York surgeon doesn’t apply one approach to every eye. Younger patients in their 30s through 50s, who typically show volume loss without much excess skin, tend to be better candidates for a transconjunctival incision hidden inside the lower lid. Older patients carrying looser skin and muscle laxity often need the more extensive skin-muscle flap approach. That method lets Jacono tighten the orbicularis muscle, something a transconjunctival incision cannot reach.
Anatomy factors into the decision too. Patients with prominent eyes and a flatter cheekbone, a combination surgeons call a negative vector, face a higher chance of the lower lid pulling away from the eye after surgery. For that group, the transcutaneous approach carries a much higher risk of retraction. Dr. Jacono favors the transconjunctival route instead and adds a canthopexy, a stitch that reinforces the outer corner of the eye, to hold the lid margin in place.
The same calculation extends to the upper lid. Removing too much fat and muscle there creates its own version of hollowness. The fold’s natural character changes instead of simply looking rested. To guard against that, Jacono asks patients to bring photographs from decades earlier and uses their own younger eyes, not a generic template, as the surgical target.
What separates a rested result from an obviously altered one rarely comes down to a single incision or a single tool. It comes down to whether a surgeon treats fat as a problem to eliminate or as tissue worth relocating, and whether the surgical plan bends to a patient’s own bone structure and skin quality instead of a fixed protocol applied to every face that walks through the door.
