ABSTRACT
Fat repositioning represents an evolution in surgical philosophy of rejuvenation of
the periorbital complex. Blepharoplasty surgery has changed substantially over the
past 30 years. In the 1970s, lower blepharoplasty was primarily about removing skin
and fat. A common sequela was hollow orbit, lower eyelid retraction, rounding of the
lateral canthal angle, and canthal dystopia with inferior displacement (Fig. [1]). When I look at results from that era, I think we sometimes made our patients look
worse than before surgery. The first evolution, 20 years ago, was to eliminate a skin
incision. We began utilizing the transconjunctival approach to the lower eyelid fat
almost exclusively. This virtually eliminated the risk of lower eyelid retraction.
Skin issues were addressed using skin pinch (we refer to this as ``anterior-posterior''
lower blepharoplasty) or rejuvenation with chemical peel or, later, laser resurfacing.
However, it is easy to remove too much fat, and when I look at postoperative results
from this period I now recognize that I commonly produced a deskeletonized lower eyelid
with hollow orbit deformity (Fig. [2]). In the third stage of evolution, over the past decade, we have developed a better
sensitivity to the contours of the lower eyelid and midface that characterize aging.
Loss of fat is an aging change, and descent of the midface, with accentuation of the
tear-trough deformity at the trailing edge of the SOOF, is a common aging characteristic.
These contour changes are not improved and, in fact, can be worsened by fat removal
alone. We now recognize that rejuvenation of the lower eyelid must take into account
the underlying bony structures, including relative maxillary hypoplasia, midface descent,
and issues of skin quality. Lower blepharoplasty now typically includes fat repositioning,[1] possible maxillary onlay implants, vertical midface elevation, and, often, laser
resurfacing or chemical peel to address skin quality issues (Fig. [3]).
KEYWORDS
Fat repositioning complications - orbital fat repositioning - blepharoplasty surgery
