Fat repositioning in lower blepharoplasty

What it treats

• Removing lower lid fat through the septum alone can leave a concave, "operated" contour (PMID 7624408).
• Lower lid aging combines a fat bulge with a hollow tear trough just below it; repositioning treats both with the same fat instead of removing the bulge and leaving the hollow (PMID 10697189).
• Fat repositioning is used for tear trough deformity with a palpable fat pad, including patients with minimal or no visible fat herniation: in 232 patients (198 with no prior lid surgery, 34 with a prior history of fat removal), tear trough deformity was eliminated in more than 85% of cases (PMID 37220233).
• Tear trough anatomy and the ligament that tethers it are covered in tear-trough-and-lid-cheek-junction.md; the transconjunctival incision itself is covered in transconjunctival-blepharoplasty.md.

How it is done

• Loeb described sliding the orbital fat pad over the rim, and grafting fat, to level lid depressions (PMID 7338007).
• Hamra released the arcus marginalis, the septal attachment at the orbital rim, and advanced lower lid fat over the rim, in 152 cases over 3 years of composite rhytidectomy and isolated blepharoplasty (PMID 7624408).
• Hamra later added the septal reset, advancing the orbital septum itself over the rim for a firmer lid undersurface than fat transposition alone provides (PMID 15253208).
• Goldberg moved medial and central fat pedicles through a transconjunctival incision into a subperiosteal pocket on the maxilla, 24 patients followed 6-30 months, with some variable fat resorption (PMID 10697189).
• Plane comparison, 40 patients, single surgeon: fat transposed to the subperiosteal plane was more meticulous, less disruptive of normal anatomy and caused less bleeding; the supraperiosteal plane was faster but more traumatic, with more bruising, swelling and temporary contour irregularity; final aesthetic result did not differ significantly (P=.45), and satisfaction was 100% in both groups (PMID 23471339).
• Supraperiosteal fat repositioning with a midface lift, 1,152 Asian patients, 2,304 eyes: performed through a transforniceal approach in 16% and a transcutaneous skin-excision approach in 84% (PMID 38353810).
• Submuscular and preorbicularis planes were developed to address difficulties reported with the subperiosteal plane; fat transposed above the orbicularis muscle was described in 41 patients followed at least 44 months (PMID 33538121).
• An orbicularis oculi muscle overlap method combined with fat repositioning was developed for thin eyelids with persistent tear trough deformity after standard fat-sliding or arcus-release technique, 10 patients (PMID 24938691).
• Septal reinforcement with inverted-T or X-shaped plication, combined with fat preservation and septal repositioning below the arcus marginalis, 93 patients, mean follow-up 25 months (PMID 29566215).
• Fat flap transposition stabilized with nasal alar base filling, 104 patients aged 22-49, to fill the tear trough and nasal alar base while preserving the fat pedicle's blood supply (PMID 39340682).
• Reconstructing the orbital fat flap to extend pedicle length and preserve its vascular supply, for more complete tear trough coverage where the standard pedicle is too short (PMID 39511024).
• Orbital septal fat release and preservation, used as a base for the orbitopalpebral sulcus rather than repositioned as a discrete pedicle, 20 patients (PMID 28180921, PMID 28337617).
• Extended transconjunctival technique, 54 patients: fat pads excised, the tear trough ligament and orbicularis retaining ligament released, and the excised fat grafted under the released ligament rather than repositioned on a pedicle (PMID 28746272).
• Extended technique with ligament release and free fat grafts, 200 consecutive patients, mean follow-up 22 months (PMID 41150997).
• Tear trough ligament release alone, allowing spontaneous repositioning of sub-orbicularis fat without a formal pedicle transfer, 73 patients (PMID 42247776).
• Midface rejuvenation combining a preperiosteal midcheek lift, lower blepharoplasty with orbital fat used as a transposition flap, and autologous fat grafting, 14 patients (PMID 28684338).

Results and evidence

• Long-term 3-dimensional volume assessment, 10 patients, mean follow-up 12 months (range 10-16): average volume gain 0.64 mL in the tear trough and upper cheek, with no significant difference between sides (P=.49); results were reproducible at long-term follow-up (PMID 26847158).
• Comparative trial, 101 patients: intraorbital fat repositioning with septal reset (51 patients, 102 eyes) produced significantly greater improvement than autologous fat grafting (50 patients, 100 eyes) in Grade II and III tear trough deformity; 4 of 102 eyes in the repositioning group and 7 of 100 in the grafting group showed no improvement (PMID 28008460).
• Minced free fat graft (69 patients) against pedicle fat flap (73 patients): no significant difference in complications or satisfaction; reoperation 5.8% against 12.3% (P=0.2) (PMID 37463504).
• Randomized trial, 50 patients, traditional excision against fat transposition, both with canthopexy: 96% improvement on photographs and improved self-esteem scores at 6 months (PMID 22124642).
• Plication series, 93 patients: immediate mild lid retraction or malposition, when it occurred, recovered without treatment within 1-2 weeks; no permanent malposition or ectropion (PMID 29566215).
• Fat flap plus nasal alar base filling, 104 patients: postoperative Hirmand grade 0 (no visible deformity) in 92.3%; self-reported satisfaction in 88.5%; ultrasound showed no gap at the fat flap 6 months after surgery (PMID 39340682).
• Fat herniation not required for benefit: in the same 232-patient series, complaints of extremely or moderately severe tear trough fell from 86.3% before surgery to 34.0% after; lower eyelid FACE-Q scores improved significantly (P<0.05) (PMID 37220233).
• Extended technique with ligament release, 54 patients, mean follow-up 10 months: revision rate 2%; no chemosis, prolonged swelling, lower eyelid retraction or ectropion (PMID 28746272).
• Extended technique with free fat grafts, 200 patients, mean follow-up 22 months: no scleral show; fat necrosis 3.5%; revision 1.0% (PMID 41150997).
• Ligament release alone, 73 patients, mean follow-up 10 months: excellent outcomes in 19 of 21 Grade I, 29 of 33 Grade II and 14 of 19 Grade III deformities, with no poor outcomes; satisfaction trended lower with more severe deformity, not a statistically significant difference (P>0.05) (PMID 42247776).
• Supraperiosteal repositioning with midface lift, 1,152 patients, average follow-up 10 months: 78% extremely satisfied and 19.1% satisfied at 6 months; no facial numbness, paralysis, new diplopia or granuloma reported (PMID 38353810).
• Midface lift through a skin-muscle flap, 130 patients: tear trough volume increased on 3D imaging whether fat was left alone, repositioned or removed, mean follow-up 12 months (PMID 36719989).
• Transconjunctival deep-plane midface lift, 124 patients, median follow-up 56 months: no significant complications; patients with heavy excess skin or festoons were advised traditional techniques instead (PMID 22859542).
• Fat above the orbicularis muscle, 41 patients, minimum 44-month follow-up: correction maintained in all patients, no contour irregularity or long-term complication (PMID 33538121).

Risks and complications

• Meta-analysis, 33 studies, 4,671 patients, fat grafting or repositioning for tear trough or lid-cheek junction: total complications 11.2%, contour irregularity or undercorrection 6.2%, hematoma/swelling/bruising 6.2%, reoperation 2.4% (PMID 39158343).
• Eye movement study, 18 eyelids in 9 patients: fat repositioning did not affect binocular vision; vertical and horizontal eye movements worsened at 3 months but did not differ significantly from baseline by 6 months (PMID 34260464).
• Supraperiosteal repositioning series, 1,152 patients: among those done through the transcutaneous route, lower lid ectropion requiring a lateral tarsal strip occurred in 0.6%; revision for residual lateral fat occurred in 0.7% (PMID 38353810).
• Fat herniation series, 232 patients: transient conjunctival bleeding in 12, eyelid numbness in 2, dry eye in 6, all resolving spontaneously; undercorrection of the tear trough occurred in 30 (PMID 37220233).
• The supraperiosteal plane caused more temporary bruising, swelling and contour irregularity than the subperiosteal plane in a single-surgeon comparison (PMID 23471339).
• Midcheek lift combined with fat-preserving blepharoplasty and fat grafting, 14 patients: 2 cases of ectropion, resolved with daily massage (PMID 28684338).

Recovery

• Repositioned fat is fixed with a suture removed at 3-5 days; contour settles over 1-2 months (PMID 10697189).
• Combined fat flap and nasal alar base filling, 104 patients: followed at least 6 months, with no obvious gap seen on ultrasound at that point (PMID 39340682).
• Extended ligament-release technique, 54 patients: mean follow-up 10 months, with a 2% revision rate and no prolonged swelling (PMID 28746272).
• Volume gain from repositioned fat was stable at a mean follow-up of 12 months, with no significant loss between the 10- and 16-month extremes of follow-up in the group studied (PMID 26847158).

With a facelift

• Hamra performed arcus marginalis release with fat preservation in every composite rhytidectomy, and in isolated blepharoplasty for patients without advanced facial aging (PMID 7624408).
• The septal reset was added to composite rhytidectomy after orbicularis repositioning and fat transposition (PMID 15253208).
• TOPS database, 13,346 facelifts: blepharoplasty was the most common added procedure, and combined procedures raised the odds of adverse events (PMID 32459769).
• Facelift approach can be chosen by midface ptosis grade, with transconjunctival blepharoplasty plus skin pinch or fat transposition as the lower lid options (PMID 33657627).
• Midcheek lift in the preperiosteal plane, combined with a fat transposition flap and autologous fat transfer, was used for concurrent midface and lower lid aging in 14 patients (PMID 28684338).
• Supraperiosteal fat repositioning is routinely combined with a midface lift; a 1,152-patient series used a transforniceal or transcutaneous route to reach the plane (PMID 38353810).

Current questions

• Subperiosteal against supraperiosteal plane: the only direct single-surgeon comparison found no significant difference in final result, though the supraperiosteal plane caused more short-term bruising and irregularity (PMID 23471339).
• Pedicled transposition against free fat grafting: a 142-patient comparison of minced graft and pedicle flap found equal outcomes (PMID 37463504); a 101-patient comparison of repositioning and lipoinjection favored pedicled repositioning for higher-grade deformity (PMID 28008460).
• Plane choice beyond subperiosteal and supraperiosteal now includes submuscular and preorbicularis placement, each proposed to solve problems reported with the others, without a head-to-head comparison identified (PMID 33538121).
• Whether visible fat herniation is required before repositioning: a 232-patient series reports benefit with only a palpable, non-herniated fat pad (PMID 37220233).
• Transposing fat is reported as probably easier to control through the transcutaneous skin approach than transconjunctivally, though a 2025 review of 24 studies found the comparative evidence too weak to be certain (PMID 41415593).
• Ligament release alone, without a formal fat pedicle, is proposed as a simpler alternative to fat transposition or septal manipulation, pending controlled trials (PMID 42247776).

Terms

• Fat repositioning (transposition): moving orbital fat on its blood-supplying pedicle over the orbital rim instead of excising it (PMID 7338007).
• Arcus marginalis: the attachment of the orbital septum to the bony orbital rim, released to allow fat to move over the rim (PMID 7624408).
• Septal reset: advancing the orbital septum itself, not just the fat, over the rim (PMID 15253208).
• Subperiosteal plane: a pocket for the fat pedicle created under the periosteum of the maxilla (PMID 10697189).
• Supraperiosteal plane: a pocket for the fat pedicle created above the periosteum, over the bone (PMID 23471339).
• Free fat graft: fat that is excised, then placed without a vascular pedicle, relying on revascularization (PMID 37463504).
• Tear trough ligament: the ligament tethering the lower lid to the bone at the tear trough, released in some repositioning techniques (PMID 28746272).
• Hirmand grade: a grading scale for tear trough deformity severity, from 0 (no visible deformity) upward (PMID 39340682).
• Orbicularis retaining ligament: the ligament tethering the lid-cheek junction laterally, released in extended techniques (PMID 28746272).

Papers