553
FACIAL PLASTIC
Lower Blepharoplasty:
Transconjunctival Fat Repositioning
a,b,c,*
Paul S. Nassif, MD
& Surgical technique
& Postoperative care
& Complications
Over the last decade, lower transconjunctival
blepharoplasty has become the method of choice
used by facial plastic surgeons for the treatment of
lower eyelid herniated fat owing to the reduced rate
of complications and the hidden incision [1,2]. The
primary complications of the transcutaneous ap-
proach are lower lid retraction with scleral show,
lower lid ectropion, and rounding of the lateral
canthal angle [3].
Traditionally, lower eyelid herniated fat is re-
moved, which may cause a sunken or hollow lid ap-
pearance, especially in patients with a tear-trough
deformity. A tear-trough deformity or nasojugal
fold is usually caused by the inferior descent of
the cheek (malar mound) with age or an ana-
tomic bony deficiency of the maxilla, producing a
depression at the medial inferior orbital rim [Fig. 1]
[4]. Additionally, the midface descends, creating a
double-convexity contour deformity (lower eyelid
herniated orbital fat convexity followed by the
cheek/malar mound convexity) [Fig. 2]. Fat preser-
vation in the lower eyelid, which was originally
described in 1996, may prevent some of these con-
tour irregularities [5]. Fat repositioning is defined
as the subperiosteal repositioning of the medial
and central lower lid herniated orbital fat into the
a
Department of Otolaryngology, University of Southern California School of Medicine, Los Angeles, CA, USA
b
Department of Otolaryngology, University of California, Los Angeles School of Medicine, Los Angeles,
CA, USA
c
Spalding Drive Cosmetic Surgery & Dermatology, 120 S. Spalding Drive, Suite 315, Beverly Hills,
CA 90212, USA
* Spalding Drive Cosmetic Surgery & Dermatology, 120 S. Spalding Drive, Suite 315, Beverly Hills, CA 90212.
E-mail address: drnassif@spaldingplasticsurgery.com
1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am 13 (2005) 553–559
& Results
& References
nasojugal fold. The lateral orbital fat pad may be
repositioned into the lateral inferior orbital region
if needed.
Advantages of fat repositioning include preven-
tion or improvement of a tear-trough deformity and
treatment of the herniated orbital fat. The disad-
vantages of fat repositioning are the steep learning
curve and potential complications such as diplopia
owing to injury of the inferior oblique muscle, fat
granulomas, prolonged edema, and, rarely, soft-
tissue irregularities.
Candidates for fat repositioning include patients
with the following:
•
Lower eyelid herniated fat
•
Presence of a tear-trough deformity
•
Acceptance of the possible risks and complications
• Realistic expectations
Often, this technique is used to soften moderate-
to-severe tear-trough deformities in patients with
minimal to no herniated fat because the fat may
be released once the septum is opened. In addi-
tion, a lower eyelid skin pinch may be performed
in patients with excess skin in the lower lid and
adequate lower lid tone. Often, lower eyelid fat
repositioning is combined with a subperiosteal
doi:10.1016/j.fsc.2005.06.006
554 Nassif

Fig. 1. Frontal view of a female patient following

traditional transconjunctival removal of lower eyelid
herniated orbital fat with resultant tear-trough defor-
mity (nasojugal fold) (arrow).
midface-lift to rejuvenate completely the lower
eyelid–cheek region.
Surgical technique
Transconjunctival fat repositioning is performed
with the patient under local or general anesthesia.
With the patient in the supine position, a surgical
marker is used to mark the nasojugal groove. One
drop of tetracaine ophthalmic solution is instilled
in each eye. One percent lidocaine (Xylocaine) with
1:100,000 epinephrine is injected into the lower
conjunctival surface and subcutaneously and sub-
periosteally over the inferior orbital rim nasal to the
nasojugal fold. With the use of a Desmarres retrac-
tor, the lower conjunctival area is exposed. The
preseptal approach involves a transconjunctival
incision at the inferior edge of the tarsus using a
Colorado needle [Fig. 3]. The incision is carried
through the lower eyelid retractors with care taken
not to injure the tarsus. A preseptal dissection
[Fig. 4] is performed bluntly with surgical q-tips.
Fig. 3. Transconjunctival incision at the inferior edge
of the tarsus (arrows) using a Colorado needle on the
right eye.
A 4-0 black silk traction suture is placed through
the posterior conjunctival flap to protect the cor-
nea and to aid with exposure of the fat pads. With
slight pressure on the globe, the medial fat is iden-
tified. With the Colorado needle, a buttonhole is
made in the septum exposing the medial fat pad.
The fat is made into a pedicle for repositioning by
thinning and elongating it with careful dissection of
the surrounding fibrous attachments. The base of
the pedicle is kept intact to ensure viability of the
fat pad. While grasping the fat pad with forceps,
blunt dissection is performed using q-tips or scis-
sors between the fat pad and the inferior oblique
muscle to ensure that the fat pad is not adherent to
the inferior oblique muscle [Fig. 5]. This maneuver
prevents tethering of the muscle to the fat pad
during repositioning. During the entire dissection,
meticulous dissection and hemostasis helps pre-
vent injury to the inferior oblique muscle.
If the central fat pad is to be repositioned, the
same procedure described previously is performed

Fig. 2. (A) Frontal view of a patient with midface descent and a double-convexity contour deformity. The lower
eyelid shows a herniated orbital fat convexity (small arrow) followed by the cheek/malar mound convexity (large
arrow). (B) One year postoperative photograph demonstrating improvement in lower eyelid contour following
lower eyelid transconjunctival fat repositioning and an endoscopic subperiosteal midface-lift. An endoscopic
brow-lift and upper blepharoplasty were also performed.
 Lower Blepharoplasty 555

Fig. 4. A preseptal dissection is performed bluntly on Fig. 6. The medial (small arrow) and central (large
the right eye keeping the septum intact. arrow) fat pads are grasped with forceps and a “see-
saw” movement is made in the left eye, allowing free
movement of the fat pads from the inferior oblique
with one caveat. Fibrous attachments between the muscle (arrowhead).
medial and central fat pads need to be released with
blunt or sharp dissection to prevent tethering of the
fat pads to the inferior oblique muscle. Following
nerve but may extend to the lateral rim if reposi-
this maneuver, both fat pads are grasped with for-
tioning is to be performed with the lateral fat pad.
ceps, and a ‘‘see-saw’’ movement is made allowing
A Freer elevator is used to elevate a nonconstricted
free movement of the fat pads from the inferior
subperiosteal pocket along the inferior orbital rim
oblique muscle [Fig. 6]. The lateral fat pad is
from the infraorbital nerve to the medial/inferior
usually excised or may be used for repositioning
aspect of the nasojugal fold.
if indicated.
A 4-0 polypropylene suture on a FS-2 needle is
For the repositioning portion of the procedure, a
passed through the skin medial to the nasojugal
Jaeger plate is placed over the fat pads and the
groove and retrieved in the subperiosteal pocket
inferior oblique muscle. A Senn retractor is used
[Fig. 8]. Next, the suture is placed through the
to retract the lower eyelid and the orbicularis oculi,
medial fat pad pedicle while the pedicle is splayed
exposing the inferior orbital rim and arcus margi-
out [Fig. 9], into the subperiosteal pocket, and,
nalis [Fig. 7]. Using the Colorado needle, an in-
finally, exiting the skin just inferolateral to the
ferior orbital rim incision is made through the
location of the first suture. The suture is used to
periosteum approximately 2 mm inferior to the
pull the pedicle toward the distal aspect of the
arcus marginalis. The medial border of the inci-
medial subperiosteal dissection, in essence, bring-
sion is immediately lateral to the medial puncta.
ing the pedicle through the tear-trough deformity
The lateral border of the incision on the inferior
orbital rim is approximately above the infraorbital

Fig. 7. A retractor is used to retract the lower eye-

Fig. 5. Sharp dissection is performed on the right eye lid and the orbicularis oculi muscle in the left eye,
between the medial fat pad (small arrow) and the exposing the inferior orbital rim and arcus margina-
inferior oblique muscle (large arrow) using scissors. lis (arrows).
556 Nassif
Fig. 8. A suture and needle (white arrow) are passed
through the skin and orbicularis oculi muscle (black
arrow) in the right eye medial to the nasojugal groove
and retrieved in the subperiosteal pocket.
while ensuring that the fat pedicle is splayed out
and not bunched. Once again, care is taken to en-
sure that the inferior oblique muscle is free from
the fat pedicle. The polypropylene suture is gently
tied down over a cotton bolster. The central fat pad
is repositioned inferolateral to the medial fat
pad with the same suture technique [Fig. 10]. The
subperiosteal pocket is irrigated, and platelet-rich
plasma (if used) is sprayed into the pocket. Forced
ductions are performed to confirm the absence of
inferior oblique muscle tethering. There should be
no movement on the fat pedicle as the globe is
rotated. This procedure is repeated on the contra-
lateral side. If a lower eyelid skin pinch is to be
performed, a Frost stitch may be used if mild laxity
of the lower eyelid is diagnosed preoperatively. If
moderate-to-severe lower eyelid laxity is present, a
lower eyelid tightening procedure should be per-
formed. Following the procedure, both sides are
Fig. 9. The medial fat pad pedicle (arrow) in the left
eye is splayed out before placement of suture.
Fig. 10. The central fat pad in the left eye (small arrow)
is repositioned inferolateral to the medial fat pad
(large arrow).
checked for symmetry. An antibiotic-steroid oph-
thalmic ointment is placed in each eye.
Postoperative care
Patients are instructed to apply cold compresses to
the eyes for 48 hours. For 1 week, patients are in-
structed to maintain a semi-upright position when
sleeping or resting. An antibiotic-steroid ophthal-
mic drop is used for 5 days because chemosis in
not uncommon. Artificial tears are used frequently
throughout the day for 5 days. A steroid dose pack
is prescribed as needed.
A cursory eye examination checking for diplopia,
gross visual acuity, edema, and chemosis is per-
formed on the first postoperative day. On day 5,
the polypropylene suture is removed, and the repo-
sitioned fat is checked for symmetry. Patients may
resume full activities after 3 weeks.
Complications
The complications from fat repositioning are gen-
erally the same as for transconjunctival blepha-
Fig. 11. Fat granuloma (arrow) of the right lower eye-
lid following fat repositioning.
 Lower Blepharoplasty 557

Fig. 12. Frontal view (A) before and (B) 1 year after lower eyelid transconjunctival fat repositioning, endoscopic
brow-lift, and bilateral upper blepharoplasty performed on a 55-year-old-woman with dermatochalasis and
herniated lower eyelid fat. Oblique view (C ) before and (D) after surgery. Notice the improvement of the
lower eyelid contour and tear-trough deformity.

Fig. 13. Frontal view (A) before and (B) 20 months after lower eyelid transconjunctival fat repositioning, endo-
scopic brow- and midface-lift, and bilateral upper blepharoplasty performed in a middle-aged woman with
brow and midface ptosis, dermatochalasis, and herniated lower eyelid fat. Oblique view (C ) before and
(D) after surgery.
558 Nassif

Fig. 14. Frontal view (A) before and (B) after lower eyelid transconjunctival fat repositioning and upper blephar-
oplasty in a 38-year-old woman complaining of “a deep groove under her eyes and heavy upper eyelids.” The
before photograph reveals minimal herniated lower eyelid fat with a moderate tear-trough deformity. The after
photograph shows improvement of the tear-trough deformity.

roplasty except that the potential risk is higher
for diplopia owing to injury of the inferior oblique
muscle, fat granulomas, prolonged edema, and
soft-tissue irregularities. Diplopia is usually tran-
sient owing to edema; persistent diplopia re-
quires evaluation by an ophthalmology colleague.
Although rare, a fat granuloma [Fig. 11] may
be treated conservatively with intralesional ste-
roids or, if needed, more aggressively with local
excision. Prolonged edema (persisting for more
than 6 weeks) may be treated with oral steroids
and ultrasound.
Results
Since January 2001, the author and his colleagues
have performed fat repositioning procedures in
more than 100 patients with no visible fat reab-
sportion [Figs. 12–15]. This procedure has the
advantage of addressing the herniated fat while

Fig. 15. Frontal view (A) before and (B) after lower eyelid transconjunctival fat repositioning in a 35-year-old man
complaining of a “deep groove below my eyes.” Right frontal close up (C ) before and (D) after surgery. The
before photograph demonstrates minimal to no visible herniated lower eyelid fat with a moderate tear-trough
deformity, especially of the right eye. Following the fat repositioning, the hollowness is improved.

preventing lower eyelid hollowness and improv-
ing a tear-trough deformity. Fat repositioning
may be combined with one or more of the follow-
ing procedures:
• Endoscopic subperiosteal midface-lift
• Transcutaneous skin pinch
• Transconjunctival orbicularis oculi excision
As is true for any new procedure, thorough knowl-
edge of the current literature and anatomy and
observation of the procedure performed by an ex-
perienced surgeon should prelude any attempt at
lower eyelid transconjunctival fat repositioning.
References
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tival lower eyelid blepharoplasty: technique
Lower Blepharoplasty 559
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[2] Goldberg RA, Lesner AM, Shorr N, et al. The
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[3] Baylis HI, Goldberg RA, Groth MJ. Complications
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