Semin Plast Surg 2002; 16(2): 199-206
DOI: 10.1055/s-2002-32261
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Avoiding Complications of Fat Repositioning

Robert Alan Goldberg
  • Department of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA
Further Information

Publication History

Publication Date:
17 June 2002 (online)


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]).