Demographic Data of Orbital Fat Removal for Dark Circles Under Eyes in Nationwide Cosmetic Surgery Group

Abstract

Background:

Transconjunctival orbital fat removal has exhibited an increasing trend in Japan. This study, conducted in more than 100 clinics in Japan, aimed to contribute to the evolving body of evidence guiding surgical procedures.

Methods:

We analyzed data from our institutional database of 127,505 patients who underwent orbital fat removal for dark circles under the eyes at our clinic. Parameters evaluated included age, sex, occupation, number of debridement sites, medications, and comorbidities.

Results:

The number of procedures has been increasing annually, surpassing 70,000 in 2023. A total of 86.5% of patients were women and 13% were men. The top 3 occupations of patients included company employees (46.2%), housewives (10.4%), and others (9.9%). The median age of patients was 43 (range 33–51) years, showing a trend toward older age. Nearly all excess orbital fatty areas were removed via total resection. Patients undergoing total resection were significantly older on average compared with those undergoing partial resection. Comorbidities, including hypertension, glaucoma, and retinal disease, tended to increase annually. Both steroids and antiplatelet/anticoagulant medications were increasingly used, with the former accounting for 26.5 patients per month and the latter for 10.8 patients per month in the last year.

Conclusions:

The number of middle-aged and older patients is increasing, suggesting a future increase in procedures. The aging demographic will likely lead to a higher prevalence of comorbidities and high-risk medications in the patient population. Surgeons must be aware of these risk factors and possess the skills to manage them safely and effectively.

Takeaways

Question: Knowing the trends in this treatment can improve the management of orbital fat removal in the future.

Findings: Large retrospective studies have shown that the age of patients undergoing orbital fat removal is increasing, and with it the comorbidities and high-risk medications.

Meaning: The age of patients undergoing the orbital fat removal is increasing, as are comorbidities and high-risk medications.

INTRODUCTION

Cosmetic surgery in Japan has witnessed a surge in recent years. Notably, eyelid surgery dominates the field, accounting for 60% of all cosmetic procedures.¹ Orbital fat removal for treating dark circles under the eyes has also seen a significant rise. Initially accounting for 4.2% of all procedures performed from September 2018 to August 2021, its prevalence surged to 11.5% from September 2021 to February 2023, accompanied by shifts in patient demographics.²

As the fastest-growing and largest cosmetic surgery group in Japan, our team aimed to leverage extensive data analysis to gain deeper insights into the current landscape and evolving trends of cosmetic surgery in the country. In recent years, research on cosmetic surgery has intensified worldwide, underscoring the need for further evidence accumulation on procedural efficacy.

With a dearth of current data on transconjunctival orbital fat removal in Japan, it is important to provide an initial overview of the status of this procedure. Therefore, this study aimed to understand the background and trends of patients undergoing transconjunctival orbital fat removal and to accumulate evidence in this area for the optimal management of this procedure.

METHODS

This study was approved by the ethical review board of Tokyo Chuo Beauty Clinic (approval number: UMEDAERB-2024Feb001). The requirement for informed consent was waived owing to the retrospective nature of this study.

Data Analysis

We analyzed data from our institutional database of 127,505 patients who underwent orbital fat removal for under-eye dark circles at our clinic between October 2020 and April 2024. A combination of orbital fat removal with fat grafting or hyaluronic acid injection was included in this study according to the cosmetic surgeon’s diagnosis. Fat redistribution through the transconjunctival approach was excluded from this study. All data with no missing values were included. To understand how this procedure changed over time in our group, we compared annual data on the procedure. We evaluated factors such as the number of procedures, patient age, sex, occupation, procedure type, medications, and medical history. The chi-square test (2-tailed P value) and Tukey multiple comparison test were used for statistical analyses, with a P-value less than 0.05 deemed statistically significant.

Procedure

The indication for orbital fat removal was determined by a consultation with a cosmetic surgeon. In some cases, dark circles become more prominent after orbital fat removal. Hyaluronic acid or autologous fat is injected as appropriate under the cosmetic surgeon’s diagnosis.

RESULTS

Patient Backgrounds and Demographics

Figure 1 depicts the patient background and demographics, with approximately 86% being women and the rest being men. Company employees formed the largest occupational group, followed by housewives, other, self-employed, and medical professionals.

Fig. 1.

Patient backgrounds and demographics.

Number of Procedures

Figure 2 illustrates the number of treatments per year. The number of procedures has steadily increased each year, notably surpassing 70,000 in 2023. This figure doubled annually from 2020 to 2023 and has remained consistent in 2024.

Fig. 2.

Number of procedures per year.

Patient Age Distribution

Figure 3 displays the median patient age as 43 (range 33–51) years. The average age has shown a gradual increase over the years. Notably, the mean age in 2022, 2023, and 2024 was significantly higher compared with 2020 and 2021, indicating a trend toward older patient demographics. Additionally, the mean age was significantly higher in both 2023 and 2024 compared with 2021 and 2022, respectively. No significant differences were observed in the average age between 2023 and 2024. Notably, the average age plateaued in 2024.

Fig. 3.

Age of patients. ※:, P < 0.05 vs 2020; #, P < 0.05 vs 2021, *, P < 0.05 vs 2022.

Type of Procedure (Partial Versus Total Removal)

Nearly all procedures involved total fat removal (116,653 patients; 92.2%), with only 7.8% (9874 patients) opting for partial removal (Fig. 4). The mean age by procedure type was 36.7 ± 0.7 for partial removal and 42.4 ± 0.05 for total removal, with a significant difference between the 2 groups (P < 0.05).

Fig. 4.

Percentage and average age of patients for each procedure type (partial vs total removal).

Medical History

The prevalence of preexisting conditions such as hypertension, glaucoma, and retinal disease showed a yearly increase, reaching approximately 8.4, 5.6, and 2.8 per 1000 patients by 2024 (Fig. 5).

Fig. 5.

Comorbidity of patients who underwent transconjunctival orbital fat removal for dark circles under the eyes.

Medication Usage

The steroids administered included prednisolone in 294 (75.0%), betamethasone in 51 (13.0%), hydrocortisone in 23 (5.9%), methylprednisolone in 18 (4.6%), and dexamethasone in 6 (1.5%) patients. The number of patients taking oral steroids increased rapidly from 2.7 patients per month in 2020–2023 to 26.5 patients per month in 2023–2024. The breakdown of anticoagulant usage was as follows: aspirin, 94 (50.0%); direct oral anticoagulants, 34 (18.0%); warfarin, 17 (9.0%); clopidogrel, 6 (3.2%); and other medications, 38 (20.1%). The number of patients taking oral anticoagulants increased rapidly from 2.2 patients per month in 2020–2023 to 10.8 patients month in 2023–2024 (Fig. 6).

Fig. 6.

Number of patients using high-risk medication.

DISCUSSION

In this study, the status of transconjunctival orbital fat removal for dark circles under the eyes within our study group was summarized, providing a clearer understanding of the current status of cosmetic surgery in Japan. Transconjunctival orbital fat removal has been increasing each year, with a particularly sharp increase over the last 2 years. Currently, dark circles under the eyes are the third most common procedure, after eye-area procedures and facelifts.²

Perceptions of fatigue and age are often based on the aesthetics of the periorbital area. Across cultures, periorbital dark circles give the impression of tiredness, old age, and even sadness.³ These circles are caused by age-related changes in the skin, subcutaneous tissue, orbicularis oculi muscle, blood vessels, lower eyelids, and cheek ligament structures.⁴ This study has also shown that the average age of patients undergoing transconjunctival orbital fat removal is increasing annually, with an average age of 42 years as of 2024. Age comparisons by procedure type also showed that the number of patients undergoing total orbital fat removal was greater than those undergoing partial orbital fat removal.

Transconjunctival orbital fat removal has been increasing every year, especially in the last 2 years, and the average age of patients undergoing it is increasing annually, along with the number of patients with a history of orbital fat removal. Moreover, the number of patients taking high-risk medications, such as steroids and anticoagulants, has also increased in recent years.

The results of this study indicate that the percentage of patients with comorbidities undergoing transconjunctival orbital fat removal is rising. In particular, glaucoma and retinal disease, which require attention to intraocular pressure, are also increasing. These diseases can cause blindness if intraocular pressure is inadvertently increased. Patients with glaucoma need to know whether they have closed- or open-angle glaucoma. It is important to note that acute glaucomatous attacks and retinal detachment can occur, and appropriate measures must be taken when these occur.

Postoperative retro-orbital hemorrhage is the most common complication associated with transconjunctival orbital fat removal. This rare but potentially sight-threatening condition requires immediate attention.⁵ Steroids and anticoagulants cause intraoperative and postoperative bleeding. The results of this study indicate that the number of patients taking high-risk drugs for postoperative bleeding is rising annually. Systemic administration of steroids does not increase postoperative bleeding events; however, it increases the severity of bleeding when it occurs, potentially raising the reoperation rate for bleeding.⁶ Furthermore, approximately 26.5 and 10.8 patients per month were treated with antiplatelet and anticoagulant medications, respectively. Although it is unclear whether a direct relationship exists between these high-risk drugs and postoperative bleeding, some cases of postoperative bleeding require emergency medical treatment. Further follow-up is needed to determine the association between postoperative bleeding and high-risk medication use.

Our safety strategy for transconjunctival orbital fat removal is as follows: thoroughly interviewing patients for oral medications, performing intraoperative blood pressure monitoring in hypertensive patients, allowing longer postoperative follow-up time for patients at high risk for postoperative bleeding, and adhering to the guideline-recommended withdrawal periods for anticoagulant medications.

Our study had some limitations. This study, while encompassing a nationwide network of cosmetic surgery clinics, is retrospective in nature. The number of procedures performed may vary across clinics and physicians, potentially influenced by the group’s management strategies and expansion. Additionally, the patient population has shifted significantly with nationwide expansion from major cities to regional areas. The database used in this study may be inadequate, potentially lacking complete information for a robust evaluation. Data on occupation and medical history, collected through questionnaires, may be inaccurate. This study had all the limitations and risks of bias inherent in the study design. Furthermore, because this study was conducted only in Japan, the results cannot be generalized to other populations.

CONCLUSIONS

This study revealed the current status of transconjunctival orbital fat removal in Japan. We observed an increasing number of middle-aged and older patients, suggesting a future rise in procedures. This trend will likely lead to a higher prevalence of comorbidities and high-risk medications in patients undergoing this procedure. Surgeons must be aware of these factors and possess the skills needed to manage them effectively. Further research to develop safer surgical procedures and management strategies while comparing them with conventional methods is warranted.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

The authors would like to thank Editage (www.editage.jp) for English language editing.