Effectiveness of Transconjunctival Fat Removal and Resected Fat Grafting for Lower Eye Bag and Tear Trough Deformity

This study reviews the outcomes of transconjunctival fat removal followed by resected fat grafting in patients undergoing treatment for eye bags.

Key Points

Question

What is an alternative method of eye bag treatment that can overcome the disadvantages of fat repositioning techniques?

Findings

This analysis of 229 patients found that 224 patients (97.8%) were satisfied with outcomes, and the modified Goldberg scores improved significantly after surgery except for the skin elasticity scores.

Meaning

Transconjunctival fat removal followed by resected fat grafting may be an effective and safe technique to treat lower eye bags without increased complication rates and may provide good patient and surgeon satisfaction.

Abstract

Importance

The main treatment of lower eye bags is changing from fat removal techniques to fat repositioning techniques. However, fat repositioning techniques have potential complications because of disruption of the middle lamellae, leading to contracture and shortening.

Objective

To determine whether transconjunctival fat removal followed by resected fat grafting is an effective alternative method of eye bag treatment.

Design, Setting, and Participants

This retrospective study of 229 consecutive patients who underwent transconjunctival fat removal followed by resected fat grafting from November 1, 2011, to October 31, 2017, was conducted by review of medical records from the Seoul H Dermatology Clinic in Seoul, Korea.

Main Outcomes and Measures

Comparison of patient satisfaction and modified Goldberg scores before and after surgery.

Results

A total of 229 patients (mean [SD] age, 41.24 [11.11] years; range, 20-69 years; 164 [71.6%] female) underwent transconjunctival fat removal followed by resected fat grafting. Of the 229 patients, 224 (97.8%) were satisfied with their surgical results, and major improvements were seen in the mean (SD) preoperative and postoperative scores for orbital fat prolapse (preoperative: 1.94 [0.63]; postoperative: 0.07 [0.21]), tear trough depression (preoperative: 1.61 [0.75]; postoperative: 0.33 [0.42]), skin transparency (preoperative: 1.15 [0.97]: postoperative: 0.22 [0.37]), and triangular malar mound (preoperative: 0.37 [0.61]; postoperative: 0.34 [0.58]). Although the orbicularis prominence worsened after surgery, this outcome should be interpreted as a good result for Asian patients. Skin elasticity deteriorated postoperatively.

Conclusions and Relevance

The findings suggest that transconjunctival fat removal followed by resected fat grafting is an effective and safe technique to treat lower eyelid fat herniation without increased complication rates and provides good patient and surgeon satisfaction.

Level of Evidence

4.

Introduction

The classic concept of lower eye bag treatment involves fat excision.¹ Young patients with true excess or herniated orbital fat and minimal excess skin have had excellent results after fat excision.² However, some patients experience undesirable contours, such as deepening of the tear trough and a hollowed-out appearance. Therefore, the concept of fat-preserving techniques instead of fat excision was introduced. Some studies have demonstrated returning the infraorbital fat to the original site by plication of the orbital septum at the midportion,³ recruitment of the capsulopalpebral fascia to the infraorbital rim to fortify the septum,^4,5,6,7,8 or tightening of the orbital septum to the infraorbital rim.^9,10 Although these fat-returning techniques can avoid infraorbital hollowness, they cannot address the multifactorial misshaping of the infraorbital region alone. Meanwhile, various methods to reposition the infraorbital fat to the area below the infraorbital rim have been promoted to create a smooth junction over the groove on which the orbicularis oculi muscle can redrape. To reposition infraorbital fat, methods that involve septal incision followed by the direct manipulation of pedicled fat^{2,11,12,13,14,15} or fat repositioning through septal resetting^16,17 are possible.

Fat transposition techniques have some problems compared with fat removal techniques. These techniques violate the septum and may involve a higher incidence of lower eyelid retraction. Other problems include concern about motility disturbances of the eye, longer downtime periods, and a steep learning curve. Another method of transconjunctival fat removal followed by autologous fat grafting to mitigate tear trough deformity is also widely used. However, this method also has the inconvenience of additional fat harvesting procedures. In this article, we analyzed the effectiveness of an alternative method of treating eye bags: transconjunctival fat removal followed by resected fat grafting (eFigure 1 in the Supplement).

Methods

Patients

From November 1, 2011, to October 31, 2017, a total of 2181 patients underwent transconjunctival fat removal followed by resected fat grafting at a single private clinic (Seoul H Dermatology Clinic). Among these patients, 229 who provided written consent for the use of their preoperative and postoperative photographs for research or marketing were included in this study. This retrospective study of consecutive patients was conducted by medical record review. All data were deidentified. This study was approved by the Public Institutional Bioethics Committee, Seoul, Korea.

Patient information, including demographics, follow-up periods, satisfaction, complications, and additional treatments, was retrieved, and objective assessment was performed using preoperative and postoperative photographs by 3 experienced dermatologists, including a surgeon (H.S.K., C.W.C., and B.R.K.), who were masked to each other’s interpretations. The modified Goldberg score, which was modified to evaluate skin transparency instead of eyelid fluid among the 6 categories of Goldberg scores, was used for objective assessment.¹⁸ The Goldberg score is the scoring system first introduced in 2005, which consists of 6 main categories of anatomical contributions to the lower eyelid bags: tear trough depression, orbital fat prolapse, loss of skin elasticity, eyelid fluid, orbicularis prominence, and triangular malar mound. Each of the 6 anatomical problems was scored from 0 to 4 points, with 0 indicating no involvement; 1, mild; 2, moderate; 3, marked; and 4, severe. However, the eyelid fluid bulge by fluid accumulation is difficult to clearly distinguish from the fat bulge in photographs, and the dark glow of dilating and increased blood flow underneath the thin skin of the lower eyelid is regarded as an important factor in the formation of dark circles in Asian patients. Therefore, in our study, skin transparency was evaluated instead of eyelid fluid because skin transparency was easier to assess than eyelid fluid and cosmetically more meaningful in Asian patients.

Preoperative Assessment

To evaluate skin laxity, a snap back test was performed, and patients with severe laxity of the lower eyelid skin were excluded. To rule out orbicularis oculi muscle hypertrophy, the patients were asked to smile and frown. When muscular hypertrophy was present in their eyes, it appeared more prominent during orbicularis contraction, whereas when infraorbital fat herniation was present, hypertrophy was concealed during muscle contraction. To distinguish malar fat from infraorbital fat herniation, gentle pressure was applied to the globe. Malar fat is not accentuated by pressure and is located more laterally and inferiorly than infraorbital fat. Finally, we captured a preoperative photograph with each patient in a seated position. For the preoperative photograph, we asked the patients to look upward and toward both lateral sides. We determined the location and amount of fat to remove with the patient in the seated position because the operation is performed with the patient in a supine position, which makes the herniated fat hide.

Surgical Procedure

One drop of 0.5% proparacaine hydrochloride ophthalmic solution was instilled in each eye. Surgery can be performed with the patient under conscious sedation by intravenous propofol or without sedation. The assistant retracted the lower eyelid caudally and injected lidocaine, 1%, with 1:100 000 epinephrine into each medial, central, and lateral intraorbital fat pad adjacent to the conjunctiva. An incision was made using a carbon dioxide laser on the conjunctiva 5 mm below the lower eyelid margin. In white patients, the incision near the eyelid margin is more advantageous for a preseptal approach because the orbital septum and capsulopalpebral fascia meet before attaching to the tarsal plate of lower eyelid and is attached to the tarsal plate in a fused state. However, in Asian patients, the orbital septum and capsulopalpebral fascia usually attach to the tarsal plate separately without fusion before they attach to the tarsal plate; thus, this high level of incision can be used in both the preseptal and retroseptal approaches. A traction suture placed through the posterior conjunctival flap was secured to the head drape for additional corneal protection and fat pad exposure. The eyelid edge of the divided conjunctiva was similarly retracted caudally using a lid retractor (Desmarres lid retractor, Medical Land Korea).

A further incision was made directly on the capsulopalpebral fascia toward the infraorbital fat pads to keep the orbital septum intact, and a retroseptal dissection was performed. After the orbital fat pads were exposed, gentle pressure was placed on the globe to allow the fat to herniate through the incision site. At this point, fat protruding through the incision was carefully excised using the carbon dioxide electrocautery laser.

The fat removal sequence depends on surgeon preference. We usually excise the central and lateral fat first as a unit. The fascial band overlying the lateral compartment must be incised to allow resection of the lateral fat pad as a unit with the central fat pad. We subsequently resected the medial fat pad while being careful not to injure the inferior oblique muscle. The resected fat should be immediately soaked in normal saline. After the planned amount of fat was excised, the divided capsulopalpebral fascia and conjunctiva were returned to their original locations and were left there without suturing.

We minced the resected fat using scissors to allow it to pass through the injection cannula (Figure 1A and B) and transferred it to a 1-mL Luer lock syringe for fat injection (Figure 1C). Either 1 or 2 entry points can be made on the lateral end of the palpebromalar groove and extension line of the nasojugal groove. We used a Tulip 0.9-mm blunt tip injector (Tulip Medical Inc) to inject the fat into the space between the orbicularis oculi muscle and the infraorbital septum (Figure 1D). If the dark circles under the translucent skin were visible, we further injected the fat between the orbicularis oculi muscle and the overlying skin. For the concurrent anterior malar augmentation or correction of the midcheek groove, the suborbicularis oculi fat pad can be another target layer of the injection. A cold compress was used postoperatively, as tolerated, for the first 48 hours.

Figure 1. Resected Intraorbital Fat In Situ Grafting Technique.

A and B, Mince the resected fat. C, Transfer the fat to a 1-mL Luer lock syringe for fat injection. D, Inject the fat into the space between the orbicularis oculi muscle and the infraorbital septum.

Statistical Analysis

Descriptive statistics were used to summarize the demographics, follow-up periods, satisfaction, complications, and additional treatments after transconjunctival fat removal and resected grafting. Numbers and percentages were calculated for categorical variables and means and ranges for continuous variables. To compare the modified Goldberg scores before and after surgery, a paired, 2-tailed t test was performed. Comparisons of the differences between the preoperative and postoperative scores according to patient satisfaction were performed using the Kruskal-Wallis test and in the post hoc analysis using the Mann-Whitney method. The results were considered to be significant at P < .05. Data were analyzed using SPSS software, version 22.0 (IBM Corp).

Results

A total of 229 patients (mean [SD] age, 41.24 [11.11] years; range, 20-69 years; 164 [71.6%] female) underwent transconjunctival fat removal and resected fat grafting. The mean follow-up duration was 6.45 months (range, 1-80 months). Of the patients, 220 (96.1%) underwent their first operation and 9 (3.9%) underwent their second operation because of recurrence of lower eye bags after a previous operation in another clinic, including both transconjunctival and transcutaneous approaches. All operations were performed by the same surgeon (H.S.K.). The approximate operating time for the bilateral lower eyelid was 20 minutes. A total of 224 patients (97.8%) were satisfied with the surgical results: 68 (29.7%) were very satisfied and 156 (68.1%) were satisfied. Only 5 patients (2.2%) had concerns. Preoperative and postoperative photographs of good and unsatisfactory results are shown in eFigures 2 and 3 in the Supplement.

Comparison of preoperative and postoperative photographs using the modified Goldberg score also revealed major improvements in the mean (SD) preoperative and postoperative scores for orbital fat prolapse (preoperative: 1.94 [0.63]; postoperative: 0.07 [0.21]), tear trough depression (preoperative: 1.61 [0.75]; postoperative: 0.33 [0.42]), skin transparency (preoperative: 1.15 [0.97]; postoperative: 0.22 [0.37]), and triangular malar mound (preoperative: 0.37 [0.61]; postoperative: 0.34 [0.58]) (Figure 2).

Figure 2. Changes in the Mean Modified Goldberg Scores After Transconjunctival Fat Removal and Resected Grafting .

Statistical significance was evaluated using a paired, 2-tailed t test (P < .05). Error bars extend to the least and greatest values excluding the outliers.

^aP < .05.

The mean (SD) scores for the orbicularis prominence, also called the pretarsal roll, worsened after surgery (preoperative: 0.79 [0.67]; postoperative: 1.21 [0.70]). The orbicularis prominence is usually more prominent in Asian patients and is preferred because it is considered to be a symbol of a young and pleasant face. Thus, worsening of the orbicularis prominence score in Asians should be interpreted as a good result.

Mean (SD) scores for loss of skin elasticity also worsened significantly after surgery (preoperative: 0.66 [0.72]; postoperative: 1.05 [1.09]). However, in terms of patient satisfaction score, only 3 patients were disappointed about their wrinkles despite the worsening of their skin elasticity scores. This paradox occurs because all patients had understood the merit and demerit of the transconjunctival and transcutaneous approaches and had chosen the natural look with wrinkles over the artificial look without wrinkles. However, wrinkle formation is an unavoidable drawback of the transconjunctival approach, especially in older patients, and additional treatments should be considered.

Another patient was concerned about lateral infraorbital hollowness. In an Asian patient with a prominent zygomatic bone, removal of the infraorbital fat can cause lateral infraorbital hollowness. However, the underresection of lateral fat to avoid lateral hollowness can cause early recurrence or a dog ear–like lateral fat herniation. Thus, minimal resection of lateral fat is needed, especially in patients with zygomatic bone prominence.

One patient was concerned about remnant eye bags. However, remnant eye bag was not a real fat protrusion; rather, it was a misdiagnosed hypertrophied orbicularis oculi muscle. Thus, additional botulinum toxin injection to the orbicularis oculi muscle and a filler injection into the margin of the orbital part of the orbicularis oculi muscle reduced the remnant protrusion.

When comparing the differences in preoperative and postoperative modified Goldberg scores according to patient satisfaction, only the changes in the scores of loss of skin elasticity in the very satisfied and satisfied groups were significantly different (Figure 3). Patient satisfaction was significantly decreased as the skin elasticity decreased after surgery (mean [SD] difference in loss of skin elasticity in the very satisfied group vs the satisfied group, −0.25 [0.43] vs −0.44 [0.54]; P = .01). Although the tear trough depression scores of the very satisfied and satisfied groups were significantly different, the tear trough depression score of the satisfied group was better (mean [SD] Δ tear trough depression in the very satisfied group vs the satisfied group, 1.12 [0.65] vs 1.35 [0.62]; P = .02). These findings suggest that although the absolute improvement of the orbital fat prolapse and tear trough depression after surgery are the most important factors of patient satisfaction, the degree of improvement of the scores is not necessarily associated with the degree of patient satisfaction, and the degree of reduction of skin elasticity is a critical factor for the difference of patient satisfaction.

Figure 3. Comparison of the Differences Between the Preoperative and Postoperative Mean Modified Goldberg Scores According to Patient Satisfaction.

Δ indicates the difference between the preoperative and postoperative scores. Statistical significance was evaluated using the Kruskal-Wallis and Mann-Whitney tests (P < .05). Error bars extend to the least and greatest values excluding the outliers.

^aP < .05.

Local complications included transient darkening of the lower eyelids, granuloma formation at the incision site, transient hardening or palpable subcutaneous nodule formation on the lower eyelids, periorbital hollowness, bloodshot eyes, orbicularis oculi muscle cramping, electrocautery burns, and transient ectropion (Table). Nearly one-third of patients had infraorbital hardening or subcutaneous nodules, and almost all had spontaneous regression of the hardness in 1 month. Six patients had long-lasting subcutaneous nodules for 1 month, but all had subsided within 3 months. Previous studies stated that this outcome was suspected because of some varying degree of liponecrosis and lipogranuloma formation.² A total of 86 patients (37.6%) had darkening of the infraorbital area, whereas 3 patients (1.3%) experienced intermittent orbicularis oculi muscle cramping. These conditions all resolved spontaneously at 4 to 6 months. One patient had mild ectropion that subsided within 2 months, and there were no instances of prolonged eyelid retraction or ectropion.

Table. Complications After Transconjunctival Fat Removal and Resected Fat Grafting .

Complication	No. (%) of Patients (N = 229)
Deep wrinkles	17 (7.4)
Fine winkles	139 (60.7)
Transient darkening of the lower eyelids	86 (37.6)
Infraorbital hollowness	7 (3.0)
Supraorbital hollowness	1 (0.4)
Bloodshot eye	1 (0.4)
Intermittent orbicularis oculi muscle cramping	3 (1.3)
Infraorbital hardening of subcutaneous nodule lasting >1 mo	6 (3.0)
Conjunctival incision site granuloma	6 (2.6)
Burn	1 (0.4)
Transient ectropion	1 (0.4)

Postoperative additional treatments are listed in the eTable in the Supplement. Nearly half were treated with a fractional erbium glass laser to improve wrinkle formation and had good results.

Discussion

Most studies^{2,3,5,6,7,8,9,11,12,13} report that many techniques of infraorbital fat operations, including transcutaneous or transconjunctival operations, fat removal, or fat-preserving techniques, produce good results and achieve high patient satisfaction. However, all operations to treat infraorbital fat herniation have advantages and disadvantages. We believe that the results mainly depend on patient selection and preference. In this study, almost all patients were satisfied with the surgical results despite worsening of their skin elasticity, which is mainly attributed to proper patient selection.

Mainstream treatment is moving from fat removal techniques to fat repositioning techniques. The transconjunctival fat repositioning technique may involve direct manipulation of the pedicled fat from under the septum or fat repositioning through septal reset of the entire fat-septum unit. The fat can be repositioned into the supraperiosteal or subperiosteal plane; ultimately, the aesthetic results are comparable between the 2 approaches.¹⁹ The disadvantage of fat repositioning techniques includes a steep learning curve, prolonged edema, and potential complications attributable to disruption of the middle lamellae, leading to contracture and shortening. To avoid these disadvantages, addressing the tear trough without disrupting the middle lamellae is important. Thus, autologous fat grafts can address the tear trough deformity without disrupting the middle lamellae. Previous studies^19,20 reported that fat repositioning and autologous fat grafting are acceptable for correcting mild tear trough deformities.

In addition, tear trough deformity is a less serious problem in Asian patients, who have more thick skin and less descent of the suborbicularis oculi fat than do white patients. Instead, in many Asian patients, a type of dark circle caused by skin transparency is more problematic. Infraorbital dark circles caused by thin and translucent lower eyelid skin overlying the orbicularis oculi muscle can be treated successfully with autologous fat transplantation.²¹ Another advantage of autologous fat grafting to the infraorbital area is achieving midcheek augmentation and simultaneous improvement of the palpebromalar groove. Palpebromalar groove improvement and midcheek augmentation are not easily achieved using a fat transposition technique alone. Thus, transconjunctival fat removal followed by autologous fat transplantation to the infraorbital area, including tear trough deformity and transparent-type dark circles, can be an alternative treatment to overcoming the disadvantage of fat transposition techniques.

However, transconjunctival fat removal and autologous fat graft are separate operations. These 2-step operations are inconvenient. If autologous fat graft uses resected infraorbital fat, it will be more convenient. Thus, we have performed transconjunctival fat removal followed by resected infraorbital fat grafting into the tear trough from 2010 onward and have observed good results. Among the 229 patients who underwent the surgery, more than 95% were satisfied with the results. Although previous studies^14,21,22 already reported the successful use of micro free orbital fat grafts to treat tear trough deformities during transcutaneous blepharoplasty, this is the first study, to our knowledge, of resected infraorbital fat grafting with a similar method of autologous fat grafting using a cannula during transconjunctival lower blepharoplasty.

The main problem after autologous fat graft is its absorption rate over time. It is now commonly believed that only 30% of injected fat can be expected to survive for 1 year.²³ In past studies, 2 different theories about fat graft survival rates have been proposed: the cell survival theory in which grafted fat survives intact and the final volume after fat grafts depends on the number of vital fat cells present at the time of the graft²⁴ and the host cell replacement theory that grafted fat completely dies and is replaced by fibrous tissue or newly formed metaplastic fat.^25,26 In our methods, we minced the resected fat before the grafting process. There are some doubts about the survival of minced infraorbital fat grafts. We think that the survival of fat chopped by scissors is not much lower than that of fat harvested by cannula for a few reasons. First, chopped fat is lumpier than cannula-harvested fat that passes through the injection cannula, which means that much bigger parcels are contained in minced fat. Second, there is no need for centrifugation or freezing, which negatively influences fat survival. Third, we experienced that transconjunctival fat removal followed by resected fat grafting is better than transconjunctival fat removal alone, which means that surviving fat cells may play a beneficial role in the infraorbital area. However, further studies on the survival of minced infraorbital fat are needed.

Limitations

Our study has some limitations. First, most of the patients (65.1%) were followed up for 1 to 2 months postoperatively, and 26 of 149 patients (17.4%) were followed up for longer than 12 months. The relatively short follow-up period has limitations in the analysis of postoperative maintenance duration and long-term adverse effects. Second, this study compared the preoperative and postoperative outcomes of those who underwent transconjunctival fat removal followed by resected fat grafting and did not directly compare the outcomes with those of other surgical techniques. Third, we used modified Goldberg scores to objectively assess postoperative status, but it is impossible to completely exclude the subjectivity of evaluators. In addition, the modified Goldberg scores are grading systems for which the evaluators scored 0 to 4 points for each category, not a continuous variable, making it difficult to capture subtle changes.

Conclusions

Our findings suggest that transconjunctival fat removal followed by resected fat grafting is an effective and safe technique to treat lower eyelid fat herniation without increasing complication rates and achieves high patient and surgeon satisfaction. In addition, this technique does not disturb the middle lamellae and is relatively easier to learn and perform than transconjunctival fat repositioning techniques. Thus, it may be considered as an alternative surgical option for treating lower eyelid fat herniation.

Supplement.

eFigure 1. Schematic Diagram of Transconjunctival Fat Removal and Resected Fat Grafting

eFigure 2. Preoperative and Postoperative Photographs of Good Results

eFigure 3. Preoperative and Postoperative Photographs of Unsatisfactory Results

eTable. Summary of Additional Treatments (N = 229)