Primary goal: Utilize (rather than remove) lower eyelid fat to fill in any depression that may be present at the junction between the lower eyelid and the cheek caused by the gravitational descent of soft tissues of the midface (fat, muscle, fascia).
Secondary goals: Avoid the hollowed-out appearance that may result from lower eyelid fat removal (especially if aggressive) and from on-going aging
Anesthesia: A wider area of tissue is manipulated and so the required injection of local anesthetic is larger. Deeper sedation may be required.
Operative technique: Fat repositioning is not so much a distinct operation as it is a different method of handling the problem of bulging fat during a blepharoplasty. The fat pockets may be approached surgically from either a transcutaneous or transconjunctival route, after which they are dissected free of their surrounding thin "capsules" but not removed. Most typically, the loosened fat is reflected over the rim of bone and advanced into any hollowness that may have developed from age-related descent of the cheek ("arcus marginalis release with fat transfer"). The fat is usually sutured to the bone to keep it in place. Alternatively, external skin sutures may be placed in such a way that they trap the deeper reflected fat in the desired position until the healing process begins to "scar it down," at which time the sutures are removed.
Variations: Rather than reflecting the fat layer over the bony orbital rim, it may be redistributed within the eyelid to even out any imbalances that may have developed naturally or after injury or prior surgery. Less commonly, the fat may be pushed back into the socket below the eyeball, after which the tissue layers in front of the fat are tightened with sutures. Reflected fat may be placed into a pocket dissected either above or below the periosteum (lining of the bone).
Advantages: As noted above. Generally, the effect is subtle.
Limitations: See below. In addition, the technique is effective only in milder cases of cheek descent. If descent of the cheek is more advanced, a full midface lift is indicated, as any improvement in advanced hollowness below the eyelid is akin to a "drop in the bucket". Also, the technique is more applicable to the fat in the nasal and middle thirds of the eyelid; excess fat in the lateral third of the eyelid usually must be trimmed. Not all advocates are "purists"; many surgeons will remove fat in some areas while preserving fat in others. Deeper hollow areas, especially towards the nose, may require placement of artificial implants rather than fat.
Care and recovery: Since the fat may be anchored by temporary sutures that come through the skin, additional stitches must eventually be removed. Initial swelling and bruising may be increased due to the additional tissue manipulation. Swelling is slower to resolve and may be noticeable for several months.
Risks and complications: Additional risks are related to any uneven distribution of the repositioned fat at the time of reflection over the orbital rim. Because of the thin and transparent nature of lower eyelid skin, any irregularities in the contour will be visible. There have been reports of "granuloma" formation (inflammatory cystic changes) in the transferred fat causing further deformity. In some cases, cortisone injections have been used to try to shrink the masses. There are no long-term studies to demonstrate that such transferred fat will remain viable in its new position, but often it does seem to last. In some cases, however, transferred fat has absorbed almost immediately, producing a final result no different than had it been removed.
Comments: Fat repositioning is one of the newer and more developmental areas of blepharoplasty surgery. Be aware that if this procedure is not performed with skill, the irregular (bumpy) nature of the final result can be disturbing. Carried to its extreme, the procedure adds another level of complexity and more time to the standard operation. It is, however, an intriguing innovation that flies in the face of traditional "wisdom". It may be instructive to note that several highly experienced eyelid specialists who were early advocates have returned to the more standard practice of conservative fat removal because of an unacceptably high rate of problems. This procedure should, in our opinion, be considered only after careful discussion with your surgeon (who may be excited by the theoretical advantages of this newer technique but only actually tried it out once or twice). The jury is still out on this one.
