Rejuvenation of the lower eyelid complex is based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. When a deep groove is present along the orbital rim in the area of the tear trough deformity, it is advantageous, rather than removing orbital fat, to reposition the fat over the orbital rim through the opened arcus marginalis onto the superior face of the maxilla.
Orbital fat repositioning can be accomplished through a transconjunctival approach. The arcus marginalis is exposed and incised, and a subperiosteal pocket is created over the superior face of the maxilla. The subperiosteal pocket shape and location are customized based on the desired location of the orbital fat pedicle; often the origins of the levator superioris labialis and the levator alae nasi muscles are partially dissected. Medial and central fat pedicles are created and rotated over the orbital rim into the subperiosteal pocket. A 6-0 polypropylene externalized sutured is used to fixate the fat pedicle in position. The suture can be removed after 3 to 5 days.
Twenty-four patients were followed clinically after orbital fat repositioning, with follow-up ranging from 6 to 30 months. Although the fat pedicle undergoes some variable resorption, the viability of the graft, the texture and contour of the repositioned fat after a healing period of 1 to 2 months, and the excellent patient acceptance are indicative of the viability of orbital fat repositioning.