• Other names: Arcus marginalis release, fat mobilization, fat reflection, fat redraping, fat preservation, fat transposition, septal reset.
• Primary goal: Use bulging orbital fat to camouflage a depression at the junction between the lower eyelid and the cheek caused by heredity and/or age-related gravitational descent of the midface.
Before & Four Months After Fat Repositioning (no fat removed)
• Anesthesia: While a wider area of tissue is manipulated, local anesthesia with sedation is adequate.
• Operative technique: Fat repositioning is not so much a distinct operation as it is a different method of handling the bulging fat during a blepharoplasty. The fat pockets may be approached surgically from either a transcutaneous or transconjunctival route, after which they are dissected out of their thin "capsules" but not removed. The fat is then fashioned into a uniform layer still connected to its blood supply.
Most typically, this layer is reflected over the rim of bone and advanced into areas of depression, a procedure sometimes called arcus marginalis release with fat transfer. The leading edge of the fat is usually tucked under a small flap of periosteum that has been elevated from the bone and anchored in place with removable sutures that exit the skin of the cheek.
• Limitations: Draping of available fat over the orbital rim is only effective in mild cases of cheek descent and even then only partially.
• Care and recovery: Bruising may be increased due to the additional dissection out of the eyelid and onto the cheek. Swelling remains noticeable for at least several weeks longer than with fat removal alone. Less commonly, the fat may go through a period of "hardening" that can persist for 3-6 months and make the lid still look full. If the fat is anchored below the lining of the bone (periosteum) to hide its leading edge from view through the thin eyelid skin, swelling may be even slower to resolve and persist for several months.
• Special risks and complications: Because of the transparent nature of lower eyelid skin, any uneven distribution of the repositioned fat may be visible as an irregular contour or lumpiness. There are reports of "granuloma" formation (inflammatory cystic changes) in the transferred fat as well as double vision caused by restriction of normal movement of the eyeball's muscles.
Lower eyelid retraction is a real risk, especially when the technique is performed through a skin (transcutaneous) incision.
The most common adverse outcome is the inadvertent creation of either immediate or late term eyelid hollowenss.
• Comments: When performed through a transconjunctival approach (to avoid the problems commonly associated the trancutaneous approach. most notably lower eyelid retraction), the procedure adds another level of complexity and invasiveness to an operation that may already feel challenging enough to the occasional blepharoplasty surgeon.
Lower eyelid fat repositioning is an surgical example of "robbing Peter to pay Paul," as discussed immediately after the following operation photo essay.