| Note: The following information is provided for archival purposes and because this procedure is still in wide use elsewhere. We currently feel that orbital fat is best left in its natural anatomic location rather than being used to try to camouflage cheek depressions. |
• Other names: Arcus marginalis release, fat mobilization, fat reflection, fat redraping, fat preservation, fat transposition, septal reset.
(For fat injection or free fat grafting, see Fat Injection, Collagen, and Tissue Fillers and Eyelid Hollowness: Fat Grafting)
• 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.
• 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.
Photos of operation
• Limitations: (See "Comments" below.) Draping of available fat over the orbital rim is only effective in very mild cases of cheek descent and even then only partially. While the term "fat preservation - conservation" has a certain ring to it, such terminology can be misleading. Relocating orbital fat out of the socket, through the eyelid, and onto the surface of the cheek bone is not preserving the fat in its anatomically-correct compartment. As far as the eyeball and socket are concerned, transferring fat onto the cheek is no different than removing it.
• 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.
• Risks and complications: See Chapter 28. Because of the transparent nature of lower eyelid skin, any uneven distribution of the repositioned fat may be visible as an irregular contour. 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 risk 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.
A common misconception is that fat redraping is somehow superior to fat removal and more anatomically "responsible." In fact, it's a good example of "robbing Peter to pay Paul." Both fat excision and repositioning entail removing fat from its natural location within the orbit. While either technique may result in hollowing of the orbit and eyelid if overdone, it is much easier to do so while trying to camouflage a cheek hollow, both because of the need to mobilize more fat than may be safely expendable as well as later shrinkage, or atrophy, resulting from excessive surgical manipulation.
In our practice, fat repositioning is no longer offered. With the continued refinement of injectable fillers, the procedure has lost much of its previous lustre.
Before and After Photos
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Cheek and Midface Lift
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