This post covers the surgical approaches for lower eyelid fat repositioning and fat removal.
There is the external (subciliary) approach and the transconjunctival approach.
Here we are entering through the conjunctiva.
You can see the groove along the lower lid in this patient. That groove is the target of the operation.
What you are seeing there is a ligamentous structure called the tear trough ligament (TTL).
When the orbital fat bulges forward and the TTL stays anchored to the underlying bone, the ligament creates that visible demarcation.
We release the TTL partially and then redrape the fat over the orbital rim.
Here is the same patient at six months. The demarcation line has resolved.
If there is a bit of hollowing in the cheek front, we supplement with fat grafting.
The contour improves, but pigmentation-based dark circles are not addressed by this surgery.
These figures are excerpted from a chapter I co-authored in Aesthetic Plastic Surgery, Volume 2 (Koonja Publishing).
