Fat Repositioning with Deep Fat Excision in Transcutaneous Lower Blepharoplasty

BACKGROUND: Lower blepharoplasty has shifted from fat resection to preservation by means of repositioning, yet severe fat herniation still requires selective excision. Traditional resection may compromise transposition. This study introduces deep fat excision to optimize the balance between removal and repositioning, enhancing aesthetic outcomes. METHODS: From 2018 to 2024, 107 patients underwent transcutaneous lower blepharoplasty with deep fat excision. The technique involved incising the orbital septum at the arcus marginalis to selectively resect the deep-layer fat, followed by septum-fat flap transposition to correct tear-trough deformities. Surgical outcomes were assessed using the Hirmand grading system through evaluations by clinicians, 2 publicly available artificial intelligence (AI) platforms, and the FACE-Q survey. RESULTS: Clinically, 91.6% of patients achieved complete elimination of fat bulges and tear-trough deformity, whereas 8.4% exhibited undercorrection in these areas. AI assessments showed 70.9% consistency with clinical evaluations (Cohen kappa, 0.58). Lower eyelid FACE-Q scores improved significantly from 66.7 ± 12.5 preoperatively to 21.9 ± 15.4 postoperatively ( P < 0.001), with high decision satisfaction (71.1 ± 19.9) and a perceived age reduction of 3.3 years (patient-perceived) and 5.8 years (AI-predicted). Minor complications included undercorrection, orbital hematoma, and residual tear-trough deformity. CONCLUSIONS: Deep fat excision achieves the balance between fat excision and repositioning, improving aesthetic outcomes in severe fat herniation cases. In addition, integrating AI-assisted analysis enhances preoperative planning and postoperative evaluation, supporting its potential role in aesthetic surgery.