To the Editor We read with interest the description by Kim et al1 of their lower blepharoplasty technique using autologous fat grafting. We recognize their excellent surgical results, but respectfully dissent against the authors’ claims of the technique’s superior safety relative to lower blepharoplasty with fat transposition.
Recognition of how an aging face changes, including maxillary retrusion and midfacial volume loss,2 has heightened the appreciation of facial volume and its preservation.3 The authors report that fat transposition increases eyelid retraction risk, which is unsubstantiated in the literature4 and by our anecdotal experience. Disruption of the middle lamella is necessary during any transconjunctival approach. Septal manipulation could cause postoperative retraction; however, anterior lamellar shortening, orbicularis oculi trauma, and uncorrected lateral canthal tendon laxity are likely the primary contributors. Lower blepharoplasty carries a low risk of motility disturbance from inferior oblique disruption. Meticulous surgical dissection with release of the muscle and supporting pulleys during fat pedicle development prevents tethering.