Orbital Septal Fascial Flap with Extensive Release of a Long Orbital Fat Flap for Correcting Lower Eyelid Bags Associated with Midface Depression

Conventional lower blepharoplasty remains constrained by limited fat availability and insufficient transposition distance in patients with severe tear trough deformity and midfacial depression. This study aimed to assess the clinical outcomes of a technique combining an orbital septal fascial flap with extensive release of an elongated orbital fat flap (>2 cm). A total of 121 patients treated from December 2019 to March 2025 were enrolled for retrospective analysis. Of these, 68 cases underwent a transconjunctival approach (median age 28 years), while 53 cases with obvious skin laxity received a transcutaneous approach (median age 45 years). With precise dissection of the prezygomatic space, a pedicled orbital septal fascial flap was harvested to cover the 2.0-2.5 cm vascularized fat flap advanced into the midfacial recipient site. The rates of complete tear trough effacement (Barton Grade 0) were 89.7% and 92.5% in the two groups, respectively, with no statistically significant intergroup difference (P = 0.607). Given the substantial baseline differences between groups, this should not be interpreted as evidence of equivalence. Median operative time was 61 min vs. 125 min, and median recovery time was 11 days vs. 15 days (both P < 0.001). The overall complication rates were 1.47% and 3.77% (P = 0.581). No surgical site infection or permanent lower eyelid ectropion occurred. Over a median follow-up of 8.0 months, no cases of diplopia, sensory nerve injury, enophthalmos, or fat necrosis/displacement were recorded. However, these events were not assessed with a pre-specified standardized protocol. This composite flap technique is designed to address the anatomical constraints of conventional fat transposition. The fascial flap may provide additional microcirculatory support and mechanical fixation, and was associated with favorable aesthetic outcomes and a low complication rate. These findings from a single-center retrospective cohort require confirmation in prospective, controlled studies.