Age-dependent efficacy of transconjunctival lower eyelid fat removal: receiver operating characteristic curve-derived thresholds and multimodal recommendations

Background Transconjunctival lower eyelid fat removal is widely performed in Asian aesthetic practice, yet the domain-specific outcomes and the effects of age or adjunctive procedures remain unclear.Methods Fifty patients (median age, 50 years) completed a 1-month postoperative assessment. Satisfaction with bulging, pigmentation, and laxity was evaluated using the 5-point Periorbital Satisfaction Likert Scale (PSLS). Preoperative and postoperative photographs were independently assessed by two blinded physicians, and their mean score constituted the physician rating. Nonparametric tests, receiver operating characteristic (ROC) curve analysis (area under the curve, AUC), and ordinal logistic regression were performed.Results Median patient scores were 5 for bulging and 4 for pigmentation and laxity. Physician scores were significantly lower for pigmentation (P<0.001) and laxity (P=0.002) but not for bulging (P=0.080). Patient–physician correlations were moderate to strong (ρ=0.55–0.70), and inter-rater reliability was good (intraclass correlation coefficient=0.78). Patients younger than 50 years rated bulging (P=0.026) and laxity (P=0.003) more favorably than older patients. ROC analysis identified age cutoffs of 54 years for bulging (AUC=0.61) and pigmentation (AUC=0.51) and 47 years for laxity (AUC=0.75). Age negatively predicted bulging (odds ratio [OR], 0.95) and laxity (OR, 0.94), whereas periosteal hyaluronic acid filler positively predicted bulging (OR, 6.90) and pigmentation (OR, 5.05).Conclusions One month after surgery, satisfaction is highest for bulging but declines beyond the late forties, particularly for laxity. Deep periosteal hyaluronic acid augmentation enhances outcomes in bulging and pigmentation. The PSLS demonstrated good convergent validity and may support age-specific, multimodal strategies for periorbital rejuvenation.