Application of a “Door-Shaped” Orbital Septal Fat Flap Combined With Granular Autologous Fat Precision Grafting in Lower-Eyelid Blepharoplasty

This retrospective single-surgeon series evaluated a composite lower-eyelid rejuvenation technique that combines a transconjunctival, door-shaped orbital septal fat flap with granular autologous fat precision grafting. Consecutive patients treated between June 2024 and February 2025 were reviewed with a minimum 6-month follow-up. Primary morphometrics included m (deepest point-to-ciliary margin) and n (distal end of the tear trough-to-deepest point); the ratio m/(m+n) indexed contour improvement. Severity was graded using the Modified Barton's system, and patient-reported outcomes were captured by the Global Aesthetic Improvement Scale (GAIS). Thirty-eight patients (31 women; mean age 29.6 ± 6.2 y) were followed for 7.6 ± 1.7 months. Tear-trough severity decreased significantly (paired Wilcoxon W = 0; Z = -5.37; P < 0.001). The m distance declined (Δ = -8.08 mm; 95% CI: -8.95 to -7.21; t(37) = -18.87; P = 1.41 × 10-20), whereas n increased (Δ = +8.08 mm; 95% CI: 7.22-8.95; t(37) = 18.89; P = 1.37 × 10-20), indicating upward advancement and smoothing of the lid-cheek junction. By GAIS, 50.0% of patients rated outcomes "very much improved," 47.37% "much improved," and 2.63% "improved"; overall satisfaction was high (32 very satisfied, 6 moderately satisfied). One early unilateral revision for recurrent bulging was performed; no oil cysts were observed. These findings suggest that a vascularized septal fat flap acting as a biologic cap over precisely dosed free-fat granules can enhance coverage, stabilize graft position, and deliver consistent aesthetic improvement with a favorable safety profile. Larger prospective studies with longer follow-up are warranted to validate durability and refine indications.