Transconjunctival fat removal (TFR) for lower eyelid bulging is among the most frequently performed aesthetic surgical procedures in Japan, ranking third after double eyelid blepharoplasty and facelift procedures [1,2]. In addition to conventional orbital fat excision, advanced techniques such as orbital fat repositioning have been developed, broadening the surgical options available for TFR [3-7]. With the increasing number and advancing age of patients undergoing such procedures, the prevalence of anticoagulant and steroid use has risen, underscoring the importance of meticulous perioperative management [8]. Well-known postoperative complications of TFR include lower eyelid malposition, conjunctival edema and internal hemorrhage, residual orbital fat, orbital hemorrhage, and infection [9-11]. Among these, retrobulbar hemorrhage and visual impairment represent particularly serious adverse events [9]. Accordingly, refinement of surgical techniques aimed at improving safety is essential to reduce complication rates and increase patient satisfaction.

The traction method, in which skin or muscle hooks are used to retract the conjunctiva and secure the surgical field, is commonly employed during TFR procedures [2,4]. While this technique offers improved intraoperative visibility, it is associated with potential complications such as skin injury due to lower eyelid penetration and strabismus resulting from trauma to the extraocular muscles [12,13]. To mitigate these risks, we employed a compression method that increases intraorbital pressure through external orbital compression, allowing the procedure to be completed using only blunt dissection and without energy-based instruments or traction devices, except for hemostatic purposes. Therefore, this approach may minimize serious complications associated with sharp instruments.

We hypothesized that the compression method would have a safety profile comparable to that of the traction method. To examine this hypothesis, we performed a retrospective analysis to compare postoperative complications and evaluate the non-inferiority of the compression technique relative to the conventional traction approach.

A total of 60 TFR cases performed by a single surgeon at our institution between March 2024 and February 2025 were included. The indication for TFR was defined as the presence of lower eyelid bulging deemed amenable to correction with this procedure. Patients receiving anticoagulant therapy or with a history of glaucoma were excluded from enrollment.

In both the compression and traction techniques, the orbital septum was incised, followed by excision of the medial, central, and lateral orbital fat compartments (Fig. 1). In the compression technique, the assistant applied external pressure to the orbit and inverted the conjunctiva. A 10-mm conjunctival incision was made, and an appropriate volume of preseptal fat was excised to expose the capsulopalpebral fascia (CPF) (Fig. 2). Blunt dissection was then performed caudally using gauze to identify the orbital septum. During the TFR procedure, traction devices were not used in the compression group. In the traction technique, a small conjunctival incision was created, and the conjunctiva was retracted using a skin hook (Fig. 3). With countertraction, preseptal fat was removed using an electrocautery scalpel, the CPF was visualized, and dissection between the fibers of the orbicularis oculi muscle was performed. A muscle hook was subsequently inserted to expose the orbital septum. The extent of orbital fat excision was determined intraoperatively by the surgeon based on the degree of lower eyelid bulging reduction observed in the seated position. In this study, the use of the compression and traction techniques did not overlap. The compression method was utilized during the initial phase of the study, whereas the traction method was adopted in the later phase.

Patients included in the study underwent retrospective review of clinical background characteristics and postoperative complications based on medical records. The postoperative observation period was defined as 1 month, during which all complications were assessed. Postoperative complications were categorized as follows: (1) conjunctival hyperemia, (2) residual orbital fat, (3) lower eyelid swelling, (4) strabismus, (5) retrobulbar hemorrhage, (6) infection, (7) lower eyelid retraction, (8) sensory disturbances, (9) scleral exposure, and (10) corneal ulceration. Based on the technique used for surgical field exposure, patients were classified into two groups: the compression group and the traction group.

Statistical analyses were performed using JMP version 17.0 (SAS Institute). The Student t-test and the chi-square test were applied, with statistical significance set at P<0.05.

This study was reviewed and approved by the Ethics Committee of Tokyo Chuo Beauty Clinic (Approval No. UMEDAERB-2025 Mar001). Given the retrospective design, the requirement for written informed consent was waived. All procedures were conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent revisions, including the 2013 Fortaleza amendment.

Among the 60 cases of TFR included in this study, nine patients were male and 51 were female, with a mean age of 41.2 years (range, 21–70 years). All patients were of Asian ethnicity (Japanese) (Table 1).

Based on the surgical field exposure technique, 30 cases were assigned to the compression method group and 30 to the traction method group. No significant differences were observed between the groups in baseline characteristics, including sex and age. Postoperative complications occurred in three cases (10.0%) in the compression group and two cases (6.7%) in the traction group. In the compression group, complications included two cases of postoperative hemorrhage (6.7%) and one case of residual orbital fat (3.3%). In the traction group, one case of postoperative hemorrhage (3.3%) and one case of lower eyelid swelling (3.3%) were noted (Table 2, Fig. 4). No statistically significant difference was found in the incidence of postoperative complications between the two groups (P=0.640). No reoperations were required, and no severe complications, such as retrobulbar hemorrhage, infection, or strabismus, were observed in either group (Table 3).

This study compared postoperative complication rates between the compression and traction method groups in TFR and found no statistically significant differences. These findings suggest that the compression method may be a comparably safe alternative to the conventional traction approach.

Previous studies have reported complication rates for TFR as follows: lower eyelid retraction (5.8%), sensory abnormalities (3.4%), scleral show (3%), residual orbital fat (2.7%), revision surgery for skin ptosis (2.3%), hemorrhage (1%), and corneal ulceration (1%) [9]. In this study, the overall postoperative complication rate was 8.3%; however, all complications were mild, with no cases requiring reoperation or resulting in serious adverse outcomes. These results support the overall safety of both the compression and traction techniques, as serious complications, while possible, are exceedingly rare. A detailed assessment identified one case of residual orbital fat in the compression group, attributed to suboptimal visualization of the operative field due to the need to apply orbital compression during access to the fat layer. This limitation highlights a potential disadvantage of the compression technique compared to the traction method, in which orbital fat can be directly visualized. To mitigate this issue, it is important to perform intraoperative positional changes—from supine to sitting—after fat excision to assess the adequacy of lower eyelid fat removal, particularly when using the compression approach. Furthermore, establishing a shared understanding of the compression technique between the surgeon and assistant before the procedure is critical for safe and effective execution.

Although the traction method offers superior visualization of the surgical field, it primarily relies on dissection using energy-based instruments. These maneuvers require a thorough understanding of orbital anatomy and advanced technical proficiency because of the risks of lower eyelid skin penetration and strabismus resulting from injury to the extraocular muscles. In contrast, the compression method increases intraorbital pressure through external orbital compression, allowing straightforward access to the orbital septum via conjunctival incision, identification of the CPF, and subsequent caudal blunt dissection. Compression facilitates clear visualization of the target adipose tissue, improving its accessibility for removal. This technique enables access to the orbital fat through blunt dissection using gauze or comparable materials, without the need for energy-based devices. By avoiding sharp dissection, the risk of tissue injury—including damage to the inferior oblique muscle or skin perforation—is minimized. Thus, this technique facilitates safe execution of TFR even by less experienced surgeons. From an educational perspective, the compression method represents a practical and safe approach for surgical training in TFR. Additionally, applying compression techniques during traction enables a more detailed evaluation of fat exposure and residual adipose tissue. Early proficiency in compression methods before initiating traction can enhance the effective use of traction devices.

This study has several limitations. First, the choice between the compression and traction methods was determined by the timing of surgery; the compression method was predominantly employed during the early phase, whereas the traction method was introduced later. Consequently, comparisons between the groups may have been affected by selection bias and improvements in surgical proficiency over time. Second, the observation period was limited to 1 month, which allowed for evaluation of short-term complications but not long-term outcomes such as patient satisfaction or recurrence. A longer follow-up period is warranted to assess these endpoints. Additionally, the study’s retrospective design, involving a single surgeon at a single institution, limits the generalizability of the findings. Moreover, the efficacy of the compression technique is contingent upon the proficiency of the supervising surgeon, and the extent of fat herniation cannot be objectively quantified based on the applied pressure. Patient responses, including discomfort or pain during the procedure, may also vary according to the specific technique employed. To address these limitations, future investigations should include prospective, multicenter trials with multiple surgeons and randomized controlled designs to validate these results.

The compression technique in TFR demonstrated a safety profile comparable to that of the traditional traction method. Given its relative simplicity and reduced reliance on sharp instruments, the compression method can serve as a viable option for less experienced surgeons seeking to perform TFR while minimizing the risk of serious complications.