Patient Satisfaction After Transconjunctival Orbital Fat Removal: A Multicenter Prospective Study of 920 Cases

BACKGROUND: Although transconjunctival orbital fat removal (TOFR)-a minimally invasive procedure-is increasingly performed to correct lower eyelid bulging, multicenter prospective studies evaluating patient satisfaction across multiple dimensions-bulging, pigmentation, and skin laxity-remain scarce. OBJECTIVES: To evaluate post-TOFR satisfaction and identify factors influencing patient-reported outcomes. METHODS: This prospective observational study included 920 consecutive patients undergoing standardized TOFR between July and August 2025 across 60 aesthetic surgery clinics in Japan. A 5-point Likert scale assessed satisfaction with bulging, pigmentation, and skin laxity; scores of ≥4 indicated high satisfaction. Adjunctive treatments-hyaluronic acid (HA), collagen filler, and extracellular matrix (ECM) products-were analyzed. RESULTS: Satisfaction with skin laxity-but not bulging and pigmentation-significantly declined with age (ρ = -0.093, P = .005). Total removal yielded higher satisfaction than partial removal but without statistical significance. HA adjunctive treatment significantly improved satisfaction with pigmentation (65.4 vs 75.9%, P = .002) and skin laxity (76.2 vs 82.9%, P = .026). In multivariate analysis, HA (odds ratio, 1.56, P = .026) and HA + ECM (odds ratio 1.76, P = .013) were independent predictors of higher pigmentation-related satisfaction. Age cutoffs identified via Youden's index indicated significant declines in satisfaction beyond 38-48 years, particularly for skin laxity. Overall satisfaction (high satisfaction across all 3 domains) ranged from 64% to 73%, with trends toward improvement in groups receiving HA and multiple adjunctive procedures. CONCLUSIONS: TOFR yielded high satisfaction regarding lower eyelid bulging. However, satisfaction with skin laxity declined with age. Adjunctive HA treatment improved pigmentation and skin laxity outcomes, underscoring the importance of individualized multimodal treatment, particularly in older patients. LEVEL OF EVIDENCE: 3 (THERAPEUTIC): For image description, please refer to the figure legend and surrounding text.