Sagging nasolacrimal folds can lead to dark circles under the eyes and give a tired appearance, which can not only give a bad impression to others, but also damage one’s self-confidence. In order to correct the nasolacrimal folds more comprehensively and permanently, midface facelifts, orbicularis oculi fat removal, and transdermal fat grafting are recommended. The lateral pulling of the orbicularis oris muscle used in lower blepharoplasty to achieve external canthal fixation is also positive for correcting nasolacrimal folds. 1. Choice of therapy If a patient has only a mild nasolacrimal fold deformity and no prominent fat pads, then hyaluronic acid therapy alone is feasible. The midface facelift technique allows for a permanent correction. Using the removal of soft tissue from the orbital rim similar to the superior orbicularis fascia of the arcuate rim, the thicker tissue of the upper cheek/lower eyelid area fills in the space created by the nasolacrimal deformity with an upward and outward pull. This technique of removing the orbicularis fascia has a greater impact than the method we will mention below, but transcutaneous fat grafting is effective in cases of nasolacrimal dysmorphism, but it can lead to minor deformities, such as the appearance of lumpiness, which are permanent or not easily corrected. Implementation of transcutaneous grafting with removal of the protruding fat pad seems to be unnecessary. The alternative is the removal of the periosteum from the anterior orbital rim, which allows the protruding orbital fat to simply redistribute in a normal manner along the orbital rim in the subperiosteal and orbicularis muscle regions. In this way, the fat is used as a filler to reduce the depth of the nasolacrimal folds. This technique has been used by some surgeons with more satisfactory results, but if there are still some unconventional defects or deformities in the nasolacrimal area, surgical correction is still needed. Before discussing the technical options, we need to clarify one anatomical issue: finding the shortest distance between the nasolacrimal folds and the orbital rim. The skin between here is thin, while the orbicularis oculi muscle above and below the depression is thicker. During the lower blepharoplasty, the partial removal of the swollen fat pad protrusion – combined with the removal of the orbicularis fascia, which is concealed 2 mm above and parallel to the nearby arcuate rim – allows the collapse of the nasolacrimal sulcus to disappear immediately. The fat obtained is injected caudally into the orbicularis oris muscle via the orbital rim to restore volume in this area. When performing lower blepharoplasty, only a little more time is required to complete this operation, and the result is both long-lasting and aesthetically pleasing. This approach often results in minor puffiness and contusion. Many plastic surgeons use fat removal or fat injection to beautify the contours, eyelids and shape of the face and have found better and longer lasting results in these areas. In the authors’ experience, about 1/3 of patients have excellent results with fat grafting, about 1/3 have good results, and the remaining 1/3 have fair or poor results and require reoperation. When the procedure of removing the orbicularis fascia was added to the fat grafting procedure, the percentage of patients achieving very good and good results increased. This technique described in this article first improves the collapse between the medial canthus tendon and the outer 2/3 of the orbital rim. If fascial clipping and fat grafting are extended to the outer side where the tissue is thinner, it can lead to the consequence of fat unity. In addition, although fascial clipping improves the lateral collapse, it is operated with great care to avoid the fine facial nerve bifurcations, which are located under the muscles of the lateral surface, making the operation risky. 2. Operation technique This procedure is suitable for use in conjunction with lower eyelid blepharoplasty, or independently in the absence of a prominent lower eyelid fat pad. For both applications, it is necessary to harvest the fat needed for grafting to augment the nasolacrimal fold area of the lower eyelid. Although there are many fat donors in the body and many methods of fat removal, the authors prefer to use an open-hole 14G syringe to harvest fat from the lateral femoral gluteal region. The advantage of lateral femoral gluteal fat over abdominal fat is that it is denser, more porous, and less liquid fat. If there is no excess skin or wrinkles, only a limited incision is required in the lower eyelid from the medial canthus tendon to the lateral canthus. The procedure is performed approximately as follows: (A) A small incision is made at the lower lid margin with a 15-gauge scalpel- (B) The flap is dissected down to the dermis (C) The orbicularis oris muscle is cut horizontally (D) The protruding fat pad is cut away (E) The dissected orbicularis fascia is clearly marked with a blue pen (F) The fascia is peeled away (G) The fat is grafted into the orbicularis oris muscle. It is an interesting anatomical phenomenon that after fat removal, the facial nerve bifurcation can be seen passing horizontally under the orbicularis oculi, a clearly visible facial nerve that is rarely seen. After fascial removal and fat implantation, the skin is closed with 6-0 nylon sutures. If there is unconventional fat swelling in the orbital rim orbicularis muscle area, this can be resolved by massage with a fingertip or blunt instrument. If excess lower eyelid skin and wrinkles need to be removed with lower blepharoplasty, a full incision to the corner of the eye is required. Surgery A blunt instrument peel using the back of scissors during the fascial peel will reduce bleeding. Secondary repair using hyaluronic acid fillers or smaller contour corrections can be performed a few weeks after surgery, after the surgical site has smoothed out naturally. From this point on, small contour corrections can be achieved with hyaluronic acid fillers or fat grafting. In conclusion: The actual cause of the sunken nasal tear trough is the atrophy of the fat in the dermis and the underlying orbicularis oculi muscle, which develops with age. Subcutaneous fat grafting allows its repair to be achieved, but the procedure is tedious and may cause fat unity in that area. The technique described above, based on lower blepharoplasty, removes the orbicularis fascia over the arcuate rim, allowing the fat implanted by syringe to enter the orbital rim and suborbital rim. This technique has been used by the authors in hundreds of cases and has yielded excellent results in the correction of nasolacrimal folds. The authors concluded that this method is safe and effective, that small depressions, etc., can be corrected with postoperative adjuncts, and that it only takes a little more time to achieve in the lower blepharoplasty procedure.