Background Tear trough deformity is a primary complaint in those who believe it causes an old and tired appearance. This deformity naturally increases with aging, but there are younger people that also complain about the appearance of their lower eyelid area. Recently, many authors have reported good results treating this deformity with transconjunctival orbital fat repositioning. Although Kawamoto has pointed out a possible need for a procedure modification in Asians with a brachycephalic face, thus far, there have been no reports evaluating such procedures in Asians. Objective In November 2004, to validate past clinical experiences, we planned a prospective study in young Japanese Asians to assess the efficacy of orbital fat repositioning for improvement of lower eyelid disfigurement. Our goal was to evaluate the viability of transconjunctival repositioning of orbital fat using a preseptal dissection and supraperiosteal pocket method. Methods The prospective study was performed in 20 Japanese patients younger than 40 years of age who were referred to our department over a 1-year period. These patients, in whom eyelid skin tightening was deemed unnecessary, underwent transconjunctival blepharoplasty. Using a transconjunctival incision, a preseptal dissection was performed, extending over the arcus marginalis. A supraperiosteal pocket was made below the orbicularis oculi muscle with blunt scissor dissection. The arcus marginalis was then released by cautery cutting. Both the orbital fat and orbital septum were anchored across the orbital rim with 5-0 polyglactin sutures. Results Results in 18 of 20 patients (90%) were rated as “excellent,” the result for 1 patient (5%) was rated as “good,” and the result for the 1 remaining patient was rated as “fair.” No major eye or eyelid complications, such as lower eyelid retraction, ectropion, or diplopia, were observed. Conclusions Transconjunctival orbital fat repositioning (incorporating preseptal dissection and supraperiosteal pockets) is an effective and safe method for relatively young Asians complaining of lower eyelid disfigurement.