Autologous fat grafting is a common treatment for tear trough deformities. This procedure involves a potential complication of fat nodule formation, leading to abnormal bulging of the lower eyelid. However, limited information exists about this complication, and an effective treatment is lacking. The present study aimed to present a novel surgical approach for the removal of fat nodules caused by autologous fat grafting in the tear trough.This retrospective study included 33 patients who underwent surgery for the removal of fat nodules formed after autologous fat grafting. The procedure was performed using a conjunctival approach, allowing exposure and removal of all fat nodules in the anterior septal space, with the method adapted according to the severity of the deformity.A total of 66 eyelids were treated surgically, including 30 (45.45%) with mild nodular deformity, 23 (34.85%) with moderate nodular deformity, and 13 (10.70%) with severe nodular deformity. A second surgical procedure was required on 3 eyelids (4.56%). The main complications of the surgery were conjunctival congestion (21.21%), and localized depression (18.18%), bruising (12.12%). Among the patients, 29 (87.88%) were satisfied and 4 (12.12%) were dissatisfied with the treatment results.Conjunctival approach surgery is an effective method of removing fat nodules formed after autologous fat grafting in the tear trough, with good results and high levels of patient satisfaction. This approach enables the effective management of a common complication of autologous fat grafting and may enable the wider application of autologous fat grafting in the periorbital region.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.