This patient demonstrates cavernous upper hollowness following previous blepharoplasty performed elsewhere (Doll's Eye Deformity). Such severe orbital volume deficieny is beyond the reach of strip fat grafting using a closed method.

An open approach resembling that developed for treating lower eyelid hollowness was employed. Pearl fat was used to augment deeper orbital volume, while strip fat was applied as an overlay to provide a more stable and smoother external contour.

Shown below is a simplified depiction of this more complex solution for advanced orbital volume deficiency.