In advanced cases of volume deficiency caused by inherited or surgical loss of both orbital and sub-brow fat, the upper eyelid's more superficial skin and muscle layers collapse onto the deeper structures. The crease disappears, turning the lid into one expansive flattened platform that seems to dive into the socket.

The hollowness may be so deep and cavernous that the contour of the rim of bone above the eye becomes noticeably exposed, resetting the focus of a viewer's attention away from the eye's pupil and into the shadowed depression.

Because advanced upper hollowness tends to be seen most commonly in the elderly and the ill, its cosmetic effect is far from flattering.

Many patients with a doll's eye deformity show at least some evidence of ptosis, or drooping of the upper eyelid, probably caused by a mechanical limitation from the collapsed overlying structure.

Missing adequate structural support from below, the brow may sit low. While not always desirable, a low brow position can serve to conceal the extent of deep upper hollowness. Brow lift can lead to increased exposure of the basic flaw and worsening of the overall appearance.

For ease of reference, we have named the following characteristic and not uncommon collection of findings the doll's eye deformity:

• advanced upper eyelid and sub-brow hollowness
• exposure of the bony orbital rim
• absence of an eyelid crease
• often accompanied by mild ptosis
• often accompanied by a low brow position

The only effective treatment for a doll's eye disorder is orbital fat grafting using a more extensive approach than typically employed for simple hollowness following upper blepharoplasty. More than one operation may be necessary to restore optimal volume to both the orbit and sub-brow spaces. When ptosis is objectionable, it may be improved with a later operation.