• Except in severe cases, the consequences of orbital fat shortage are purely cosmetic. Since advancing age and illness are the most common natural causes of orbital fat loss, hollowed lids tend to make even a young face look older and sometimes unhealthy.

Interestingly, mild to moderate orbital "hollowness" may be the norm rather than the exception in certain populations and be present from an early age. Due to anatomic variations in orbital and facial bone structure, people of, for instance, eastern European or southern Asian lineage show a much higher incidence of noticeable but natural eyelid hollowness. Predictably, this trait is not perceived nearly as negatively as it is in populations where eyelids are more commonly full.

By far, those most bothered by eyelid hollowness are people in whom fat shortage is not genetic but acquired. Not surprisingly, aggressive tissue resection during blepharoplasty is the most common factor in patients consulting us for orbital fat grafting.

• Most older methods used to treat hollowed eyes involve either plumping up the overlying skin or tucking surrounding normal structures. None are very effective.

Orbital fat grafting is different in that it directly addresses the basic defect in eyelid hollowness: lack of underlying fat volume causing loss of support and deflation of the lid.

Rather than simply blunting the cosmetic effect of the problem much like a concealer, orbital fat grafting is designed to be anatomically restorative by returning fat into the compartment from which it is missing.

As with any advanced operation, there are limitations and compromises. However, the benefits of orbital fat grafting appear to be substantial, and most patients with realistic expectations are pleased.

• A healthy patient with moderate to severe eyelid hollowness from fat loss caused by previous blepharoplasty, trauma, or unusual aging who is bothered enough by his or her appearance to undergo an invasive procedure that is still relatively new.

• Smokers and patients with diabetes, vascular disease, lipodystrophy, or other general systemic diseases have shown a substantially lower rate of fat survival.

Patients with eyelid skin shortage, internal eyelid scarring or retraction, a history of having undergone more than one blepharoplasty, or a history of having already undergone a previous attempt at revision are at a major disadvantage.

Treatment is not indicated when the appearance of eyelid hollowness is actually the consequence of a natural variation in normal anatomy. Inherited "pseudo-hollowness" is sometimes noted in those with shallow sockets and prominent eyes. The lower eyelid hugs the eye's curvature and is pushed downward, resulting in a concavity that may simulate orbital fat deficiency. Most younger patients who contact us regarding fat grafting but have not undergone previous blepharoplasty show only pseudo-hollowness.

Irrespective of cause, we do not accept patients who show only mild hollowing, are over the age of 60, exhibit a high psychological fixation on the deficit, or seem to harbor expectations of a result free of imperfections.

• We are unaware of other operations that can address true orbital fat deficiency. While operations such as midface lift, SOOF lift, canthoplasty, canthopexy, orbicularis muscle resuspension, and placement of tear trough implants can be very effective in treating upper cheek depressions (sometimes called "undereye hollows"), they is no way for them to introduce new volume into the actual orbital cavity.

With a hollowed eyelid, the problem is lack of support from within, much like a deflated balloon. You can't push or pull it back into shape.
	You have to blow air into it.

• Upper blepharoplasty is a subtractive procedure that cannot truly add volume. However, in some patients with naturally-occurring upper hollowness, a variation known as "tissue-sparing" upper blepharoplasty may be able to partially mask a mild fat deficiency by compressing excess orbicularis muscle. Any volume enhancement is, of course, the result of camouflage rather than restoration.

Most patients who might benefit from this procedure have such mild hollowness that they don't actually identity themselves as suffering from the condition. The procedure is, obviously, of no value when the root cause of existing hollowness is previous blepharoplasty.

In our practice, we employ tissue-sparing more as a way of avoiding orbital hollowness than treating it. To learn more, access the Tissue-Sparing Blepharoplasty section of our website from the link located next to the green icon near the bottom of this page.

• While bone grafts and silicone blocks can be implanted after, for instance, orbital fractures, such materials are rigid and unyielding and so not ideal replacements for missing soft tissue.

• Despite widespread confusion generated by the loose use of terminology as well as non-discriminating diagnosis, the answer is no.

Temporary injectable dermal fillers like hyaluronic acid may indeed work well when treating more common conditions such as under-eye dark circles and the tear trough. Although such upper cheek depressions are located near the eyelids, they otherwise share almost nothing in common with problems stemming from deeper orbital tissue inadequacy.

Hyaluronic acid fillers (or liposuctioned fat) injected at and over the upper rim of orbital bone are sometimes used to blunt the harshness of upper hollowness. Since the material is placed relatively superficially, its use provides a means of temporary camouflage rather than deeper tissue restoration with its attendant benefits. While only recently reported in the American literature, the technique has been widely used in East Asia for over five years.

Since some clinicians and many patients fail to approach injections near the eyes as invasive procedures with serious known risks, treatment of eyelid hollowness with off-the-shelf fillers injected around the edge of bone may be viewed as a more prudent alternative to orbital fat grafting. While easy to perform, such camouflage fails to restore missing orbital fat, may worsen the sunken appearance by rimming the real depression with unneeded volume, and, of course, requires repeat treatment on an ongoing basis.

Placement of more permanent injectable fillers into the orbit of a seeing eye has not been studied. Potential problems include tissue injury or reaction, migration, and mechanical interference with eyelid function. After having performed revision surgery on a number of patients in whom permanent fillers had been injected into the brow area only to later migrate into the upper eyelid, we are not at all enthusiastic about this approach.

Interestingly, most patients we have treated for eyelid hollowness report that they have already tried injectable fillers (usually, hyaluronic acid) and found them of limited or no value.

• Lower fat repositioning, sometimes called an arcus marginalis release, is, we believe, a misunderstood operation that we no longer offer to our patients.

While fat repositioning out of the orbit and onto the upper cheek is still used by some doctors to try to fill in cheek depressions, the procedure offers absolutely no benefit in treating real eyelid hollowness (where, after all, the orbit is already too short on fat). In fact, a substantial number of patients we have treated for post-blepharoplasty lower hollowness developed their problems only after ill-advised fat repositioning to try to camouflage an upper cheek depression or tear trough.

• In many cases, augmentation of fat volume helps to improve on lid retraction by restoring the natural support to an eyelid that has collapsed down and in.

In cases of significant eyelid retraction due to skin shortage or internal scarring, however, orbital fat grafting alone will not correct lid position.

• Attempting to lower a crease after aggressive blepharoplasty is one of the more difficult goals in revision surgery.

While upper orbital fat grafting provides a means for augmenting deep fat volume, a high crease after blepharoplasty may be caused by a number of factors, including excessive skin, muscle, and/or fat removal.

If too much skin or muscle were removed, adding fat cannot correct a deficiency in the lid's outer coverings.

If too much fat was removed but the remaining skin is adequate, fat grafting can reinflate sunken skin and allow it to drape more naturally, thus reshaping the crease.

In cases of poor eyelid closure due to excessive upper lid skin removal, orbital fat grafting will not help. Lower eyelid retraction is considered in the previous question.

• Particulate fat grafting is not brand new but rather built around surgical techniques that have existed for many years. Fat grafting to fill facial depressions was first described in the late 1800s. We and several other surgeons have sporatically employed pearl fat grafting into and nearby the eyelids for two decades.

In the late 1990s, Dr. Meronk began in earnest to explore the potential of applying these seldom-used techniques to the problem of post-blepharoplasty orbital hollowness. The term "orbital fat grafting" was coined by Dr. Meronk in 2002 to denote our still-evolving class of operations used to graft structurally-intact fat into the deeper recesses around the eye in quantities sufficient to treat advanced upper and lower eyelid hollowing.

Most patients and many doctors still confuse orbital fat grafting with the much more widely-available injection of fat harvested by syringe aspiration or vacuum extraction (autologous fat transplantation, sometimes called structural fat grafting) that has existed in less sophisticated forms for well over half a century. As noted previously, the two procedures share little in common and address different problems.

• As with all revision operations in medicine, there is nothing "standard" about orbital fat grafting for eyelid hollowness. Every patient presents with a unique situation, both with respect to the given shape of his or her anatomy and the cause and magnitude of the volume deficiency.

We employ several methods for orbital fat graft placement as well as two additional procedures closely related to orbital fat grafting -- internal orbital fat relocation and orbit-to-orbit fat transfer (see links in the navigation panel near the bottom of this page).

Since a patient's general health and previous surgical history will greatly affect his or her ability to retain grafted fat, the depth of a given depression is not the only main variable.

• With skin grafting, it is never possible to predict ahead of time just how successful a given operation will be. Most skin grafts shrink about 15-20% during healing, but some shrink almost nothing at all while a few fail completely.

So it goes with orbital fat grafting. Adding fat back into a hollowed orbit is always less precise and predictable than it is when taking it out during first-time blepharoplasty. This is the biggest drawback to orbital fat grafting but also a feature of all revisional surgery.

Exact statistical determination of graft take is hindered by lack of a practical method for objectively measuring the result. Judged subjectively, the amount of grafted fat that survives the operation can vary from 20% to 95% patient to patient but typically falls within the 60 to 80% range. It may vary between the two eyelids of a given patient or even within different areas of a single lid.

This means that although most patients will achieve a nice enhancement that is reasonably even and symmetrical, some will be noticeably undercorrected while others may be overcorrected.

Having refined and standardized our surgical procedures over the course of hundreds of such operations, we do not believe that such lack of full control is related to variability in technique.

Rather, such is simply the nature of this advanced revisional operation.

• The long-term answer for a relatively new procedure is still not available. It appears, however, that while grafted fat that takes initially is quite durable in most cases, its longevity will vary patient to patient.

Factors such as scarring and vascular interruption from previous eyelid surgery, genetic predisposition to fat absorption, excessive facial expression, smoking, aging, and general health issues are just as likely to have negative consequences on grafted fat as on normal fat native to the orbit. One non-smoking patient noted good graft retention for well over a year. Upon becoming a heavy smoker, volume diminished gradually over the next two years.

Most patients, however, have reported essentially stable volume after a period of about three to six months. Orbital fat grafts seem to behave much like other structurally-intact tissue grafts, which after initial healing become a stable part of the anatomy.

In the few cases where we have explored the surgical site a year later, the grafts have appeared healthy with normal color and vascularity.

• While orbital fat grafting is not an operation that lends itself to easy "touch-ups," removing at least some of the healed fat may be feasible in some cases if truly indicated. More

Adding more fat to try to refine an already satisfactory improvement is seldom recommended.

• Probably, although the weight gain or loss would have to be sizeable. After all, abdominal donor fat is a tissue designed to store calories.

We have observed several cases in which a weight loss led to a noticeable but reversible reduction in orbital volume while weight gain led to slight volume increase.

Due to hormonal changes, many people redistribute fat volume out of the face and onto the lower abdomen as they age. While unproven, there is thus at least theoretical reason to suspect that grafted fat may be more hardy over time than natural orbital fat, especially in those with a family tendency to progressively hollow their eyelids with advancing age.

• Bilateral upper or lower orbital fat grafting takes about two hours of 'hands-on' time.

The operation is performed in our office operating room under local anesthesia with moderate sedation. General anesthesia or deep intravenous sedation is neither required nor even desirable. Most patients report little or no discomfort.

To minimize orbital swelling that could interfere with graft survival or pose a threat to the eye, we never operate on both the upper and lower orbit during a single surgery.

For patients residing far from our office but interested in undergoing both upper and lower orbital fat grafting during a single visit, we suggest waiting two weeks between operations.

• Orbital fat grafting is an invasive and most frequently revisional operation undertaken on both the eyelid and the orbit and so requires real time to heal.

Sutures are removed on the fourth day after surgery. Although initial swelling and bruising are mostly gone within 2-3 weeks, resolution of deeper inflammation and full tissue remodeling are much slower biological processes that take many months.

Even after the grafted fat has developed a secure blood supply, it remains inflammed for several more months, during which time it can feel hard or "rubbery" and look more irregular than it will later on.

As with cosmetic blepharoplasty, healing to a final result takes one year or more. Once the graft becomes settled, it softens, thins down, and feels almost normal to the touch.

• While no operation in all of medicine yields a 100% approval rate, the majority of our patients have been satisfied.

Corrective surgery that is additive (restoration) is always less predictable than first-time surgery that is primarily subtractive (tissue removal). Patients who are unrealistic about the inherent limitations of revision surgery or who grow overly impatient with the healing process are less likely to be pleased.

• All operations performed around the eyes come with risks, some of which are substantial. Potential complications include those common to all forms of invasive eyelid and orbital surgery. Since the number of orbital fat grafting operations is still comparatively low, most of these problems have never been encountered. Over time, however, it is almost certain that they will since orbital fat grafting is usually revisional in nature and thus involves working on damaged tissue.

To date, the most significant adverse events encountered have been three instances of immediate graft failure, one in the lower lids of the oldest patient in our series, one in the upper lids of a patient who had undergone three previous operations, and one in a patient with primary (non-surgical) hollowness.

While moderate overcorrections and undercorrections have occurred, only a few have warranted additional surgery. Some unevennes is to be expected after any revisional surgery, especially in the lower lids and in patients with thin skin. This is seldom a valid indication to risk more surgery.

While a small number of patients have experienced noticeable drooping of one or both upper eyelids lasting weeks to months after upper orbital fat grafting, in only two cases has this problem not resolved fully within one year. None have thus far required additional later surgery.

While one laboratory study on rabbits demonstrated the possibility of creating scarring between eye and bone after surgically sewing fat to the eye muscles, we have not noted limitation of eye movement following orbital fat grafting.

• Since 2002, we have provided general observations on eyelid and orbital hollowness as well as an ongoing summary of the development of this novel class of operations here on this website. However, the surgical details of orbital fat grafting remain proprietary, and no other surgeons have been personally trained by Dr. Meronk.

Dr. Meronk's technique to treat post-blepharoplasty lower hollowness was first publicly discussed at the ISLSM 2005 (International Society for Laser Surgery and Medicine) meeting in Tokyo. A summary description was published in the United States medical literature in May, 2006.

• Fees vary with the nature and severity of the problem.

Check here for a general range.