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Orbital Fat Grafting
Restoring Youthful Fullness to
Hollowed and Sunken Eyes
A Compehensive Tutorial
on Orbital Fat Restoration
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Orbital Fat Grafting offers an innovative solution to the difficult problems of eyelid hollowness, structural collapse, and lid retraction caused by prior cosmetic eye surgery, trauma, or spontaneous absorption from aging, genetics, or disease.
It is entirely different from fat injections around the eye, a simple but common technique with which it is often confused.
Initially employed and refined by Dr. Meronk to reverse sunken eyes after ill-advised or overdone blepharoplasty, we later learned to use this family of sophisticated operations to address a wider range of formerly untreatable or poorly treatable eyelid disorders.
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THE HOLLOWED EYELID TUTORIAL is
EXCLUSIVE CONTENT
The first nine panels below are
available for preview.
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Understanding Orbital Fat Restoration |
• Physical appearance is determined by two main factors: inheritance and the effect of the environment on the expression of such traits.
In the past, the most common cause of hollowed eyelids was overwhelmingly genetic. Unfortunately, that has changed. Today, a very common cause is "environmental," namely, the result of surgical trauma from overdone blepharoplasty.
Hollowness following cosmetic blepharoplasty does not always appear immediately. Sometimes it takes a while. Sometimes it takes a long while.
Although the sunken effect from excessive fat removal will often become visible shortly after surgical swelling subsides, hollowing from traumatic fat "atrophy" due to over-manipulation of the orbital fat may sometimes not develop for a year or two.
In fact, many cases of eyelid hollowness emerge years later, even decades later, when the normal biological process of orbital fat loss from aging finds itself markedly helped along by previous aggressive fat removal at a younger age.
As the population of patients who have undergone cosmetic blepharoplasty ages and increases, the incidence of sunken eyelids has begun to escalate rapidly. Problems that were seldom encountered thirty years ago are becoming almost common. Even today, many surgeons continue to employ the aggressive techniques of years past, the sad consequences of which will only continue to add to this present and future trend.
• Orbital Fat Grafting ℠ is our name for our advanced class of operations designed to restore fullness to hollowed and sunken upper or lower eyelids by implanting structurally-intact fat obtained from a patient's own body into the orbit, the space within the bony socket surrounding the eye.
The techniques as described here have been developed and refined by Dr. Meronk since 2002 and remain proprietary.
Orbital fat grafting is entirely different from fat injections around the eyes. Apart from confusingly similar names, the two techniques share almost nothing in common. |
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By restoring healthy fat into its natural anatomic compartment, both the appearance and function of even severely deflated and sunken eyelids can be improved in a manner not achievable with other techniques, including injection of liposuctioned fat or commercial fillers.
| Upper Hollowness |
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| Eight Months After |
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Other methods used to treat sunken eyelids involve either plumping up the overlying skin with fillers or tucking surrounding normal structures. None are restorative.
Orbital fat grafting is different in that it directly addresses the basic defect in eyelid hollowness: lack of underlying orbital fat tissue causing internal structural imbalance, loss of support, and deflation of the lid.
Rather than simply camouflaging the cosmetic effect of the problem much like a concealer, orbital fat grafting is restorative by (1) replenishing fat into the compartment from which it is missing, and (2) allowing for reconfiguration of disturbed relationships between the multiple layers of the eyelid.
As with any advanced operation, there are limitations and compromises. However, the benefits of grafting structurally intact fat into the orbit appear to be substantial, and most patients with realistic expectations are pleased. |
• While this may come as a surprise, a normal upper or lower eyelid contains almost no fat of its own.
What is commonly referred to as "eyelid fat" is actually the most forward extension of the orbital fat (shown in yellow), a large fat compartment that surrounds and protects the eye, eye muscles, nerves, and blood vessels inside of their bony socket.
If orbital fat becomes deficient for any of a variety of reasons, the eyelids will deflate and sink inward and sometimes downward.
Thus, a hollow-appearing eyelid is really a hollowed orbit. |
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• While advanced eyelid hollowness can make the eyes feel vaguely uncomfortable and easily tired, the most worrisome consequences of orbital fat shortage in most patients are cosmetic.
Since advancing age and illness are the most common natural causes of orbital fat loss, sunken eyelids tend to make even a young face look older (especially with upper hollowness), unhealthy (especially with lower hollowness), as well as tired and less expressive.
Interestingly, mild to moderate orbital "hollowness" may be the norm 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, the people most bothered by eyelid hollowness are those in whom fat shortage is not simply genetic or related to normal aging but rather acquired unexpectedly after surgery.
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• Signs and symptoms of orbital hollowness can vary with the severity of the volume deficiency and a person's starting bone structure. |
Upper Hollowness
Mild to moderate
• High or abnormally arched crease, which can make the face appear older or ill
• One or more rolls of thin (deflated) skin extending across the lid
• In the Asian upper lid, an abnormal rim of concavity midway between the brow and crease
Moderate to advanced
• Skin no longer drapes and the natural crease is lost; lid become one continuous platform
• Upper eyelid droops (ptosis) due to tissue collapse that impedes opening
• Rim of orbital bone above the eye becomes visible (skeletonization)
• Brow descends due to lack of support from below
• Depression between the bone and eye can become cavernous and deeply shadowed
• Eye feels uncomfortable with movement
Lower Hollowness
Mild
• Abnormally deep indentation between the eyelashes and rim of orbital bone
Moderate to advanced
• Deeper indentation, often noticed most along the outer third of the eyelid
• Sagging or collapse of the lower eyelid due to lack of support from below
• Change in the shape of the eyelid opening (too rounded or tilted down)
• Discomfort and fatigue with intense visual activities
• Lashes may turn inward when looking down and to the side |
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• No. Surgically implanting structurally-intact fat into the orbital cavity is indeed an example of true tissue grafting. Injecting structurally-disrupted fat aspirate under the skin through a blunt needle is not the equivalent.
Because liposuctioned fat aspirate is so disrupted, it must immediately be surrounded by normal intact tissue to receive oxygen and sustenance. This requires inserting the fat as very thin cores, much like a pencil lead surrounded by wood. If the fat is simply injected as a "pool," its death is guaranteed. To treat more than a tiny area, many such cores need to inserted and layered to deliver any real volume.
The hollowed orbit is not very receptive to such poking and probing. For one thing, its filmy tissues are not firm enough to sufficiently encase an injected core of donor fat. For another, many blind passes of a needle into a space filled with critical but delicate complex structures (including the eyeball) risks significant injury. For yet another, many patients seeking orbital volume restoration have deep scar tissue from previous surgery that is hard to penetrate and cannot be seen through the skin.
Unfortunately, present medical terminology is inconsistent. Because the older technique of "fat injection" is often referred to as "fat grafting" or even "structural fat grafting," it is very easy for patients and doctors to become confused. |
• Apart from having been divorced from its main blood supply, a "structurally intact" graft is otherwise anatomically normal. The relationships between its cells, connective tissue, nerves, blood vessels, and so on are fully preserved. Except around its very edges, the tissue is no different from how it exists in the body. Under a microscope, it appears normal. A good example is a skin graft.
Orbital fat grafting employs structurally intact tissue.
Fat injection, on the other hand, uses structurally disrupted tissue liposuctioned out of the body under pressure. Like coffee beans put through a grinder, the trauma to a living tissue can be extreme.
Not only are normal tissue relationships severely destroyed, but many of the cells have been killed or are near-dead even before grafting. |
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• Because simple doesn't mean better.
While injection of liposuctioned fat into and under the skin and muscle is sometimes recommended to patients with hollowed eyelids, the technique cannot correct a deficiency in deep orbital volume.
The superficial expansion following needle injection of fat aspirate is more a matter of surface camouflage, not unlike filling in a pavement's cracks and dips with tar. |
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A hollowed eyelid more resembles a sinkhole.
The pavement is fine. The problem comes from what's missing down below. |
Because as strange at this may seem, most doctors using the term "eyelid fat transfer" or sometimes "eyelid fat grafting" aren't really talking about treating eyelid hollowness or even the eyelids.
Instead, they're referring to an extremely common rim of upper cheek depression known as a "tear trough." Most frequently noted towards the inner side but below the actual eyelid, the concavity can extend across the entire rim of cheek bone as a semicircular groove of depression.
This is not an example of eyelid hollowness from a shortage of orbital fat, no matter how close the depression may sit to the lid.
The anatomy of the upper cheek is distinct from the anatomy of lower lid, and disorders and treatments for these two areas are different. |
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There is no good reason to lump orbital hollowness and tear trough depressions together in overly vague discussions. Again, this is an example of imprecise use of terminology and the source of much confusion . . .
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