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Orbital Fat Grafting


Restoring Youthful Fullness to
Hollowed and Sunken Eyes


orbital fat

Orbital fat grafting offers a solution to the difficult problems of eyelid hollowness, structural collapse, and lid retraction caused by prior cosmetic eye surgery, trauma, spontaneous absorption from aging, genetics, or disease.

It is different from fat injections around the eye, a simple but common technique with which it is often confused.

Initially employed to reverse sunken eyes after ill-advised or overdone blepharoplasty, this family of sophisticated operations is now used to address a wider range of formerly untreatable or poorly treatable eyelid disorders.

Before and After Photos
photos upper eyelid hollowness
photos lower eyelid hollowness


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.


upper eyelid hollowness lower eyelid hollowness
Advanced upper eyelid hollowness
("doll's eye deformity")
Advanced lower eyelid hollowness
("orbital flat tire")

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.


orbital fat grafting location

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
upper hollowness before
Before
upper hollowenss after
Eight Months After

 

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.

side view of eye and lids

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.

hollowed eyelid signs

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

pencil cores

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.

structural disruption

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.


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.

tear trough depression

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.

(As an aside, we feel that the tear trough is far better treated with fillers than by fat transfer anyway, but that's a whole different topic.)

orbital fat grafting patient

A healthy patient with moderate to severe upper or lower eyelid hollowness from fat loss caused by previous blepharoplasty, trauma, genetics, or aging who is bothered enough by his or her appearance to undergo an invasive surgical procedure.

Smokers and patients with diabetes, vascular disease, lipodystrophy, or other general systemic diseases may show 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.

pseudo-hollowness

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 much over the age of 60, exhibit a high psychological fixation on the deficit, or seem to harbor expectations of a result free of imperfections.

No. Cheek depressions below the eyelid (tear trough, suborbital deficiency, inadequate cheek bone projection, etc.) are unrelated to orbital volume deficiency.

Lower orbital fat grafting places fat behind the orbital septum and so is effective only for true eyelid hollowness located above the rim of bone but not below it.

Pearl fat implanted into upper cheek depressions can result in noticeable lumpiness.

lower lid and upper cheek
The easiest way to distinguish between the two is to look straight ahead into a mirror, place your finger over the depression, and push gently inward.
orbital bone

If you feel bone, the hollowness is on your upper cheek. Such a hollow, often called a "tear trough" or "infraorbital depression," does not benefit from orbital fat grafting.

If instead you feel the eyeball, the source of the problem is probably orbital.

Most patients who contact us about lower hollowness unrelated to previous eyelid surgery actually have common upper cheek depression.

On the other hand, if the hollowness developed only after blepharoplasty and was not present prior to surgery, it is very likely orbital in origin. More

If the lids appear hollowed once most the initial postoperative swelling is gone (usually a few weeks to one month), waiting for spontaneous improvement to appear constitutes little more than wishful thinking.

Fat taken out will not grow back in.

Final resolution of all remaining swelling over the next six months or so will only unmask even more eye hollowness.

No. Only orbital fat grafting can enhance deep fat volume around the eye and thereby correct disturbed tissue relationships seen with eyelid hollowness.

Although operations such as midface lift, SOOF lift, canthoplasty, canthopexy, orbicularis muscle resuspension, and placement of tear trough implants may be effective in treating upper cheek depressions (sometimes called "undereye hollows"), none of these procedures introduce new volume into the orbital cavity.

With a hollowed eyelid, the basic problem is lack of support from within, much like a deflated balloon.

You can't just pull on it to bring it back into shape.

deflated balloon
inflated balloon You have to blow air into it.

No. 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.

tissue-sparing upper blepharoplasty

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 "sort of" at the most, "no" to be realistic.

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.

caulk dermal fillers

Injectable hyaluronic acid fillers have been used to blunt milder cases of upper eyelid hollowness.

Much like applying caulk along the edge of the rim of orbital bone, the material is placed in front of the orbital septum (not in the orbit) and provides a means of temporary camouflage rather than true tissue restoration with its attendant benefits.

Although only recently reported in the American medical literature, the technique has been used in East Asia for over five years.

As with all dermal fillers, any improvement is temporary.

A few physicians have tried injecting fillers in back of the orbital septum (into the orbit). The safety of such use has not been established. Since the orbital contents are not tight like skin and muscle on the face, filler migration could become an issue.

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.

No. Lower fat repositioning, sometimes called an arcus marginalis release, is, we believe, a misunderstood operation that we ceased offering to our patients over five years ago.

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.

fat repositioning

In some cases, orbital fat grafting can dramatically improve on eyelid retraction, a feared complication of overdone lower blepharoplasty.

eyelid retraction  

Internal scarring and shrinkage and loss of vital support (the main causes of most post-blepharoplasty lid retraction) can be remedied in a manner that is not just more successful than most current methods now in use but also far more restorative of normal lid anatomy and physiology.

If the primary cause of the retraction is instead excessive skin removal (less common), orbital fat grafting alone will not correct the problem.

Before

lid retraction repaired
After lower orbital fat grafting only

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

While upper orbital fat grafting provides a means for augmenting deep fat volume, a high crease after blepharoplasty can 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.

ofg before

Orbital fat grafting has wide application in the field of Asian eyelid surgery.

Not only has it revolutionized our approach to the revision of unsatisfactory results after double eyelid surgery, but it can also address previously untreatable premature aging changes in the Asian upper and lower lids.

More details on the use of orbital fat grafting in the Asian eyelid can be found here.

Before
ofg after
After
Orbital fat grafting can also help restore lost volume around the eye that is the consequence of previous serious orbital surgery (for instance, after decompression for thyroid eye disease, retinal detachment repair, or tumor removal) or eye socket fractures complicated by later fat loss.

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 sporadically 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 superficial recesses around the eye in quantities sufficient to improve upon advanced upper and lower eyelid hollowness.

Most patients and some 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.

different orbits

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.

While one-piece "strip" or "block" fat grafts have definite limits, a larger amount of "pearl" fat can be introduced into the upper or lower orbit if placed properly.

fat pearls

The large surface area-to-volume ratio of roughly spherical fat pearls allows for rapid vascularization.

Determination of exactly how much fat to implant depends on a wide range of anatomical variables but most of all on surgeon skill and experience.

While we generally aim for a slight undercorrection, overcorrection can indeed occur.

A realistic goal is to achieve a noticeable improvement rather than a perfect or near perfect restoration.

In cases of severe volume deficit, even a modest change may make a patient feel more comfortable with his or her appearance.

Any eyelid hollowness caused by previous skin or muscle removal is not helped by orbital fat grafting, which can address only the fat component of the deficiency.

When transferring living tissue from one area of the body to another, survival -- both immediate and long-term -- is always a main concern. To maximize chances, the tissue to be moved should be as unharmed as possible, the method should be gentle, and the new environment should be as similar and receptive as possible. Our techniques of orbital fat grafting have been designed around these principles.

live tissue transfer

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 tissue back into an injured orbit will always be less precise and predictable than taking it out during first-time blepharoplasty.

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 in the higher end of this range. "Take" may vary between the two eyelids of a given patient or even within different areas of a single lid.

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

More than with any other eyelid operation, proper care after surgery is imperative. Patients who have compulsively followed postoperative instructions have, as a group, demonstrated superior survival of grafted fat.

Still, limitations are inherent to and to be expected with any complex revision surgery undertaken to improve upon previously untreatable problems.

Our longest photographic follow-ups to date are six years and still demonstrate excellent retention.

If grafted fat survives initial healing, it appears, in most cases, to remain stable. Several factors, however, may possibly affect future longevity.

fat loss

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 reported unchanging volume after a period of about three to six months. Orbital fat grafts seem to behave much like other structurally-intact tissue grafts (such as a skin graft), which after initial healing become a stable and permanent part of the anatomy.

In the cases where we have explored the surgical site a year later and visually inspected the graft, the fat has appeared fully healthy with normal color and vascularity.

While reported retention rates vary widely and seem to be extremely surgeon-dependent, most studies on injected liposuctioned fat indicate only about a 10% survival at one year.

There are several possible explanations to account for increased long-term survival with direct grafting of fat pearls:

(1) Following liposuction and any subsequent treatment of fat aspirate (for instance, centrifugation, washing, and then injection through a tiny cannula), many of the harvested cells are severely traumatized if not killed.

In contrast, excising fat with scissors and then layering the grafts using tiny forceps is less stressful on the cells and preserves the basic architecture of fat as a complete tissue made up of not just adipocytes but also their associated blood vessels, nerves, and fibrous (or supporting) elements.

 

(2) One study showed five times the survival rate at six months for fat injected into subcutaneous tissue versus fat injected into muscle, suggesting that fat placed into atypical areas may be more quickly remodeled away by the body's repair mechanisms.

In contrast to injection techniques that call for the fanning out of fat aspirate into multiple tunnels and different tissues, particulate fat grafts are distributed into precisely the one deeper tissue space naturally intended to house orbital fat.

adding fat

removing fat

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 certain cases if truly indicated. More

Adding more pearl fat into the orbit to try to refine an already satisfactory improvement is seldom recommended. However, once a foundation has been reestablished with orbital fat grafting, less invasive fat or filler injection techniques might serve to blunt noticeable irregularities.

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 desirable.

Most patients report little or no discomfort.

meronk office operating room


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 at least one month between operations.

Orbital fat grafting is an invasive and most frequently revisional operation undertaken on both the eyelid and the orbit and so requires longer to heal than standard blepharoplasty.

Sutures are removed on the fourth or fifth day after surgery. Although noticeable 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 can take months.

Even after the grafted fat has developed a secure blood supply, it remains inflamed for several months, during which time it may feel "rubbery" and the lid may look more irregular than it will later on. With upper fat grafting, some patients may experience difficulty opening the eyes fully and/or a feeling of pressure in the upper socket.

Healing to the very best result can take a full year or more. Once the graft becomes settled and matures, it softens, thins, and allows the skin above it to drape more freely and the eye to open normally. Photos

Not every patient will be pleased, but then no known operation whether first time or revisional carries a 100% satisfaction rate. While the majority of our patients have been grateful and some have been elated, results with orbital fat grafting seldom approach perfection and are uncommonly disappointing.

Corrective surgery that is additive (restoration) is always less predictable than first-time surgery that is primarily subtractive (tissue removal). Patients who cannot accept that limitations exist with all revision surgery undertaken to address difficult problems or who become overly impatient during healing are likely to be dissatisfied.

People who consider themselves to be "perfectionists" should not pursue this operation.

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, especially since orbital fat grafting is usually revisional in nature and thus involves working on damaged tissue.

To date, we have performed more than 600 orbital fat grafting procedures. The most significant adverse events encountered have been four 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, one in the upper lids of a young patient who had undergone one previous operation, 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 unevenness is to be expected after any revision surgery, especially in the lower lids and in patients with thin skin. This is seldom a valid indication to risk more surgery.

While some patients experience mild or even worrisome drooping of one or both upper eyelids (ptosis) lasting from a few weeks to several months after upper orbital fat grafting, in only two cases has this problem not resolved fully within one year.

A few patients have experienced difficulty with full eyelid closure, but it is not clear that this was the result of the fat grafting rather than previous damage to eyelid structure during their initial surgeries.

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 any limitation of eyeball movement following orbital fat grafting.

Despite tremendous interest in the potential of stem cell therapy and other forms of tissue engineering, the prospect of producing fat suitable for orbital volume enhancement is at best futuristic.

Generating human fat in a laboratory remains a daunting scientific challenge on many fronts. Any suggestion of replenishing a human orbit by injecting stem cells is at present science fiction.

stem cells
travel

Yes. In fact, most of our patients come from far away.

We routinely treat patients from around the United States, Canada, Asia-Pacific, and Europe.

Most are able to travel by auto or air within four or five days after surgery.

 

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 on this website.

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 2006.

Representative before and after photos (upper, lower), surgical photos, and much more information can be accessed from the navigation element immediately following this tutorial as well as near the bottom of most pages in this Section.

Although the concept may seem easy to grasp from reading our website and the basic strategies behind tissue grafting, orbital surgery, and eyelid revision surgery should be familiar to most experienced oculoplastic surgeons, there are many unpublished details regarding our methods and insights.

Until Dr. Meronk began refining the procedures described in this section, the treatment of eyelid hollowness was essentially an ignored discipline of little interest to anyone but a few oculoplastic surgeons.

right eye before   Today, this class of operations can be used to address a variety of previously untreatable disorders as well as several eyelid problems for which present therapies yield far from satisfactory results.

Nevertheless, orbital fat grafting remains an "orphan" operation.

While not rare, patients suffering from the effects of orbital volume deficiency are uncommonly diagnosed as such and so the condition goes widely unrecognized.

Some eyelid surgeons have explored the concept and developed their own techniques, while others have never observed or performed this type of fat transfer. If you believe you may be a candidate for orbital fat grafting, be sure to research your options and consult with several oculoplastic specialists.

Before

 
right after  
After  




Orbital Fat Grafting
Restoring Fullness to Sunken and Hollow Eyelids

Before and After Photos
photos upper eyelid hollowness
photos lower eyelid hollowness

Overview | Pertinent Anatomy | Preventable Causes

The Orbital Flat Tire | Doll's Eye Deformity
Hollowness in the Asian Upper Eyelid

Not the Same as Fat Injections

That Tiny Roll of Upper Eyelid Skin:
It's Not What You Think (video)



Treatment Options: Introduction
Upper Eyelid Hollowness | Lower Eyelid Hollowness
Upper Cheek Hollowness

Pearl Fat Grafting | Strip Fat Grafting
Combination Strip-Pearl Fat Grafting Technique
Small Incision Approach

Orbit-to-Orbit Fat Transfer | Internal Orbital Fat Relocation
Dermal Fat Grafts | Fat Injection | Dermal Fillers



What is Meant By Under-Eye Hollows?
Dark Circles

Orbital Hollowness and Brow Lift



Healing and Recovery
Sequential Photos from Before to 18 Months After
Removal of Excess Grafted Fat



eyelid surgery resource
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