Q: What is 'orbital fat grafting'?
A: Orbital fat grafting is a method for the augmentation or restoration of deficient upper or lower orbital volume caused by excessive fat resection during blepharoplasty, spontaneous fat absorption associated with aging, or congenital hollowness.
Q: Why is there a need for these procedures?
A: Injection of a filler material into and under the skin and muscle of a hollowed eyelid is often recommended. Unfortunately, the technique will not correct a deficiency of orbital volume.
The superficial plumping effect from needle injection of temporary commercial fillers (for instance, hyaluronic acid) or fat particles obtained by liposuction 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.
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Q: Compared to other surgical approaches, what is the biggest advantage of orbital fat grafting in the treatment of orbital hollowness?
A: Orbital fat grafting addresses the basic defect in eyelid hollowness: lack of underlying volume. As with any operation, there are limitations and compromises. While new, the benefits of orbital fat grafting appear to be substantial and most patients with realistic expectations are pleased.
Q: Who is a good candidate for this operation?
A: A healthy patient with moderate to severe orbital hollowness caused by previous eyelid surgery or trauma who is bothered enough by his or her appearance to undergo a procedure that is still relatively new. Mild hollowness is best left alone.
Q: Who is a not a good candidate?
A: Smokers and patients with diabetes, vascular disease, lipodystrophy, or other general systemic diseases seem to have a substantially lower rate of fat survival. Other negative factors include eyelid skin shortage, excessive scarring, having undergone more than one blepharoplasty, or having already undegone a previous attempt at revision. Patients with noticeably prominent eyes (forward-placed, "bulging") not uncommonly misdiagnose themselves as being short on orbital fat.
Regardless of cause, we do not accept patients if the hollowness is mild, if we judge the patient to have an overly high psychological fixation on the deficit, or if the patient is expecting perfection or near-perfection after surgery. If an orbital voume deficiency is inherited or due solely to aging, we offer treatment only in advanced cases.
Q: Can hollowness on the upper cheek ("dark circles below the eyes") be treated by orbital fat grafting?
A: No. Hollowness located below the eyelid (tear trough, suborbital deficiency, inadequate cheek bone projection, etc.) is unrelated to orbital volume deficiency. Orbital fat grafting is effective only for lower eyelid hollowness that is located above the rim of bone and not below it.
Q: How can I tell if the dark hollows beneath my eyes are due to orbital or cheek volume deficiency?
A: This is a common point of confusion. 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. If you feel bone, the hollowness is on your upper cheek and not orbital in nature. Such hollows do not benefit from orbital fat grafting. If instead you feel the eyeball, then the source of the problem is orbital. Furthermore, if the hollowness developed only after blepharoplasty and was not present prior to surgery, it is most likely orbital in origin.
Q: What if I have both lower orbital hollowness and upper cheek depression?
A: Not uncommonly, hollowness below the eyes is the result of a combination of factors. As noted above, orbital fat grafting will only help to improve on orbital hollowness. Any upper cheek hollowness will, if desired, require later treatment by a facial cosmetic surgeon. If upper cheek hollowness seems to be the primary problem, it is advisable to forego orbital fat grafting until first trying treatment with a temporary injectable filler.
Q: What is the survival rate of grafted fat?
A: Orbital graft 'take' has been high, typically in the range of 60-80%. Fat survival is most influenced by surgical technique, the patient's overall state of health, and the amount of internal scarring. In two patients who had each undergone numerous previous attempts at revision elsewhere, graft take was negligible.
Q: Why does tissue survival seem higher and more predictable with orbital fat grafting than with injection of liposuctioned fat into the eyelid?
A: There are at least several theoretical reasons:
 (1) Following liposuction and any subsequent treatment of the aspirate (for instance, centrifugation and then injection through a tiny cannula), many of the harvested fat cells are severely traumatized if not disrupted or killed. On the other hand, harvesting fat as intact chunks 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. Thus, pearl fat grafting is more akin to skin grafting, a time-tested and accepted surgical treatment for skin deficiency. Placing an intact piece of donor skin onto a recipient bed is almost always successful (although imagine the very same skin put through a blender and then applied as a paste).
(2) Pearl fat and/or strip fat are grafted into precisely the natural tissue space intended for orbital fat. When injected through a needle, the fat ends up anywhere from just under the skin to inside of the muscle to anterior to the orbital septum, none of which is a natural location for orbital fat. It seems probable that the placement of fat into its intended environment would be conducive to graft survival and yield a more natural-appearing result.
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Q: How long will the augmentation last?
A: While the answer for a relatively new procedure is obviously unknown, it is most likely that (1) rates of graft longevity will vary patient to patient and (2) a variable degree of the initial improvement may be lost over time. 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 area. In the few cases where we have gone back into the eyelid six or more months later, the grafts have appeared entirely healthy with good color, texture, and vascularity.
Q: How much fat can be grafted at one time?
A: There seems to be no practical limit to the amount of pearl fat that can be grafted into the orbit, probably because the size and large surface area of the fat pearls favors their ready incorporation and survival.
The amount of strip fat that can be grafted is, in contrast, limited since the graft consists of a single piece. While its length and height may vary without influencing survival, the thickness of the graft "take" is limited to about 3 mm. Thus, a deeply hollowed upper eyelid treated by strip fat grafting alone may require more than one operation to achieve optimal augmentation. Over the past year, we have developed several modifications combining pearl and strip fat that appear to allow for fuller upper restoration with a single operation.
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Q: I had a blepharoplasty and my lower eyelids ended up hollowed. How long should I wait to see if this improves?
A: Once the initial swelling is gone (a few weeks to a month), waiting for spontaneous improvement to occur in post-blepharoplasty hollowness constitutes little more than wishful thinking. Fat taken out will not grow back, and resolution of any remaining swelling will only unmask more hollowness.
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Q: Do any of the following procedures address the problem of orbital hollowness after blepharoplasty: midface lift, SOOF lift, canthoplasty, canthopexy, tear trough implants?
A: No. Such procedures add no volume to the orbital cavity (although they may help cheek depressions located below the eyelid). While milder hollowness may be helped by dermal fat grafting, the only way to address more advanced orbital volume loss and associated eyelid collapse is with fat grafting into the orbit.
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Q: My doctor said (s)he's never heard of these operations. Why?
A: Particulate fat grafting into the eyelids and surrounding area has been done on a small scale since the late 1980s. The term "orbital fat grafting" was first coined by Dr. Meronk to denote a series of operations employing particulate fat grafting into the orbit rather than the eyelids. Surgical details of the techniques described here remain proprietary for reasons noted in the next question.
Q: How difficult are these operations to perform?
A: Orbital fat grafting is a serious operation with a steep learning curve that requires solid experience with both orbital and revisional eyelid surgery. Few doctors have the sort of specialized practice that attracts a sufficient number of hollowness patients needed to gain competence with these advanced operations. If not performed skillfully, surgery is more risky and will not work.
Q: Have complications been encountered?
A: 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.
While one laboratory study in rabbits suggested the possibility of creating scarring by implanting fat between the eye and orbital floor, we have not experienced such changes in any of our patients.
To date, the most significant adverse events encountered have been two instances of complete graft failure, one in the lower lids of the oldest patient in our series and the other in the upper lids of a patient who had undergone three previous operations.
Moderate overcorrections and undercorrections have occurred, several of which have required additional surgery. While a numbr of patients have experienced temporary mild drooping of the upper eyelid, in only two cases has such "ptosis" not resolved within one year. Slight uneveness is not uncommon, especially in cases of advanced hollowing requiring larger amounts of grafted fat.
Q: How long does the operation take to do both upper or lower lids?
A: About two hours of 'hands-on' time.
Q: Following lower blepharoplasty, I developed both hollowness and eyelid retraction? Can orbital fat grafting help both?
A: 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 retraction due to skin shortage or internal eyelid scarring, however, orbital fat grafting alone will not help.
Q: How does the surgeon determine which method to use and how much fat to implant?
A: These are two of the trickiest aspects of the operation. We have developed five methods for orbital fat graft placement and vary their use depending upon the nature of each patient's problem. The amount of fat is calculated using our own algorithm that factors in a number of pre-existing variables as well as the clinical judgment gained from performing nearly four hundred such procedures. Since a patient's general health and previous surgical history will greatly affect his or her ability to retain fat, the depth of a given depression is not the only main variable.
Q: How complete is the augmentation?
A: We generally aim for an undercorrection. Since results will vary with such a complex procedure, a reasonable goal is to achieve a helpful improvement and not complete or near complete restoration. In advanced cases, even a modest improvement can make a big physical and psychological difference. In the minority of cases, more than one operation may be needed. It is important to understand that any hollowness caused by previous skin or muscle removal is not helped by orbital fat grafting.
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Q: Can the healed grafted fat change in volume with weight gain or weight loss?
A: Yes. Abdominal fat is a tissue designed to store calories. We have observed several cases in which weight loss led to a noticeable reduction in orbital volume while weight gain led to undesirable volume increase.
Q: Is it possible to remove grafted fat from the orbit once it has healed?
A: Removing at least some of the fat is possible. However, doing so risks creating cosmetic irregularity or even functional problems. More
Q: Where can I find more details on orbital fat grafting?
A: Dr. Meronk's technique for orbital pearl fat grafting to treat post-blepharoplasty lower hollowness was first presented 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. For now, however, our most up-to-date thoughts on orbital fat grafting will continue to appear here on this website rather than in print. For more on this decision, see Why Provide Advanced Medical Information Online?
Q: How much does orbital fat grafting cost?
A: Fees vary depending upon the severity of the problem. Check here for a general range.
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