While due to a shortage of orbital fat, upper eyelid hollowness can be seen in a variety of settings ranging from heredity to aging to trauma to overdone surgery.

If orbital fat (F) is deficient and has little or no forward projection against the orbital septum (E), the course of the levator muscle complex (L) becomes clearly visualized whenever eye is opened. Minus any "padding," the top part of the upper eyelid seems to tuck immediately under the socket bone (I) into a deep hollow ("superior sulcus").

When due to inherited family traits, such fat shortage reflects the way the lid is naturally "put together." When mild, any associated hollowness is most often of little cosmetic concern.

When acquired later in life due to aging or surgery, however, many patients are quite bothered by the loss of their previous eyelid contour and may seek volume augmentation to help restore the former appearance.

A	Eyeball	Front portion of eye
B	Skin	Epidermis on surface, dermis below
C	Orbicularis Muscle	Eyelid closing muscle
D	Tarsus (Tarsal Plate)	Stiffening element (like cartilage)
E	Orbital Septum	Layer holding back the orbital fat
F	Orbital Fat	Fat from the socket extending into lid
H	Eyelid Retractors	Structures that help retract the lids
I	Orbital Bone	Bone surrounding the eye; socket
J	Conjunctiva	Lining of the back of eyelid and front of eye
K	Periosteum	Lining of the bone (called 'periorbita' in orbit)
L	Levator	Main upper lid opening muscle/tendon

Eyelid and orbital trauma may result in the loss of orbital fat due to direct injury with later absorption or more indirectly from fractures in the socket bone that allow the fat to fall into the adjacent sinuses. Extensive eye surgery (such as retinal detachment operations) may result in gradual loss of orbital fat.

While some people bulge orbital fat as they age, others tend to absorb it. Especially when a patient with this tendency has undergone earlier aggressive fat removal during upper blepharoplasty, the progressive hollowness over time can become very noticeable.

We have named this condition the "doll's eye deformity."

In years past, aggressive tissue removal during upper blepharoplasty was quite the norm. A better approach is to trim away only that fat or muscle that is clearly excessive (which is often none at all), thus retaining the lid's natural fullness and defined crease that project the appearance of health, youth, and vigor.

When objectionable, the harshness of upper hollowness may be softened by the placement of strip fat grafts into the orbit.

In more advanced cases, a combination of both strip and pearl fat grafts may be employed to address both the orbital and sub-brow volume deficiency.

Orbital and eyelid fat deficiency in the younger Asian patient is a more common disorder than generally recognized.