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.

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.