Hollow upper eyelid and fat grafting

What it treats

• The condition was first described as superior sulcus deformity, corrected with an alloplastic implant in 2 cases of orbital reconstruction (PMID 7447778).
• Traditional blepharoplasty often excised skin, muscle and excessive fat, leaving a long-term hollow orbit and a harsh, operated appearance; current methods favor limited, conservative resection (PMID 15536308).
• After upper blepharoplasty, a white-line disinsertion of the levator aponeurosis can bind into the septal scar left by fat removal, producing post-upper blepharoplasty syndrome: ptosis, hollow sulcus, high or absent crease, eyelash ptosis and compensatory brow elevation, found in 48 of 81 eyelids studied against none of 33 ptosis-surgery control eyelids (PMID 31802837).
• Facelift technique can also cause hollow eyes: unopposed lateral tissue advancement and lower eyelid fat removal during facelift and blepharoplasty were identified as frequent causes, correctable with orbicularis repositioning and arcus marginalis release (PMID 9774028).
• Aging upper periorbits fall into two patterns: soft tissue ptosis needing excision, or volume depletion with bony resorption producing sunken, hollow, skeletonized orbits that need volume added rather than removed (PMID 21046102).
• A total orbital fat volume study by computed tomography in 130 Asian patients found fat volume increased until age 60 and decreased after, a pattern proposed to explain age-related change in eyelid fat prominence (PMID 21042175).
• Classification by hollow pattern: a photographic analysis of 32 women graded 20 eyelids with an inner shadow, or A-pattern, and 44 eyelids with the complete extension of the hollow, or C-pattern (PMID 28753160). A separate case series of 27 patients classified upper eyelid volume deficiency as medial A-shaped hollow, generalized hollow, postblepharoplasty volume loss, or hooding with subbrow deflation (PMID 19935245).
• Deep superior sulcus can progress to sunken superior sulcus syndrome: deep sulcus, lagophthalmos and exposure keratopathy from posterior retraction of skin, orbicularis and septum after orbital fat atrophy (PMID 24614548). A milder presentation causes soft contact lens displacement and wear intolerance (PMID 30555974).

How it is done

Autologous fat grafting and fat repositioning

• Structural fat transplantation for the upper eyelid complex, performed since 1986, was an early description of volume restoration for aging or iatrogenic deformity (PMID 11134987). A free fascia-fat composite graft, taken from the mons pubis, preauricular or temporal area, was used for sunken or multiply folded upper eyelids after Asian blepharoplasty (PMID 11176595).
• The lumbrical fat graft was described as a simple replacement for lost upper eyelid fat (PMID 11932621). Orbital fat anatomic repositioning combined with a fat graft applied to the retro-orbicularis oculi fat (ROOF), graded by sunken depth into 4 stages, was described for Asian eyelids (PMID 20835821).
• Fat grafting alone or combined with orbicularis oculi muscle imbrication (volumetric upper blepharoplasty), mean grafting volume 0.4 cc deep plane and 2.8 cc superficial plane, drew published discussion over patient selection (PMID 28753160), (PMID 29068899), (PMID 29068883). Dermis fat grafting has also been used for superior sulcus volumetric rejuvenation (PMID 26019236).
• Transposition of an orbital fat fascia flap, preserving its vascular pedicle, was based on cadaver anatomy and histology (PMID 37535089). Orbital fat pad repositioning combined with orbicularis oculi muscle flap folding is another described combination (PMID 36727782).
• The "pendulum movement" of orbital fat and ROOF (POR technique) was developed for revision upper blepharoplasty after over-resection, retraction or atrophy of the nasal and central fat pads (PMID 38315230).
• Combined double-eyelid surgery, orbital fat pad repositioning and autologous fat transplantation has been used for severe, grade 3-4 sunken upper eyelids (PMID 38752130), and orbital fat repositioning alone for milder sunken eyelids in young Asian adults (PMID 25804503).
• Combined orbital fat repositioning with supplemental microfragmented autologous fat grafting, assessed by high-resolution ultrasonography, has been studied for moderate hollowing (PMID 41939494). Fat grafting through a supraorbital approach into the ROOF layer has been used for post-blepharoplasty depression (PMID 42303763).
• An endoscopic ROOF transposition technique, through minimal scalp incisions, has been combined with concurrent endoscopic midface and temporal lift (PMID 41628599).
• A medial-pedicled preseptal orbicularis oculi muscle flap, a non-fat alternative, has been used for superior orbital sulcus hollowness (PMID 42332315). A central preaponeurotic fat advancement pedicle has been used during upper blepharoplasty to correct volume asymmetry between the two sulci (PMID 39718136).

Hyaluronic acid and other filler

• Serial puncture injection of hyaluronic acid gel at the superior orbital rim was used for upper eyelid filling and contouring (PMID 19935245), and reviewed as a nonsurgical option for volume deflation of the periorbital area (PMID 28255285).
• Hyaluronic acid gel injected into the superior sulcus was used to treat lagophthalmos in sunken superior sulcus syndrome (PMID 24614548), and to improve contact lens wear intolerance from deep sunken superior sulcus in a case report (PMID 30555974).
• Deep supraperiosteal hyaluronic acid injection by blunt cannula, 0.2-0.4 mL per eyelid, has been studied for supraorbital hollowing (PMID 41850033). Hyaluronic acid and poly-L-lactic acid (PLLA) have been compared for upper-eyelid hollowing, HA in a single session and PLLA over 3 sessions 4 weeks apart (PMID 41799414).

Results and evidence

• Volumetric upper blepharoplasty (fat grafting with or without orbicularis imbrication), 32 women: every inverted eyelid ratio was corrected (p<0.001) and every concave lateral contour changed to convex, regardless of approach (PMID 28753160).
• Orbital fat repositioning with ROOF fat grafting, 50 patients, mean graft 1.4 mL, mean follow-up 4.7 months: satisfactory results in most, with 4 patients needing additional surgery for a translocated fat lump (2) or undercorrection (2) (PMID 20835821).
• Orbital fat fascia flap, 36 patients followed 9-18 months: mean sunken depth improved from 6.2 mm to 2.2 mm (statistically significant); 1 case needed additional granular fat transplantation (PMID 37535089).
• Orbital fat pad repositioning with orbicularis folding, 40 patients, mean follow-up 12.7 months: sunken depth improved from 3.2 mm to 1.5 mm (statistically significant), no major complications (PMID 36727782).
• POR technique, 49 patients, median follow-up 8 months: 95.9% had improved aesthetic rating and 93.9% were satisfied (PMID 38315230).
• Combined fat repositioning and transplantation for severe (grade 3-4) sunken eyelids, 79 patients: satisfaction 92%, recurrence 6%, complications 5% at 1 year (PMID 38752130). Orbital fat repositioning alone in 250 young Asian adults: satisfaction 76%, relapse 10%, complications 8% at 1 year (PMID 25804503).
• Combined orbital fat repositioning and microfragmented fat grafting, 35 patients (70 eyelids): mean preoperative hollowing depth 5.88 mm, mean grafted volume 1.09 mL, ultrasonography-confirmed improvement stable from 3 to 6 months, satisfaction 97.14% (PMID 41939494).
• Fat grafting via supraorbital approach, 32 patients (64 eyelids) at 6 months: 81.3% "very much improved" and 12.5% "much improved" on the Global Aesthetic Improvement Scale (GAIS); 87.5% self-rated the outcome excellent; mild recurrent hollowing in 12.5%, of whom most had secondary grafting (PMID 42303763).
• Endoscopic ROOF transposition, 26 patients: stable improvement in eyelid contour and lateral orbital fullness at 12 months (PMID 41628599). Preseptal orbicularis oculi flap versus conventional blepharoplasty, 45 versus 481 patients: no significant difference in FACE-Q scores (p=0.251) (PMID 42332315).
• Micro-fat graft long-term review, 1,047 patients over 15 years: 21 judged to have bad outcomes and 4 categorized as "ugly" over a 3-190 month follow-up range (PMID 32944851).
• Hyaluronic acid gel filling, 27 patients, mean follow-up 13 months: photographic improvement in 85%, satisfaction 96%, though 19% requested additional filler and 2 of 3 hooding-type patients still needed blepharoplasty or ptosis surgery (PMID 19935245).
• Hyaluronic acid gel for lagophthalmos in sunken superior sulcus syndrome, 5 patients, mean follow-up 9.5 months: lagophthalmos improved 69% on the right and 71% on the left (p=0.02, p=0.01) (PMID 24614548).
• Supraperiosteal hyaluronic acid, 46 adults at 6 months: mean physician GAIS 4.3±0.5, mean patient GAIS 4.5±0.6, 91% rated "very good" or "exceptional" (PMID 41850033).
• Hyaluronic acid versus PLLA, 36 patients: HA outperformed PLLA on hollow area and sulcus curvature through 6 months (p<.01), but PLLA showed greater improvement on all 3 image metrics by 9 months (p<.001) (PMID 41799414).
• Systematic review of hyaluronic acid after blepharoplasty, 5 studies, sample sizes 5-109, follow-up 1 month to 7 years: volume retention persisted beyond 12 months in most cases; lipofilling had a lower complication rate (12%) than isolated blepharoplasty (20%) as an adjuvant (PMID 40648944).

Risks and complications

• Ptosis after autologous fat injection into the upper eyelid, reported in 5 cases: grafted fat removal, with or without levator aponeurosis advancement, was required in all 5 (PMID 26229134).
• Granulomatous inflammation with foreign body reaction and fat necrosis developed in the upper eyelid after an autologous fat injection in the forehead, from migration of the injected fat, in a single case (PMID 30615002).
• Complications after periumbilical fat implantation into the upper eyelid, 20 patients (33 eyes): swollen appearance in 78.8%, unsmooth double-eyelid line in 69.7%, adhesion in 66.7%; after corrective surgery, 66.7% had an excellent result and only the 2 eyes with the most severe damage (type III) had a poor outcome (PMID 37430215).
• With the preseptal orbicularis oculi flap, transient supraorbital hypoesthesia occurred in 71% of patients, resolving within a few months, with no flap necrosis; the conventional blepharoplasty comparison group had medial canthal scarring in 16 of its patients, 4 needing revision (PMID 42332315).
• A first reported case of chronic upper eyelid edema from temporal hyaluronic acid filler injected 2 years earlier required surgical, not hyaluronidase, resolution because the diagnosis was delayed (PMID 41959944).
• Across the systematic review of post-blepharoplasty hyaluronic acid, lipofilling carried a 12% complication rate against 20% for blepharoplasty alone, and hyaluronidase resolved recalcitrant edema in 50-100% of treated cases (PMID 40648944).

Recovery

• After endoscopic ROOF transposition, early postoperative edema and bruising resolved within 1 week, with stable results through 12 months (PMID 41628599).
• After supraperiosteal hyaluronic acid injection, transient bruising (28%) and edema (26%) resolved without intervention (PMID 41850033).
• After combined orbital fat repositioning and fat grafting, ultrasonography showed outcomes stabilized by 3 months, with no further significant change to 6 months (PMID 41939494).
• After hyaluronic acid gel for sunken superior sulcus syndrome, complications were limited to bruising and temporary uneven contour (PMID 24614548).

With a facelift

• Hollow eyes are described as a frequent facelift sequela, corrected with orbicularis repositioning and arcus marginalis release performed as part of the facelift itself (PMID 9774028).
• In the endoscopic ROOF transposition series, 24 of 26 patients had concurrent endoscopic midface and temporal lift and 2 had a forehead lift in the same operation (PMID 41628599).

Current questions

• Fat grafting versus filler: one group considers structural fat grafting more invasive, with greater morbidity and downtime, and favors HA filler as the preferred nonsurgical option (PMID 21046102); published correspondence on a major fat-grafting series shows continued debate over patient selection (PMID 29068899), (PMID 29068883).
• HA against PLLA: one comparative cohort found HA faster-acting through 6 months but PLLA more effective by 9 months, without a resolved recommendation for which to prefer over time (PMID 41799414).
• Late-onset filler complications, presenting years after injection and far from the injection site, remain poorly understood and likely underdiagnosed (PMID 41959944).
• Donor fat source: periumbilical fat grafting carries a distinct complication profile from orbital or standard autologous fat, with swelling and adhesion in most of one series (PMID 37430215).
• Non-fat alternatives: the preseptal orbicularis oculi flap showed outcomes statistically similar to conventional blepharoplasty but in a small, selected sample (PMID 42332315).
• Long-term durability: a 15-year fat-graft review found most outcomes good but still catalogued poor results years after treatment (PMID 32944851).

Terms

• Superior sulcus (deformity): the deepened groove between the upper eyelid crease and the orbital rim when volume is lost (PMID 7447778).
• Sunken superior sulcus syndrome (SSSS): deep superior sulcus with lagophthalmos and exposure keratopathy from orbital fat atrophy (PMID 24614548).
• Retro-orbicularis oculi fat (ROOF): the fat layer beneath the orbicularis oculi muscle, a common fat-graft recipient site for upper lid hollowing (PMID 20835821).
• A-pattern / A-shaped hollow: an inner (medial) shadow pattern of upper eyelid hollowing, as distinguished from a complete, full-width hollow (PMID 28753160), (PMID 19935245).
• Volumetric blepharoplasty: upper blepharoplasty that adds or preserves volume, typically with fat grafting, rather than only excising tissue (PMID 28753160).
• Lumbrical fat graft: a specific autologous fat graft technique described for replacing lost upper eyelid fat (PMID 11932621).
• Fascia-fat / dermis-fat graft: composite grafts combining fat with fascia or dermis for added structural support and survival (PMID 11176595).
• Preaponeurotic fat: the central upper eyelid fat pad, which can be advanced on a pedicle to correct volume asymmetry (PMID 39718136).
• Poly-L-lactic acid (PLLA): a biostimulatory injectable filler compared with hyaluronic acid for upper-eyelid hollowing (PMID 41799414).
• GAIS: the Global Aesthetic Improvement Scale, a clinician- and patient-rated outcome measure (PMID 41850033).
• Lagophthalmos: incomplete eyelid closure, a functional consequence of severe upper eyelid hollowing (PMID 24614548).

Papers