How Do I Mitigate my Doll's Eye (Orbital Fat Loss) Condition? (photo)

How do I mitigate my Doll's Eye (orbital fat loss) condition now that Dr. Meronk retired? I really would like someone to do Meronk's technique of fat pearl graft with the fat strip overlay in my eye crease. I am 57 and the fat loss will accelerate without intervention as I age. By the way, I had fat transfer just below the brow, above the brow and below the eye 3 weeks prior to this photo. Much of it has since resorbed.

Doctor Answers 7

Doll Eye deformity or hollow upper eyelids can be corrected with fat grafting

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Hollow upper eyelids sometimes are genetic and other times are the result of an over-aggressive eyelid surgery that removes excess skin and fat. In either circumstance, the area can be improved by structural fat grafting. I regularly perform structural fat grafting in this area,  I often use this for people seeking a revision eye surgery, but I also often use fat grafting as part of many facial rejuvenation cases I perform. My before and after gallery contains many examples of this procedure. 

An unavoidable reality of fat grafting is that the degree of fat survival cannot be completely predicted nor can it be guaranteed. Fat survival will vary somewhat from patient to patient and from procedure to procedure. My impression is that many surgeons ‘manage’ this issue by overdoing it when they perform fat grafting surgeries, assuming that a significant amount of the grafted fat will not survive. This leaves patients vulnerable to an unnatural, over-grafted appearance if fat survival is greater than the surgeon expects.
Look carefully for excessively full cheeks in your surgeon’s ‘before and after’ photos, as the fullness you’ll get from fat grafting surgery is not temporary.

My approach is to graft fat to the point that the soft tissue contour is, in my opinion, aesthetically ideal but still quite natural-appearing. This eliminates any concern of an ‘over-grafted’ and unnatural appearance. In my practice we offer secondary fat grafting for areas that I have previously treated at a significantly discounted cost from the initial procedure. That allows patients to go into their surgery with confidence that (1) they will not have unnatural appearance after recovery from surgery and (2) any areas that require additional volume enhancement can be treated at a very reasonable cost. Areas which have thinner soft tissue thickness preoperatively - such as the lower-lid cheek junction - are the areas that are most likely to require secondary (and occasionally tertiary) fat grafting procedures.

Take your time when searching for a plastic surgeon to add fat to the eye area. This requires precision, expertise, practice and specialized instrumentation.  Be sure to view many, many before and after photos of a surgeon's work to be certain they can provide a result that you desire.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Correction of Hollow Eyelids

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You did not say why you have the hollowness. Frequently this is because of over aggressive resection of the fat during Blepharoplasty. This is why I reposition rather than resect fat at the time of Blepharoplasty. The only way I have found to correct this problem or natural hollowness is with a filler, either one off the shelf or fat. Both work exceptionally well. The fillers are, however, not permanent. Hyaluronic acid fillers like Juvéderm or Restylane have been used well to do this for a number of years. Radiesse is more permanent but does not have the experience of the others. About 66% of fat takes and is permanent when done correctly. For that matter, all these injections are very injector dependant. Find a Plastic Surgeon with significant experience in using both filler and fat, and ask for success rates.


Robert T. Buchanan, MD
Highlands Plastic Surgeon

Fat grafting is better option

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I know that your fat grafting procedure did not work, but not all surgeons do the fat harvesting and grafting same way. You have mild ptosis and your hollowness is more due to the over retraction of the levator muscle. You eye brow position is another indication of your eyes over correction of the ptosis. I would suggest that you find a plastic surgeon with experience in fat grafting.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 152 reviews

Fillers are a good option.

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Dr Truong's recommendation is a good one. I'm not sure that it will last for years, but it should give you an improvement.

There are other surgeons that may be willing to try the fat pearl graft technique as well, but as you have not had great luck with fat grafting below, you may go through the surgery and the recovery and still come up short. I don't want to discourage you, but the expectations need to be reasonable in this situation.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 42 reviews

Treatment for hollow eyes

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I have had success in correcting this condition by re-arranging the existing peri-orbital fat.  This fat can be teased out from under the orbital septum and sutured in place to give added fullness to the retracted eye area.  This type of fat, since it is still attached to its own blood supply will remain viable without the risk of resorption.  If there is not enough fat to use then it can be supplemented with either fat grafting or a filler such as juvederm.   

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Volumizing Fillers Can Work Well For Orbital Fat Loss (Doll's Eyes or Upper Lid Hollowing)

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The appearance of "doll's eyes" or upper eyelid hollowing can be quite troubling and is a challenging aesthetic problem. The introduction of volumizing fillers, such as Juvederm UltraPlus XC, has provided us with a simple treatment option worth exploring in these cases for two reasons: 1) The results can be quite gratifying and generally quite long-lasting, and 2) they are also completely reversible if so desired for any reason by the injection of hyaluronidase, a natural enzyme that dissolves hyaluronic acid, the major component of this product.

Perlane-L and Radiesse, two other injectable volumizing agents, may also be used for treating this region. However, I have found the smoother flow of the Juvederm product to be most appropriate for improving this problem.

Before initiating actual treatment, I frequently test an individual's response by injecting a small amount of physiologic salt solution throughout the treatment area. While the consistency of salt solution is not that of the volumizing agent, you can get enough bulking with it to get a good sense of what the actual result would be from treatment with the actual volumizing filler itself. The salt solution is completely reabsorbed in about five to ten minutes, after which definitive treatment can be initiated.

Since the hollow area of the orbital rim is not subject to much mechanical force (unlike smile lines and marionette lines), the results of treatment with volumizing fillers injected in this region tend to persist far longer, possibly for years.

Nelson Lee Novick, MD
New York Dermatologic Surgeon
4.9 out of 5 stars 33 reviews

Orbital-upper lid fat loss

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Since fat grafting has not worked well for you in correcting the upper lid hollowing, consider Juvederm injection in that area. It works quite well, lasts for years and is reversible if there is a problem area. The obvious advantage is you avoid a surgical procedure and the risks and long healing associated with it.

Peter T. Truong, MD
Fresno Oculoplastic Surgeon
4.9 out of 5 stars 42 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.