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Section: Fat Loss

A Solution for Hollowing and Multiple Folds

While the typical youthful Asian upper eyelid is fuller than in the Occidental, lid hollowing is a common change in the Asian population that can begin during the early twenties. As the fat inside the socket begins to decrease, it becomes less effective at inflating the upper eyelid from behind. A depression appears midway between the brow and lashes due to this deep underlying fat loss.

Although the same sort of aging change may occur in anyone, it is much more common in people of East Asian and especially South Asian or Indian descent.

As time progresses, the depression may deepen considerably and cause the overlying skin to sink into a fold vaguely mimicking an upper crease but more commonly a series of tiny incomplete folds, a feature sometimes called a "triple eyelid." The contour of the bone above the eye may become plainly visible above the hollow.

Because a hollowed eye is a feature seen most commonly in the older Asian person, its occurrence during younger years can be worrisome because it makes the face look older. A similar and often more severe form of hollowing may occur after inappropriate fat removal during double eyelid surgery.

Treatment presents a challenge. Minimal changes are best left alone. If hollowing becomes advanced, the only workable option involves placing a fat graft to plump up the skin from behind.

asian hollow eyelid

Early efforts now abandoned were directed at implantation of tiny silicone-filled bags not unlike miniaturized breast implants the size of a medicine capsule. Alternatively, strips of fascia removed from the muscle of the temple were sometimes threaded into the eyelid.

Currently, the most effective approach for permanently enhancing deep volume entails open grafting of pearl-size pieces of fat from the lower abdomen directly into the orbit (eye socket). Injection of liquified fat obtained by liposuction is a much simpler procedure but is seldom recommended because of rapid resorption and the increased risk from sticking needles into the area around the eyeball without visualization.

Injection of hyaluronic acid designed as a dermal filler has been reported to yield satisfactory but temporary improvement in cases of milder eyelid hollowness lasting up to 18 months.

Unable to permanently correct the underlying cause, some plastic surgeons may recommend removing deflated and folded skin below the depression to try to create a single "crease." In the absence of adequate volume, however, a true crease cannot form, and many patients consider the resulting high arch to look worse than the starting point.

Treatment of this vexing but not uncommon Asian cosmetic condition remains problematic as no procedure can predictably yield the precise amount of correction and symmetry typically demanded by many younger patients.

"Without adequate fat, a true crease cannot exist."

Asian skin is legendary for its ability to hide aging changes and wrinkling for a decade or two longer than Occidental skin. However, there's more to an eyelid than just its outer layer.

Most young Asian eyelids are noticeably fuller than their Occidental counterparts due to an abundance of fat in the lid, orbit, and sub-brow areas.

Most of this added volume is provided by the orbital fat (yellow) that extends further downward in the Asian lid and the sub-brow fat (green) that is larger in size and also lower in position.

Most young Asian eyelids are noticeably fuller than their Occidental counterparts due to an abundance of fat in the lid, orbit, and sub-brow areas.

Most of this added volume is provided by the orbital fat (yellow) that extends further downward in the Asian lid and the sub-brow fat (green) that is larger in size and also lower in position.

Cross-Section of the Asian Upper Eyelid
Subcutaneous Fat
Tarsal Plate
Orbicularis Muscle
Orbital Septum
Orbital Fat
Levator Aponeurosis
Sub-Brow Fat Pad
Crease (if any)

It is now known that the dominant factor in facial aging is a gradual loss of fat. Such change may begin during the early thirties and progress at a variable rate based primarily upon inhertied tendencies.

Unfortunately, fat loss in the eyelid and surrounding structures (collectively known as the "periorbita") is more noticeable at earlier ages in many Asian patients. In some patients, relative fat shortage is already present by the late twenties.

As fat loss increases, the overlying skin begins to deflate. A growing concavity or depression appears midway between the brow and eyelid and then gradually deepens.

Since, as a rule, young Asian lids are full while older lids are noticeably more hollowed, the net effect of this fat loss is to make the face appear prematurely old.

By age forty (although sometimes by as early as the twenties), a sinking eyelid can generate real cosmetic concerns that cannot be addressed by either double eyelid surgery or traditional blepharoplasty since neither operation restores fat.

Asian orbital and periorbital fat deficiency can also cause other undesirable effects:

Early on and when still mild, the eyelid's natural crease may be weakened and instead turned into an arrary of dents and folds.

In advanced stages, the depth of the hollow may "pull in" so much skin that an objectionable depression (sometimes confused with a high crease) becomes the dominant facial feature.Without adequate fat, however, a true crease cannot exist. Instead, this depression signifies only a progressive collapse of the overlying skin and muscle against a hollowed interior.

For reasons not well understood, a hollowed upper eyelid is more commonly associated with ptosis, or a drooping eyelid. Ptosis makes the vertical opening between the eyelids more narrow and causes the eye to appear smaller. Since ptosis is more commonly seen in the elderly, its appearance in younger patients further ages the face.

• Results after standard double eyelid surgery in a patient with even a mildly hollowed lid can be much more unpredictable. The final crease may form unexpectedly high, and full healing may take substantially longer. Fat preservation (video) is crucial in all such patients. In some, orbital fat grafting may be indicated.

While such changes are well known within the middle-aged Asian lay population, almost nothing has appeared in the medical literature regarding fat loss over time. Perhaps this is because until recently no effective treatment was available.

Next: Post-Surgical Fat Loss

from this section: Fat Loss, Hollows, Folds >

Premature Upper Lid Hollowing
Surgical Fat Loss
Hollowness Treatment Options
Photos of Fat Grafting Results

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Frank Meronk, Jr., M.D.
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Note: Information, observations, and opinions are offered for general reference only and should not be taken as medical advice or diagnosis.

Premature Aging in the Asian Upper Lid