[Duhan Plastic Surgery Double Eyelid Revision Surgery] - [Correcting the Double Eyelid Line in Sunken Eyelids]

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Correcting the double eyelid line in a sunken eyelid

When the eyelid is sunken, it is not always corrected with revision surgery,

and the eye shape and double eyelids may also be corrected with fat grafting.

Micro fat grafting to correct an awkward double eyelid line

When the upper eyelid is sunken and the double eyelid line looks awkward, there are cases where it can be sufficiently corrected with micro fat grafting alone, without the need for incision.

If surgery is performed on a sunken double eyelid, it can be difficult to create the double eyelid line properly, and even after surgery, the sunken contour can easily lead to unsatisfactory results.

If there is a sunken eyelid, the priority is to first perform fat grafting to correct the sunken area while also adjusting the shape of the double eyelid.

Effects of upper-eyelid fat grafting for double eyelid line correction

1. Correction of a thick double eyelid line

2. Correction of a loosened double eyelid line

3. Correction of an asymmetrical double eyelid line

4. Correction of a triple double eyelid line

5. Correction of multiple wrinkle lines

6. Restoration of a lost double eyelid line

Anatomy of orbital fat in the upper eyelid

The role of orbital fat

1. It gives the eyelid contour more volume and softness.

2. It protects the eyeball from external impact.

3. It acts as a lubricant so the levator palpebrae superioris muscle (the muscle that lifts the eyelid) can move smoothly.

Effects obtained through upper-eyelid fat grafting

■ Aesthetic aspect

1. Restoration to a softer and more youthful eye shape by correcting the sunken area

2. Correction of an awkward double eyelid line

■ Functional aspect

It helps the levator palpebrae superioris muscle, which opens the eyes, move more smoothly and reduces eyelid fatigue.

Micro fat grafting placement in the upper eyelid

The goal of upper-eyelid fat grafting must satisfy both aesthetic and functional purposes.

For this, it is absolutely important to graft the right amount of fat into the correct location.

The most accurate grafting site is where orbital fat is located, and good results are achieved when the newly grafted fat blends in with the existing fat in this area.

However, if the graft is placed incorrectly into the orbicularis oculi muscle layer, the eyelid may become uneven and heavier, making opening the eyes more uncomfortable.

Therefore, upper-eyelid fat grafting must be performed precisely under accurate anatomical knowledge to achieve the desired result.

How fat grafting is performed for an attractive eye shape

1. Fat is harvested from areas where a lot of fat is stored, such as the lower abdomen, waist, or thighs.

For wrinkle correction, a large amount of fat is not needed, so harvesting from the lower abdomen is preferable.

• Because local anesthesia (painless sedative anesthesia) is used, there is no pain at all.

• A thin liposuction cannula is used to collect fat into a syringe.

2. The harvested fat is placed in a centrifuge to remove impurities (local anesthetic, serum, red blood cells, etc.).

The purpose of centrifugation is to remove impurities contained in the fat, increase the concentration of the fat, and improve the survival rate of the grafted fat.

After centrifugation, the fat undergoes a second concentration process to remove water and oil.

By removing water and oil, highly concentrated fat close to 100% is obtained.

The purified fat is transferred into a thin 1cc syringe and grafted to the desired area.

The fat is transferred again into a thin 1cc syringe and grafted to the desired area.

A micro-needle (micro grafting cannula) developed in-house is used.

The micro-needle is a special grafting cannula used only at our clinic, enabling ultra-precise grafting.

3. A micro fat grafting cannula is inserted along the planned line of the eyelid and grafted with precision.

When grafting is done into the orbital fat layer, it creates a smooth contour and a high survival rate.

After fat grafting, normal daily activities are possible right away, and face washing and makeup are possible starting the next day.

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Example of correcting a thick line with micro fat grafting

This is applied only when the upper eyelid is sunken.

Micro fat grafting requires very advanced skill and know-how.

The anatomical structure of the eyelid must be understood precisely.

Therefore, eyelid fat grafting can only be performed properly by someone with extensive experience in double eyelid revision surgery.

Because it is a highly difficult procedure that must also consider correction of the awkward double eyelid line along with the sunken eyelid, it is best not to have it performed by someone lacking experience or by a non-specialist in plastic surgery.

Example of correcting an asymmetrical line with micro fat grafting

When the eyelid is sunken due to insufficient orbital fat, the line is pulled upward and becomes larger.

In such cases, it can be simply corrected with micro fat grafting without revision surgery.

Micro fat grafting is a simple procedure in which fat is injected with a syringe.

Example of correcting a loosened line with micro fat grafting

If the eyelid is sunken and the line is pulled upward and loosened, the loosened line can be corrected together with the sunken eyelid using micro fat grafting.

However, this only applies when the loosening is caused solely by sunken eyelids.

The main purpose of the procedure is to correct the sunken eyelid, and correcting the double eyelid line is a secondary goal.

If the line does not naturally restore itself even after the eyelid is restored, revision surgery must be performed.

Example of correcting a triple line with micro fat grafting

When the eyelid is sunken, the skin is pulled upward, causing the line to become larger or creating a triple double eyelid.

Sometimes multiple layers of wrinkles also form.

Even in these cases, it can be easily corrected with micro fat grafting.

Two-dimensional plane fat grafting in the upper eyelid

Fat grafting in the upper eyelid should be done as a two-dimensional planar fat graft.

If fat is grafted under the skin, the eyelid becomes heavy and the skin may become uneven.

To avoid these side effects, the fat must be placed precisely between the orbicularis oculi muscle and the levator palpebrae superioris muscle, which requires accurate anatomical knowledge and extensive experience.

Fat grafting must be done in the correct location to be functionally and aesthetically complete.

Recovery period after upper-eyelid fat grafting

Usually, normal activity is possible right away.

There will be some swelling and bruising, but it is usually mild enough to be covered with makeup, so it does not cause major problems in daily life.

However, swelling and bruising vary from person to person, so not every case is the same. On average, severe swelling and bruising do not occur, and after about a week it usually looks natural.

Number of upper-eyelid fat grafting sessions

Eyelid fat grafting tends to have a higher survival rate than in other areas.

If one session is performed, or at most two sessions, a satisfactory effect can usually be achieved.

The interval between procedures is from 3 months to 1 year, and when repeating the procedure, the fat that was harvested and stored during the first grafting is thawed and used.

However, there are also many cases where one session is enough and a second procedure is not necessary.

Because the survival rate of fat varies by individual, the decision on whether to perform a second procedure should be made at least 3 months later.

Fat graft survival and survival rate

The survival rate of fat cells differs depending on the area of the face.

The higher the survival rate, the fewer procedures are needed and the greater the effect.

For example, a survival rate of 80% means that 80% of the total grafted fat survives and 20% is absorbed and disappears.

Therefore, the higher the survival rate, the better the result.

The area with the lowest survival rate is the lips, and the area with the highest survival rate is around the eyes.

The average survival rate after fat grafting is 50%.

In other words, if 100 units of fat are grafted, after a few months only 50% will remain.

The better the blood circulation, the higher the survival rate of fat, and since the area around the eyes has the best blood circulation on the face, fat grafting in this area has a higher survival rate than in other areas.

Therefore, around the eyes, a permanent effect can be achieved with just one procedure.

However, since repeat procedures are sometimes needed, it is better to think of fat grafting as something that may be done about twice.

Second procedure and fat harvesting

When fat is harvested from the lower abdomen or thighs, an adequate amount is collected for grafting, and the remaining fat is not discarded but stored sterilely in a freezer.

This stored fat can be kept for about 10 months, so if you return within 10 months, you can receive an additional procedure without another harvest.

Whether the fat is stored or harvested fresh makes no difference in the result.

Long-term effect of upper-eyelid fat grafting

From 3 to 6 months after fat grafting, the fat is gradually absorbed and the fullness decreases.

After that, if the fat fully survives and no further absorption occurs, the remaining fat stays permanently.

Surviving fat does not naturally melt away and disappear.

If body weight decreases overall in the future, the grafted area may be affected, but if body weight stays the same, the volume of the grafted area changes very little.

Therefore, surviving fat remains as the patient’s own tissue for life.

That does not mean the shape itself remains the same forever.

As people age, the skeleton changes, wrinkles form in the eyelids, the skin sags, and body weight may decrease, so the shape of the fat-grafted area also does not stay unchanged.

Until significant aging progresses, the effect lasts.

That is why the term “semi-permanent” is used.

Side effects of upper-eyelid fat grafting

Side effects are usually limited to slight swelling and bruising.

Other side effects can be considered virtually nonexistent.

Because the procedure uses autologous fat rather than foreign material, there is no immune rejection or inflammation.

Also, once the fat survives, it is no longer absorbed and becomes the patient’s own tissue.

In some cases, people experience side effects after having the procedure at clinics with limited fat grafting experience, but this is a matter of the operator’s skill.

If the fat is grafted into the orbicularis oculi muscle layer rather than the orbital fat layer, the eyelid may become heavier and uneven. If too much fat is injected, the eyelid may swell so much that daily life becomes difficult. If excessive fat grafting causes ptosis and makes the eyes difficult to open, or if much of the fat is absorbed and the effect is not seen, various problems can occur.

Because results vary by clinic, it is best not to have the procedure done by a non-specialist in plastic surgery who lacks sufficient fat grafting experience.

Other procedures besides fat grafting

As of now, there is no other method for correcting upper-eyelid sunkenness besides fat grafting.

Some procedures involve making an incision in the upper eyelid, as in double eyelid surgery, and grafting a lump of fat, but this has the burden of requiring an incision, and grafting a fat lump can cause the eyelid to become heavy.

In addition, various fillers used in plastic surgery, such as Restylane, Artecoll, and Juvederm, are widely commercialized and used, but if commercial fillers are injected into the upper eyelid, the eyelid may become stiff and opening the eyes may become uncomfortable, and inflammation may occur.

Therefore, micro fat grafting using the patient’s own tissue is a safe and effective method.

Types of side effects and problems from fat grafting

Of course, good results are the goal, but depending on the surgeon’s skill and technique, unavoidable problems can sometimes occur.

Poor results due to low survival rate, awkward shape, asymmetry, severe swelling, inflammation, fat necrosis, calcification, contour irregularity, sagging, and pigmentation can occur.

Inflammation	Caused when bacteria enter during the procedure, or when the fat fails to survive and melts away during the survival process
Necrosis	A state in which fat that failed to survive due to insufficient blood supply during the survival process rots and leaves behind melted remnants
Calcification	A phenomenon in which fat fails to survive due to insufficient blood supply during the survival process, hardens, and calcium deposits form, creating a firm lump
Contour irregularity	A phenomenon in which the fat is not grafted evenly, or is concentrated in only one area, resulting in an uneven appearance rather than a smooth one
Sagging	If too much is grafted or if it is not grafted in the correct place, sagging of the face may occur.
Pigmentation	When bruising or swelling is severe, depending on the person’s constitution, iron components left in the bruise may deposit in the skin, oxidize, and turn brown. This can sometimes occur after under-eye procedures depending on the individual.
Asymmetry	When the survival rate differs between left and right, or the amount is not properly adjusted during the first procedure, causing imbalance between both sides
High absorption rate	A condition in which the fat does not survive sufficiently to create the desired contour, and much of it is absorbed, so the appearance before and after the procedure does not change much
Awkward shape	A phenomenon in which too much fat survives or is grafted to an inappropriate area, disrupting the overall balance of the face

How to perform fat grafting without side effects

Performing the procedure in a sterile stateAs with all surgeries, fat grafting must also be performed with fully sterilized instruments and materials. After the procedure, any fat residue left inside the suction cannula or grafting cannula must be thoroughly cleaned with a brush, and then sterilized with a high-pressure steam sterilizer. Anesthetic agents and saline must also be carefully managed to prevent contamination. Thorough disinfection and material management can prevent bacterial infection and inflammation.
Multiple purification steps for the fatPurification of the fat must go through several steps to completely remove impurities and maximize effectiveness. Harvested fat usually contains about 80% impurities, and only about 20% is actually usable. If the remaining impurities (blood, serum, anesthetic, oil, water, etc.) are not removed, the result will be poor no matter how well the grafting is done.
Pre-grafting preparation before fat graftingTo achieve a high survival rate and a satisfactory result with one procedure if possible, the fat must be evenly placed in multiple layers. Before that, space must be secured at the grafting site so that the previously grafted fat is not compressed by surrounding tissue; this allows the fat to survive well without pressure.
Precise and even grafting into multiple tissue layersExpressing a soft, natural contour is the key to fat grafting. To achieve a soft contour, it is better to graft in a three-dimensional manner, evenly across multiple layers. The grafting locations include the subcutaneous layer, muscle layer, and fascia layer, and the fat must be spread through the tissue like sowing seeds to obtain a smooth contour without irregularities.

Common questions and answers about eyelid micro fat grafting

Is eyelid fat grafting said to have many side effects, so it shouldn’t be done at other clinics—is that true?

That is not true of every clinic.

The area that requires the greatest experience and skill in fat grafting is the upper eyelid and under-eye dark circle area.

It is not an area that can be treated carelessly without accumulated experience and skill.

We always say this in consultations: fat grafting is absolutely not a procedure that just anyone can do.

As with all surgeries, the results vary depending on the surgeon’s experience and know-how.

There are many clinics that perform fat grafting, but only a handful do it properly.

It is easy to do, but difficult to achieve proper results.

In principle, fat grafting can produce good results only when performed precisely.

Each clinic has a different technique, and results can vary greatly depending on experience.

You may have a negative impression after hearing about or experiencing poor fat grafting, but if it is done properly, satisfactory results can be achieved with just one treatment.

In particular, the upper eyelid (sunken eyelid, hollow eyelid) is an area that requires extensive experience, skill, delicacy, and precision, so it cannot be performed by just anyone.

I had eyelid fat grafting at another clinic, but almost all of it collapsed and nothing is left. Can it be done again in this case?

Yes, repeat treatment is possible even after it has nearly collapsed due to a low survival rate after treatment at another clinic.

However, it should be done at least 3 months later.

Because the survival period for fat grafting takes at least 3 months, you can have it done again after 3 months have passed since the last procedure.

Even if it is repeated at our clinic, the result is almost no different from the first treatment.

I had eyelid fat grafting at another clinic, and it looks lumpy and it is uncomfortable to open my eyes. Is this a side effect?

The goal of eyelid fat grafting is to restore the sunken eyelid and functionally improve the ability to open the eyes, thereby reducing eye fatigue.

To achieve these goals, the procedure must be performed accurately and delicately.

With fat grafting done by someone with somewhat limited experience, grafting into the orbicularis oculi muscle layer rather than the orbital fat layer can cause contour irregularities, or grafting near the deep levator palpebrae superioris layer can make opening the eyes even more uncomfortable than before the procedure.

If these side effects occur, the fat must be removed again, which is quite difficult.

To prevent side effects, it is best not to have the procedure done by someone lacking experience or by a non-specialist in plastic surgery.

What about injecting filler instead of fat into the eyelid?

Because the eyelid is a structure that keeps moving, procedures that interfere with its movement should not be done.

Fat grafting acts as a cushion and lubricant that allows eyelid movement to become smoother, but if a foreign material such as filler is injected, it can seriously impair the ability to open the eyes, apart from the shape of the eyelid. In severe cases, swelling may not go down or the eye shape may become distorted.

Inflammation can even occur, so filler should absolutely not be injected into the eyelid.

Is eyelid fat grafting dangerous because it is close to the eyeball?

Not at all.

The risk is high only when the procedure is performed by a doctor with limited experience or by a non-specialist in plastic surgery; if performed accurately by an experienced specialist, there is no need to worry.

Eyelid fat grafting must be performed by someone who has precise anatomical knowledge and know-how gained through extensive double eyelid surgery experience, and if it is done according to principles and accurately, it is one of the safe procedures.

Question) I had eyelid fat grafting at another clinic and developed a bulging side effect. Can it be corrected?

Answer) Sometimes people visit our clinic for correction because excessive fat injection at another clinic caused the eyelid to become heavy and bulge.

Depending on the condition, the fat must be removed by suction. If the fat mass can be grasped by hand, it can be corrected by inserting a fine cannula and suctioning it out.

However, 100% removal is not possible, and usually about 50–80% can be removed and corrected.

Features of our clinic

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1. All anesthesia is performed as local anesthesia (sedation anesthesia).

All fat grafting procedures are performed under local anesthesia, regardless of the area being treated.

Local anesthesia is administered together with sedation anesthesia, so the procedure can be done without any pain during anesthesia or after it ends.

Depending on the area, hyaluronidase, a swelling-preventing agent, is mixed with the local anesthetic and injected.

Hyaluronidase is an expensive anti-swelling agent that has a tissue-fluid-diffusing effect, helping prevent swelling almost immediately after the procedure.

2. We have a systematic and advanced fat grafting system.

The success of fat grafting depends on the survival rate.

To maximize the survival rate, the following are necessary.

• Living fat cells must be harvested.

• To increase fat purity, centrifugation purification and unnecessary oil removal are used to maximize purity.

• Before fat grafting, subcutaneous tunneling is performed at the graft site to secure space for the fat.

• Micro fat grafting cannulas are used for precise and detailed grafting in each area.

• A three-dimensional method is used to graft thin layers across multiple levels, increasing survival and creating a soft contour.

3. Appropriate and diverse fat-harvesting sites are selected.

The most commonly used site for fat harvesting is the lower abdomen. The lower abdomen is the first choice because it causes less pain after the procedure, has less swelling and bruising, and is a comfortable area for daily life.

If there is not enough fat in the lower abdomen or if the patient prefers another area, fat is also harvested from other sites. The next most commonly selected area is the inner thigh, followed by the outer thigh.

If there is not enough fat in the thighs either, the lower buttocks or flanks may also be used.

There is no fixed rule for which area is best for fat survival.

Results are similar no matter where the fat is harvested from, and although the area with the most excess fat on one’s body is the ideal harvesting site, it is best to choose the site by considering the amount of fat needed and post-procedure activity.

4. We maximize fat survival through a two-step purification process for harvested fat.

Harvested fat goes through a two-step purification process to completely remove impurities other than fat cells.

Among the impurities in harvested fat, the largest proportion is local anesthetic, followed by oil.

It also contains impurities such as serum and red blood cells.

In the first step, it goes through a centrifugation stage for 3–4 minutes, and then it enters the oil-removal process in the second step.

The parts purified by centrifugation are local anesthetic, red blood cells, and serum.

Oil is removed manually through a natural absorption method.

Through the two-step purification process, almost 100% concentrated fat is obtained, maximizing the effect of fat grafting while increasing fat survival to the greatest extent.

5. We secure space for fat grafting through subcutaneous tunneling.

Subcutaneous tunneling is an essential process for ensuring space in advance at the area where fat will be grafted, in order to achieve a high survival rate and even grafting.

Using a fine probe, the area under the skin is repeatedly moved in a fan-like pattern to create a space where the fat will be grafted.

The effect of subcutaneous tunneling is to improve fat survival and prevent clumping, creating an even and soft contour.

6. Three-dimensional micro fat grafting can produce a soft and even facial contour.

Although there are exceptions depending on the area, the basic method of fat grafting is the three-dimensional approach.

By grafting small amounts evenly across multiple layers in each area, fat survival is improved and survival becomes uniform, creating a soft contour.

7. Micro fat grafting cannulas are used for precise fat grafting.

In the past, fat-injection machines pushed fat under the skin under high pressure, which caused various problems.

The absorption rate of fat was high, survival was not consistent, contours became uneven, and grafting was difficult in delicate areas such as under the eyes.

To solve these problems, during fat grafting the fat is transferred again into a thin 1cc syringe and grafted to the desired area.

At our clinic, we use a micro-needle (micro grafting cannula) developed in-house.

The micro-needle is a special grafting cannula used only at our clinic, enabling ultra-precise grafting.

Fat grafting can also be performed on the upper eyelid, lower eyelid, forehead wrinkles, glabellar wrinkles, nasolabial folds, and the bridge of the nose, making fat grafting possible in almost all cases except fine wrinkles.

8. Molding immediately after fat grafting helps create a uniform and soft facial contour.

Immediately after fat grafting, delicate molding is performed so the grafted fat spreads evenly and a soft shape is created.

Molding is the final step of fat grafting and one of the most important steps.

9. Aseptic cryopreservation of remaining fat simplifies the second procedure.

When a second procedure is performed 3 months after fat grafting, the remaining fat from the first procedure is used instead of harvesting fat again.

The remaining fat after the first procedure is stored after rapid freezing and aseptic processing.

For the second procedure, the stored fat is thawed and can be used more conveniently.

The storage period for fat is up to 1 year, and if you visit within 1 year, the stored fat will be used for the procedure.

10. Thorough aftercare system

After fat grafting, we carefully monitor the progress until the fat fully survives by providing thorough aftercare.

During follow-up, when necessary, we try to minimize patient dissatisfaction through swelling-reduction injections, shape adjustments, and molding.

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