Upper Eyelid Medial Fat Reduction and Pearl Grafting: A Modification and Review of Literature

Abstract

Background:

With age, there is a progressive volume disparity between the prominent medial fat pad and the atrophic central fat pad of the upper eyelid. We present a literature review of upper eyelid fat redistribution techniques and describe a novel postseptal medial fat pad pearl grafting technique as an adjunct to upper eyelid blepharoplasty.

Methods:

Retrospective review was conducted of medial fat pad pearl grafting performed by a single surgeon between 2018 and 2024, with a minimum follow-up of 3 months. Medial and central fat pad volumes were graded by a masked observer using the Oh scale. Patient charts were assessed for adverse events such as irregularity, lipogranuloma formation, or revision surgery.

Results:

A total of 60 patients underwent the procedure, of which 45 met the inclusion criteria (86 eyelids). The median age was 60 years (range 38–90 y), with 91.1% female patients. Follow-up was for an average of 8.2 months (range 3–40 mo). Adjunctive procedures included ptosis repair (41), lower blepharoplasty (16), and other (3). Central fat pad volumes significantly increased from an average grade of 0.92 preoperatively to 1.73 postoperatively (P ≤ 0.05). Medial fat pad volumes significantly reduced from an average grade of 2.17 preoperatively to 1.77 postoperatively (P ≤ 0.05). The procedure was well tolerated, and the central volume was well retained during the follow-up period.

Conclusions:

Medial fat pad postseptal pearl grafting is a useful adjunct to upper eyelid blepharoplasty, with a favorable safety profile, minimal likelihood of lumpiness, and effectiveness in reducing fat pad disparity.

Takeaways

Question: With age, there is relative prominence of the upper eyelid medial fat pad due to progressive central fat pad atrophy. Can the medial fat pad be used as simple pearl grafts during upper blepharoplasty to reduce age-related volume disparity?

Findings: A retrospective review of medial fat pad pearl grafting as an adjunct to upper blepharoplasty was performed. The disparity between medial and central fat pads was significantly improved.

Meaning: Medial fat pad pearl grafts into the postseptal space through the same buttonhole incision can be used to further improve central upper eyelid hollows.

INTRODUCTION

In his seminal text of orbital anatomy more than 100 years ago, Whitnall¹ recognized the increasing prominence of the medial upper eyelid fat pad with age, describing it as the “bourrelet sénile” or “palpebral hernia adiposa.” In modern times, this is now understood to represent a relative “pseudoherniation” of the medial fat pad with accompanying atrophy and retraction of the central fat pad, which appears to exhibit progressive differences in volume from the fifth decade of life.² This disparity may be explained by several anatomical and physiological factors.^3–5

It is the contrast between the fat pads that results in the apparent central eyelid hollowing and the so-called A-frame deformity. As our understanding of age-associated changes in the periorbita has evolved, so too have blepharoplasty techniques, from a traditionally excisional approach to a focus on volume preservation and augmentation in contemporary surgery.⁶

Although upper eyelid blepharoplasty has received somewhat less attention in the literature compared with blepharoplasty for the lower eyelids, a variety of revolumizing strategies for the upper eyelids have been proposed over the years—from abdominal fat grafting, to local fat grafts and pedicles. Each carries its own set of potential advantages and disadvantages, but typically requires further incisions, more extensive dissections, and increased complexity in surgery.

A literature review is presented of previously published techniques of upper eyelid fat redistribution during upper blepharoplasty, and a novel alternative approach to volumetric disparity in upper blepharoplasty is described, which aims to minimize additional tissue manipulation and dissection while maximally preserving the orbital septum.

METHODS

A retrospective chart review was performed of a single surgeon’s practice, including patients who underwent medial fat pad pearl grafting to the central fat pad during upper eyelid blepharoplasty between 2018 and 2024. Cases were excluded if follow-up was less than 3 months. All patients were assessed with a comprehensive ophthalmic examination, with detailed digital photographs of the eyelids and face taken at approximately 60 cm by a single photographer. Medial and central fat pad volumes were graded in the method published by Oh et al,² using a linear scale of 0–3. Each eye was graded separately by an observer masked to the preoperative or postoperative status of the patient. Statistical analysis was carried out using matched t test (GraphPad Prism 10, Boston, MA). The patient record was also evaluated for complications relating to the fat grafting procedure, including lumpiness, irregularities, lipogranuloma formation, or revision surgery required for the fat pads. The study adhered to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained, as was patient consent for the publication of photographs.

Patient selection for this technique may naturally encompass patients with medial fat pad prominence who may have traditionally been offered fat pad reduction. The medial fat pad pearl grafting surgery aims to address volume disparity by reducing medial fat pad volume and redistributing this to the atrophic central fat pad, rather than discarding the tissue as in conventional reduction surgery. This was therefore recommended where loss of central volume and a disparity between the medial and central upper eyelid were considered present.

In addition, a literature review of local upper lid fat redistribution techniques during traditional upper blepharoplasty was carried out using PubMed. The search terms used were “upper eyelid fat pad.” English-language studies were included if a local fat graft or pedicle technique was described as an adjunct to primary traditional blepharoplasty, with the intention to treat central hollowing. Studies were excluded if the donor site was extraorbital, or if the technique was limited to a specialized population (eg, double eyelid blepharoplasty). References from articles of interest were also assessed and included where relevant.

SURGICAL TECHNIQUE

An annotated operative video of the medial fat pad pearl grafting technique is available for reference. (See Video [online], which demonstrates medial fat pad pearl grafting as an adjunct to upper blepharoplasty for treating age-related fat pad volume disparity.) The surgery is typically performed under local anesthesia and sedation. Following skin excision during upper eyelid blepharoplasty, a buttonhole incision is made in the medial preseptal orbicularis oculi and orbital septum immediately overlying the medial fat pad. Aided by the application of digital pressure to the lower eyelid and knowledge of its paler color compared with the dark yellow of the central fat pad, the medial fat pad is identified and exposed, followed by herniation through the small septal buttonhole incision.

Video 1. Surgical technique video for medial fat pad pearl grafting as an adjunct to upper blepharoplasty, for treatment of age-related fat pad volume disparity.

Download video file ^{(76.4MB, mp4)}

Based on the preoperative assessment and patient preferences regarding the volume disparity between fat pads, a targeted amount of medial fat (less than 0.5 mL) is excised. The excised fat is then divided into fat “pearls” measuring approximately 2–3 mm in diameter. Through the same medial septal buttonhole incision, closed, blunt-tipped Westcott scissors are inserted and passed laterally and postseptally, anterior to the central fat pad and immediately inferior to the orbital rim. The scissor blades are then opened during withdrawal to create a postseptal pocket immediately inferior to the orbital rim by blunt dissection. The scissors are passed twice to create a suitably sized pocket. The fat pearls are then placed into this postseptal pocket through the same incision. Preferably using nontoothed Moorfield forceps (due to the thin profile and additional length these provide), each fat pearl is gently grasped and inserted as laterally as possible. Subsequent pearls are placed immediately medial to this. For each fat pearl, before release of the delivering forceps, the pearl and overlying septum are gently grasped using toothed St. Martin forceps to avoid the grafted fat pearl being dragged back medially by the withdrawing forceps. The fat pearls are grafted postseptal and as superiorly as possible, close to the orbital rim, to avoid the risk of trauma to the levator palpebrae superioris or its aponeurosis. Typically, 3–4 pearls are grafted into the central space. Volume can be titrated to the required amount. Occasionally, with the aim of achieving symmetry, all excised fat may be grafted to 1 side only. There is no requirement to fix the pearls in situ with either sutures or glue.

Concurrent ptosis surgery, if required, was then performed through a posterior approach using a nonexcisional aponeurosis (“white-line” type) advancement technique.^7–9 Hemostasis is checked, and the blepharoplasty can be completed in the usual manner.

RESULTS

A total of 60 patients underwent medial fat pad postseptal grafting to the central fat pad during the specified period; of those, 45 cases met the inclusion criteria, representing 86 eyelids (4 cases of unilateral grafting). Fifteen cases were excluded due to the follow-up period being less than 3 months. The age of the patients ranged from 38 to 90 years, with a median of 60 years. Forty-one patients were female (91.1%).

Adjunctive procedures performed included posterior approach ptosis repair (41 cases), lower blepharoplasty (16 cases), anterior lamellar repositioning for meibomian gland inversion (1 case), and lower eyelid lateral tarsal strip for horizontal laxity (1 case). One case also had abdominal fat grafting to the temples, cheeks, and lower eyelids for periorbital hollows.

Average follow-up was 8.2 months (range 3–40 mo).

There was a significant increase in central fat pad volumes, from an average grade of 0.92 preoperatively to 1.73 postoperatively (P ≤ 0.05). Concomitantly, medial fat pad volumes significantly reduced from an average grade of 2.17 preoperatively to 1.77 postoperatively (P ≤ 0.05). Examples of the change in fat pad disparities from preoperative and postoperative states are illustrated in Figures 1 and 2.

Fig. 1.

Preoperative and postoperative appearance. A, Preoperative appearance with central fat pad hollowing and relative prominence of the medial fat pads. B, Postoperative appearance at 27 months (medial fat pad pearl grafting, upper and lower blepharoplasty, and ptosis repair), demonstrating reduction in central fat pad hollowing and medial fat pad prominence.

Fig. 2.

A, Preoperative appearance with central fat pad hollowing, predominantly on the left more than the right upper eyelid. B, Postoperative appearance at 3 months (medial fat pad pearl grafting from both medial fat pads, all grafted to the left central hollow, upper blepharoplasty, and ptosis repair), demonstrating reduction in central fat pad hollowing.

With regard to complications, there were 2 eyelids that each required unilateral revision surgery for further medial fat pad reduction. No eyelids needed central fat pad reduction, or medial fat pad revolumizing. Medial eyelid hollowness was not seen or reported by any patient postoperatively. There were no cases of persistent swelling, lipogranuloma, or complaints of lumpiness with eyes open or closed. The volume gained in the central fat pads appeared to be well retained over the follow-up period with no cases of obvious resorption. Subjectively, all patients reported satisfaction with the improvement in appearance.

The literature review is summarized in Table 1, including a comparison of similar techniques and previous pearl grafting studies, and is discussed in the following sections.

Table 1.

Summary of Fat Graft and Pedicle Techniques for the Upper Eyelid

Study	Technique Summary	Method of Study	Results Summary
Fat grafts from nonorbital site
Shorr et al10	5- to 6-mm pearl fat grafts harvested from abdomen; septum opened; pearls deposited across central fat pad	Discussion of 15 patients with varying indications; follow-up 3–42 mo	Estimated graft survival of 50%–90%, but not formally assessed; 2 patients required debulking of grafted fat
Seiff11	5- to 6-mm pearl fat grafts harvested from abdomen; septum opened; pearls deposited into sulcus with 25% overcorrection	Discussion of use in upper eyelid hollow	Not formally assessed
Frileck12	5–8 × 40 mm long fat graft harvested from abdomen/pubis; tunneled through medial incision in OO and septum to exit at lateral incision; sutured in place at both ends with 6-0 absorbable	Discussion of use in 35 patients with upper hollow	7 eyelids required debulking of grafted fat; 3 eyelids had contour irregularity
Fat grafts from the medial fat pad
Gulyás13	2-mm fat pearl grafts harvested from the medial fat pad, placed in the horizontal line at the skin crease level over the OO; OO imbricated over grafts with 6-0 Prolene	Discussion of 14 patients	No cases of irregularity
Fezza14	OO strip excised medially, medial fat excised; lateral orbicularis incision; fat graft placed in preperiosteal plane at lateral orbital rim	Retrospective chart review of 142 patients. Photographs assessed by 2 masked observers	No cases of overcorrection; 2 eyelids required resuturing of wound dehiscence
Present study	5-mm pearl fat grafts harvested from the medial fat pad; placed postseptally through same incision centrally	Retrospective chart review of 60 patients; photographs assessed by 1 masked observer; fat pads graded using Oh scale	Significant reduction in medial fat pad gradings and increase in central fat pad gradings on Oh scale; 2 eyelids required additional medial fat debulking; no cases of overcorrection, irregularity, lipogranuloma, or resorption over follow-up of average 8.3 mo
Pedicle transfers from the medial fat pad
Massry15	Septum opened to expose medial and central fat pads; the medial fat pad dissected and raised into pedicle; sutured centrally to periosteum, septum, or OO with 6-0 Nylon	Retrospective chart review of 66 patients	1 case of temporary diplopia; 2 cases of temporary ptosis; 4 cases of persistent swelling
Yoo et al16	Septum opened; the medial fat pad dissected and raised into pedicle; tunneled into supraperiosteal pocket along orbitoglabellar groove; sutured into position through skin on bolster with 5-0 Prolene	Retrospective chart review of 17 patients	No cases of overcorrection
Nicodemi and Taraschi17	Septum opened medially and laterally; the medial fat pad dissected and raised into pedicle; tunneled under septum and grasped at lateral incision; pedicle not sutured	Retrospective chart review of 11 patients; Face-Q Upper Lid questionnaire	Improvement in Face-Q Upper Lid questionnaire scores
Pedicle transfers from the central fat pad
Sozer et al18	Strip of central OO excised; the central fat pad dissected and raised into pedicle; sutured to superior orbital rim periosteum with 5-0 absorbable suture	Retrospective chart review of 31 patients	No cases of irregularity or fat necrosis
Huggins et al19	Dissection caudally; releasing connective tissue and attachments 2–3 cm above orbital rim; septum opened and the central fat pad transferred to subbrow pocket; sutured to ROOF with 6-0 gut	Retrospective chart review of 19 patients	No adverse events observed
Wang et al20	During subbrow blepharoplasty, septum opened and lateral component of the central fat pad raised into pedicle; sutured to arcus marginalis medially with 6-0 Vicryl	Retrospective chart review of 17 patients; Strasser scores	Improvement in Strasser scores
Brow fat pad transfer
Qu et al21	OO incised transversely and divided into superior one-third and inferior two-thirds; brow fat pad dissected and pedicled; sutured inferiorly to the ROOF with 5-0 absorbable suture; inferior OO portion sutured superiorly to the periosteum of superior orbital rim with Nylon; upper OO portion overlapped with inferior OO and sutured together with 5-0 absorbable suture	Prospective series of 40 patients; 3-dimensional camera assessment of depth/volume; GAIS score	Significant improvement in depth/volume of upper eyelid hollow as measured by 3-dimensional camera; improvement in GAIS scores; 3 cases of postoperative nausea/vomiting; 4 cases of forehead numbness

GAIS, Global Aesthetic Improvement Scale; OO, Orbicularis Oculi; ROOF, retro-orbicularis oculi fat.

DISCUSSION

This study aimed to assess the results of the medial fat pad, postseptal pearl grafting technique to address the volume disparity of the eyelid fat pads during upper blepharoplasty. The results demonstrate an improvement in central volume with no lumpiness and a favorable safety profile. As evidenced by the change in Oh grading, the prominence of the medial fat pad is reduced, and a more diffuse fullness is achieved, an important goal of rejuvenation procedures aiming for a more youthful appearance.^22,23

The use of fat grafting in the face actually dates back to the late 19th century, before it was “rediscovered” by Ellenbogen²⁴ in the 1980s. Although Ellenbogen himself reportedly later abandoned the technique due to near-total absorption of the grafted fat,²⁵ other authors reported success using abdominal fat in the upper eyelids, either as fat “pearls” or as a larger “lumbrical” graft.^10–12 Early reports suggested that fat pearls seemed to have better survival compared with liposuction aspirate.²⁶ However, the popularity of the Coleman technique has brought injection methods to the forefront of attention in the literature of periorbital fat grafting.^22,25,27

An important role nonetheless remains for the use of local fat, which carries with it several advantages compared with implantation from a secondary site. Operating time is reduced, and the need for a second-site surgery is obviated. There is a minimization of fat manipulation as well as the amount of time spent where fat is outside of the body. The use of local fat may be more physiological, and in general, orbital adipose tissue–derived stem cells (ADSCs) may have greater adipogenic potential compared with abdominal ADSCs.²⁸ Ultimately, the end result can also be less unpredictable compared with injectable fat grafting.⁶ The 2 strategies can also be complementary and reduce the volume of tissue grafting required.

Local fat redistribution techniques can be categorized based on the anatomical location of transfer and the method, either as free fat grafting or fat pedicle transfer, and are compared in Table 1. Previous fat grafting techniques from the medial fat pad have imbricated the grafted fat within the orbicularis,¹³ or tunneled it to a preperiosteal plane via a lateral incision.¹⁴ Meanwhile, pedicle transfer techniques from the medial fat pad have included sutured fat pedicles to central¹⁵ or medial¹⁶ structures, and nonsutured pedicles fed laterally under the septum.¹⁷ Other strategies of transfer have incorporated the central fat pad or brow fat pad as donor sites.^18,19,21,29

There are multiple potential benefits to the medial fat pad postseptal pearl grafting technique as described in the present study. First, the operation is very simple and easy to learn, requiring only a modification of the traditional upper blepharoplasty technique with medial fat pad reduction, a surgery familiar to eyelid surgeons.

No additional incisions are made into the orbital septum, and the medial buttonhole does not require extending. This allows for a septal-sparing approach and potentially reduces instability of the medial structures that are a continuum of the septum, such as the medial horn, thereby minimizing any changes to the eyelid margin contour, such as a medial droop. Furthermore, regarding restricting fat pearl grafting to a postseptal compartment, we believe this is a more physiological location for central upper eyelid hollows compared with techniques imbricating the graft within muscle. Finally, it minimizes the potential for lumpiness in comparison to preseptal fat placement near the skin fold.

The medial fat pad as a donor site is appealing due to its relative prominence and preservation with age.² Thought to be derived from neural crest lineage, it is contiguous with the intraconal fat with which it shares its morphology. It is paler, denser, and contains larger fat lobules than the mesoderm-derived central pad fat, which is akin to other adipose tissues in the body and is a darker yellow with a more fluid-like consistency.^3–5

Correspondingly, there are also differences between medial and central adipose tissue ADSCs. Medial fat pad ADSCs demonstrate twice the expression of CD34, which is classically associated with hematopoietic stem cells, although the adipogenic potential appears similar.³ Interestingly, although the chondrogenic and osteogenic potential decreases with age, the adipogenic potential conversely seems to increase in eyelid ADSCs.³⁰ It has been speculated that ADSCs may contribute to a regenerative effect over and above the initial volume boost of grafting.²²

The transfer of medial fat as free grafts rather than as a pedicle has some advantages. Free fat is easier to harvest and much more flexible in its distribution, and its volume can be titrated more precisely. In contrast, a pedicle flap is inherently limited in directionality, distance, and volume.³¹ Fat is a gliding tissue, and pedicle flaps will have a tendency for retraction when not secured³²; conversely, securing the flap could risk tethering of the orbital contents and subsequent diplopia.¹² Raising an effective pedicle flap from the medial fat pad requires careful dissection and release of connective bands to be completely freed from the surrounding tissue. Excess manipulation risks orbital hemorrhage,³³ and the trochlea of the superior oblique tendon is also vulnerable to damage at this location.¹⁶ Finally, the chief purported advantage of pedicle transfer is the potential for better blood supply, but as they are random pattern flaps, vascularization may not necessarily be superior to free grafts.³⁴

The present study has some limitations due to its retrospective nature and the high proportion of cases that underwent concomitant ptosis repair (41 of 44). Due to the small numbers of patients who had medial fat pearl grafting and upper blepharoplasty alone, there may be confounders when considering the impact of the technique in isolation.

There are also some precautions to the application of the technique. For one, it is important to note that the pseudoherniation of the medial fat pad with age is a function of the relative atrophy of the central fat pad. The medial fat pad is naturally fuller compared with the central fat pad, as it is resistant to volume loss. As such, we believe that a more subtle effect should be the desired goal to avoid skeletonization of the medial fat pad. Thus, to avoid iatrogenic hollowing, we would always advocate that a degree of caution be exercised regarding the volume excised and transferred. That said, with such a conservative approach to fat excision, there were no cases of excessive medial hollowing or supplemental volume requirement in the present study, but conversely, 2 eyelids required further debulking of the medial fat pad because the patients were dissatisfied with the degree of residual medial fat prominence. Due to the inherently limited amount of fat that can be transferred in medial fat pad pearl grafting, patients who are likely to require a larger volume of orbital volume augmentation, such as those with severe sunken superior sulcus or enophthalmos, may be better candidates for nanofat transfer or hyaluronic acid filler.

Another potential risk of fat grafting is lipogranuloma formation, which has been reported with pearls harvested from abdominal fat^10,34 as well as autologous fat injection techniques.³⁵ However, no cases have been reported in previous studies of local orbital fat pearl grafting,^13,36 and no cases were encountered in the present study. The follow-up period was in line with other similar studies^19,21,37; however, the minimum period of 3 months (average of 8.2 mo) may have limited the ability to observe more subtle or longer term complications.

Finally, the technique may be a less suitable option if traditional anterior approach ptosis repair with full release of the orbital septum is planned as an adjunct to upper eyelid blepharoplasty. If the septum is widely opened, the eventual position of the fat may hypothetically be less controlled and may increase the risk of migration and other complications. Nonetheless, ptosis repair can be accomplished alongside medial fat pad pearl grafting without opening the orbital septum, either with posterior approach techniques or with septal-sparing or minimally invasive anterior approach techniques. This allows the transferred fat to be retained in a relatively enclosed, postseptal space.

CONCLUSIONS

Local fat transposition has been criticized by some as being technically difficult and time-consuming with a long recovery.²² This study shows that this need not be the case. The medial fat pad pearl grafting technique is simple and efficient, and is a natural extension of techniques that are familiar to blepharoplasty surgeons. The results indicate that the procedure is well tolerated and helps to address the volume disparity between the medial and central eyelid fat. Patients with medial fat pad prominence, who would have been previously considered for fat pad reduction, and who also have a relatively central fat pad atrophy, may be potential candidates for this type of approach.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided written consent for the use of their images.