Treatment for Sunken Upper Eyelids: Eyelid Fat Grafting and Double Line Release for Upper Eyelid Fat Loss

Today's topic is about treating sunken upper eyelids, eyelid fat grafting, and upper eyelid fat deficiency.

This content is part of a presentation delivered at the 17th Academic Symposium of the Korean Society of Plastic and Reconstructive Surgeons (KSPRS) Eye Surgery Research Society on July 5, 2026.

It addresses methods to prevent multiple folds when lowering a high double eyelid line, as well as treatments for triple or multiple eyelid folds.

When upper eyelid hollowing occurs, it can stem from a variety of causes.

Typically, when performing procedures such as double line release, the most critical issue is tissue adhesion. In such cases, the adhesion must be completely released, and measures must be put in place to prevent re-adhesion; otherwise, no improvement will be achieved.

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These are cases where adhesions must be thoroughly and meticulously released.

In other instances, the issue is simply caused by a lack of volume.

This method involves harvesting fat using a cannula and grafting micro-fat into the hollowed area.

After the surgery:

Immediately after surgery, an instant improvement is visible. If multiple folds are still present right after surgery, it indicates that the adhesion was not released at all.

This is at 1 month post-op. These folds developed due to a lack of volume in the upper eyelid.

Typically, when fat grafting is performed, the retention rate of the grafted fat is around 50%.

However, if you inject an excessive amount upfront and more fat survives than anticipated, it can form lumps. Removing those lumps would then require an additional surgical procedure to excise the grafted fat.

Therefore, we inject a conservative amount first and proceed with a secondary touch-up. For this second session, we performed fat grafting alongside a dermal injection (Re2O).

As soon as the volume was restored, the multiple folds significantly improved.

Because this was not a wrinkle caused by tissue adhesion, it resolved quickly.

This is at 3 months post-op. While the scar has not yet fully settled, significant volume has been restored and the skin tissue appears slightly thicker.

The advantage of a dermal injection (Re2O) is that it compensates for the unevenness or lumpiness that can occur when fat is injected too superficially into the skin layer. Even when placed in superficial planes, it spreads evenly without clumping and achieves favorable engraftment.

Furthermore, there is no need to harvest fat separately, no sleep anesthesia is required, and the issue can be easily resolved through a simple injection.

That concludes today's post.

Frequently Asked Questions

What causes sunken upper eyelids or multiple eyelid folds?

The primary causes are tissue adhesions and a deficiency of upper eyelid volume. Following double eyelid surgery or a double line release procedure, adhesions can lead to multiple folds. In other cases, hollows and folds appear simply because there is insufficient fat volume in the upper eyelid area.

How are multiple upper eyelid folds treated after a double line release?

Adhesions must be thoroughly dissected and measures taken to prevent re-adhesion. If multiple folds remain immediately after surgery, it is very likely that the adhesion was not fully released. Therefore, releasing the adhesion cleanly and preventing the tissues from sticking together again is essential.

Why isn't a large amount of fat injected all at once during eyelid fat grafting?

This is to avoid complications such as lumpiness and nodule formation if an excessive amount of fat survives. The typical survival rate for upper eyelid fat grafting is around 50%. However, overfilling can lead to clumping that requires subsequent surgical removal. For safety, it is injected conservatively first and refined during a second touch-up.

What are the features and benefits of Re2O dermal injections?

Re2O can be injected into superficial skin layers without causing lumpiness or uneven textures, spreading smoothly and evenly. It does not require fat harvesting or sedation and provides a simple, injectable method to replenish dermal volume and thickness naturally.