The upper-lid fat compartments
Two fat compartments sit behind the orbital septum in the upper lid:
- Medial (nasal) fat pad — smaller, paler. Sits at the inner corner. Often the first to show with age.
- Central (preaponeurotic) fat pad — larger, yellower. Sits above and behind the levator. Common location for visible herniation.
(The lateral compartment in the upper lid is actually the lacrimal gland, not fat — an important distinction surgically.)
Fat herniation: the "puffy" upper lid
When the orbital septum weakens with age, the fat pads behind it bulge forward. The result: a visible "puff" or roundness in the upper lid, most often in the medial third (the inner corner near the nose) or the central upper lid.
Distinguishing features:
- Visible bulge, especially in the medial third
- Worse when looking down (gravity pulls fat forward)
- Worse on waking, may improve through the day as orbital edema resolves
- Can coexist with dermatochalasis — both contribute to the "tired" look
Treatment: surgical. The fat is either removed (traditional) or repositioned (modern technique) via a small incision in the lid crease. Energy-based devices and injectables do not fix fat herniation. We refer to oculoplastic surgeons.
Fat atrophy: the hollow upper sulcus
The opposite problem. Some patients lose volume in the upper sulcus rather than gain it. The sulcus (the depression above the upper lid, below the brow) becomes deep, the orbital rim becomes prominent, and the eye looks "skeletonized" or "cadaveric."
This is sometimes called the A-frame deformity — the upper sulcus takes on an inverted-V shape when viewed in profile.
Distinguishing features:
- Hollow appearance in the upper sulcus
- Visible orbital rim
- "Cadaveric" or aged appearance even with otherwise youthful features
- Can be congenital (some patients have always had it) or acquired (post-blepharoplasty, weight loss, age)
- Common after over-aggressive upper-lid blepharoplasty — too much fat was removed
Treatment: volume restoration. Options include hyaluronic acid filler (with experienced injector and cannula technique), Alb-PRF, or autologous fat grafting. Skin-tightening tools do not help.
When both occur at once
The annoying clinical reality: some patients have both fat herniation in one compartment and atrophy in another. For example, a patient may have a puffy medial fat pad and a hollow central sulcus. In these cases, treatment combines fat repositioning (rather than removal) with volume restoration in the hollow area.
This is one of the strongest arguments for fat-repositioning blepharoplasty over fat-removal blepharoplasty in patients with mixed presentations.
Hollow sulcus after over-aggressive surgery
A common late complication of older blepharoplasty techniques: too much fat was removed, leaving the patient with a hollow sulcus they did not have pre-operatively. This is not necessarily a surgical error — it was the standard approach for decades. Modern techniques are more conservative.
If you have a post-surgical hollow upper sulcus, options include:
- HA filler — conservative volume in the hollow zone. Cannula technique reduces vascular risk.
- Autologous fat grafting — durable, harvested from elsewhere on your body. Requires another procedure but the result is permanent.
- Alb-PRF — biostimulating gel; subtle volume + tissue improvement. Series of 2–3 sessions.
FAQ
Can fat herniation be treated without surgery?
No. Fat behind the septum cannot be reduced by energy-based devices, injectables, or topical treatments. If the puffiness is real fat herniation, surgical correction is the only option.
Will filler in my upper sulcus look natural?
When done well, yes. The thin skin here is forgiving for autologous gels (Alb-PRF) and unforgiving for stiff HA fillers. Soft HA via cannula, or Alb-PRF, are the most natural options. Avoid clinics that use stiff product or needle technique here.
Is a hollow upper sulcus reversible?
Volume can be restored — yes — through filler, fat grafting, or Alb-PRF. The underlying fat that was lost won't regenerate on its own, but volume replacement looks identical when well-placed.
I had blepharoplasty 10 years ago and now my upper eyes look hollow. Is that normal?
It's a recognized late outcome of older fat-removal techniques. Volume restoration is the answer — usually filler or fat grafting. Worth discussing with both us and the original surgeon.
Want to know which one you have?
A short exam identifies whether your upper sulcus is full or hollow, and which fat compartments are involved. The plan follows from the diagnosis. No commitment.