Reply: Fat Grafting in the Hollow Upper Eyelids and Volumetric Upper Blepharoplasty

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I thank Drs. Wang and Wang for their interest in the article, “Fat Grafting in the Hollow Upper Eyelids and Volumetric Upper Blepharoplasty.”1 I appreciate the opportunity to add my thoughts to their valuable observations.
I agree that Asian anatomy poses a different challenge when restoring volume on the upper eyelids. As Drs. Wang and Wang suggest, the classic lack of supratarsal crease and pretarsal fat herniation on Asian eyelids may be best addressed by an open approach. Nonetheless, volume loss in these patients usually appears as a limited dent over the already convex surface of the bulging eyelid instead of the presented hollow patterns above the tarsus.2,3 Similar to what occurs in Western patients with dermatochalasis prevalence, this limited shadow close to the orbital rim could be best suited by an augmentation blepharoplasty instead.4 After resecting the redundant skin and muscle, the closing sutures reproduce the tarsal fixation to the skin and levator aponeurosis. At the end, fat grafting can be performed only in the depressed area.
In my opinion, the advantage of volumetric upper blepharoplasty over this is that the muscle imbrications conceal the fat graft layer at the same time that the eyelid skin stretches to the point where no irregularities are visible. The result is a tight, convex, and light-reflecting surface. Conversely, the significant amount of volume obtained from the synergy of fat grafting and muscle imbrication may prove undue if applied to an already convex eyelid. In fact, my sole unfavorable result with volumetric upper blepharoplasty came from forcing its indication to a patient with minor volume loss and no hollow patterns. This issue may underlie my preference to date of using ratio measures instead of more complex analysis such as three-dimensional imaging or subjective plain observation.
Regarding ptosis of the upper eyelids, although the experience is limited, in the presented series, no patient was affected by the extra volume or weight of the graft, even those with ptotic eyelids.1 This likely occurs because the deep grafting is performed close to the orbital rim and the superficial grafting is just below the orbicularis muscle. Again, no irregularities where observed on the closed-eye view. Of course, as this was a small Western case series, larger observations and analysis should be performed. I thank you again for the opportunity to reply.

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