From February 2010 to April 2014, five women (mean age, 35 years; range, 28-52) who experienced eyelid swelling after forehead fat grafting received conservative or surgical treatment. Three cases involved both eyelids, and two cases involved only one eyelid. All patients had undergone forehead fat grafting with cryopreserved fat grafts in two cases that required surgical treatment. The eyelid swelling began approximately 5 to 7 days after the operation. The patients described intermittent eyelid swelling with heat and dull pain, which became more severe and persistent with symptoms such as foreign body sensation, redness, unilateral or bilateral ptosis, palpable lumps, and difficulty in opening the eyes, which occurred both day and night. Three cases were acute, occurring within 1 month after the fat grafting procedure, whereas two cases were chronic, occurring 4 months and 28 months after fat grafting.

All three patients with acute swelling received conservative treatment initiated the day symptoms developed, but one patient later required surgical intervention. If marked swelling of the eyes occurs after forehead fat grafting, positional drainage with bed rest may be recommended. Swelling may be worsened by gravity when sitting in an upright position or standing. In addition, ice should be used to cool the area around eyes. If no improvement occurs with 1 or 2 days, a short course of a diuretic or corticosteroid (2-3 days) may reduce the swelling.

If no improvement is observed after a week of conservative treatment, surgical exploration should be considered and performed within 30 days after the operation. Simple swelling of the eyelid usually subsides within 2 weeks. However, eyelid swelling is abnormal if it lasts more than 3 weeks, and after 4 weeks, inflammatory fibrosis results in scars. This abnormal swelling may never subside spontaneously but will likely develop into intermittent swelling or mass formation. In addition, preexisting swelling can result in more severe swelling after forehead fat grafting, leading to masses or ptosis (Fig. 1).

Before surgery, a photograph should be taken in a standard position to determine the optimal incision site. The incision line (approximately 1 cm long) is usually placed at the lateral one-third of the double eyelid crease (Fig. 2). The orbital septum opens easily at this location, because the abnormal swelling or mass is usually located near the intra-orbital fat in the septum. Immediately after the grafting procedure, the vacuoles will contain yellowish free oil, which becomes whitish emulsified fat over time. If more than a year has passed, a lump or mass will form in the intra-orbital fat, which should be excised. The lesions are usually located in the ower portion of the intra-orbital fat, near the levator sheath. Each lesion is a small individual sac, which must be ruptured to extract the oil by electrocautery. This procedure should be performed carefully, with gentle traction of the orbital fat from lateral to middle and medial intra-orbital fat lobules (Fig. 2). If the incision is made too lateral to approach the medial fat lobule, it may be elongated for a more medial position. If the swelling is located medially, it is better to make another medial incision (approximately 1 cm), with the intervening skin left intact to preserve the original eyelid crease, rather than a single long incision from lateral to medial. After removing all sacs containing free oil, the surgical field must be washed with sterile saline (with or without antibiotics), and the incision closed with 7-0 black nylon sutures.

If the lesion is left too long after the fat grafting procedure, it may become a mass that requires direct excision (Fig. 3). This mass lesion will also be located in the lower portion of the intraorbital fat, extending into the intra-orbital portion just above levator sheath. This location may explain the ptosis that appears with eyelid swelling. The mass may be attached to the levator, moving along with the levator. A large mass may make it difficult to open the eyes because of the mass effect.

A 29-year-old woman complained of mild but persistent eye swelling and ptosis of the right eye after forehead fat grafting (Fig. 4). After 3 weeks, the symptoms were treated with a diuretic (furosemide, 40 mg for 2 days), a corticosteroid (prednisolone, 20 mg for 5 days), and an antibiotic (cefmetazole, 500 mg twice per day for 3 days). The symptoms subsided without any residual complications.

A 32-year-old woman experienced marked periorbital swelling on both sides after forehead fat grafting (Fig. 5). The swelling developed approximately 5 days after the operation and became more severe in the following few days. Treatment was the same as that used for case 1, and the swelling resolved without any sequelae.

A 52-year-old woman reported swelling of the right eye, with discomfort upon opening (Fig. 6). These symptoms developed approximately 3 weeks after the operation and did not improve with conservative treatment. The swelling was treated by surgical extraction of the vacuoles containing free oil. Symptoms did not recur after the surgical intervention.

A 47-year-old woman complained of persistent eye swelling during the 4 months after forehead fat grafting, which showed only minimal response to conservative treatment (Fig. 7). The foreign body sensation worsened during follow-up. The patient was treated by surgical extraction of the oil cyst, and the swelling did not reoccur.

A 50-year-old woman complained of recurrent eyelid swelling with dull pain that developed after forehead fat grafting, which was performed approximately one and a half years previously (Fig. 8, 9). A soft marked swelling developed on both eyelids approximately 1 month after the operation. The swelling was minimally improved by anti-inflammatory agents and antibiotics, but did not completely resolve, recurring at irregular intervals depending on her overall condition. For example, if the patient was tired, the symptoms were more severe. The soft swelling developed into a harder mass with redness and dull pain, and the initially transient symptoms became more persistent and severe. The patient reported that she could not open her eyes when the symptoms were severe.