I'm getting blepharoplasty soon and am worried about the "hollowed out" look I have been reading about? (photo)

How common is this? I'm in my early 30s and have had eye bags for the past 10 years. I constantly get comments on how tired I look and finally have worked up the courage to get it done. However, I am apprehensive after reading many online reviews of dissatisfied patients. How common is the sunken/hollowed out look after blepharoplasty? Does fat transfer reduce the incidence of this significantly or marginally? Does the fat transfer usually last forever or are revisions common years down the line? Thanks!

Doctor Answers 13

Why I don't recommend fat transfers for a possible hollowed look after blepharoplasty, its causes and other treatments for it

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Puffy bags under the eyes are one of the most common things that I take care of. For years, I have had a lot of different perspectives of what hollowing is. Hollowing can be defined in many different ways and unfortunately, there are some subjective aspects to this. In my practice, I first explain to my patients that when you have lower eyelid blepharoplasty or when you address the puffy bags under the eyes, you need to imagine what the eyes would look like if the bags are not there.

In my book, “The Fine Art of Looking Younger”, I mentioned that facial aging is not just sagging, but it is also volume loss. The people who are complaining about hollowing are not only referring to the under eye directly but also to the area below the eye called the eyelid-cheek area. As we get older, we lose volume in this area. After the puffiness is addressed, a person may look at their face and say they still look tired or hollow. If it isn’t discussed with the patient about what can be done after the surgery, then they would feel that the fat removal made them look hollow.

To address this hollowing issue, a lot of my colleagues including myself, have tried a variety of strategies for years which includes fat transposition, fat transfer and septal tightening. As a specialist, I have found out that it is very difficult to address hollowing because the tissue’s quality or the integrity of the skin under the eyes is very thin. If you transfer fat under the eye to fill a hollow, it will look bumpy. Fat transfer is something I would do in areas that the skin is thicker. I’ll place it in the cheeks, nasolabial folds, mandibular notch and in the mesolabial folds or the marionette lines, but the one place I won’t place directly is the under eye area. I have seen so many patients from all over the world who have had lumps, irregularities and scars from fat transfer. The problem when you do fat transfer is that you are not just transferring fat, you’re transferring fatty tissue. You can go to different types of processes to purify it but it has still been associated with variability and need for additional surgeries. It is also associated with chronic and persistent swelling.

In my practice, I examine my patients and show them that there are puffy bags and they have relative hollowing in the tear trough area. I advise them that after the surgery, they can consider adding a filler. This will address the hollowing in the area after the puffy bags are gone. In addition, good communication with your doctor and understanding of the procedure will help you decide what steps you should take. Many online personal reviews and forums will give different perspectives about surgery and procedures. Things may sound right but may not be as practical in the real world. So meeting with a doctor and having a discussion about what the realistic impact will be after a lower lid blepharoplasty will alleviate your concerns. I hope that was helpful, and thank you for your question.

New York Oculoplastic Surgeon
4.4 out of 5 stars 80 reviews

Blepharoplasty and Hollowing of the Eyes

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Conservative blepharoplasty can be performed in a manner to reduce the appearence of hollowed eyes. It can also be performed in conjuction with fat grafting. It is recommended to be evaluated by a plastic surgeon to discuss your individual options.

Craig Mezrow, MS, MD, FACS
Philadelphia Plastic Surgeon

Lower eyelid blepharoplasty surgery, avoiding the hollowed out look

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With almost any technique of lower eyelid blepharoplasty that manipulates the fat pads you are at risk of hollowing in the future. However there are methods to perform this procedure that can minimize the risk. More important than anything is choosing the right surgery for your eyelids and not performing a cookie cutter procedure. Based on your photo (and without a live consultation) it appears you have a significant tear trough deformity (area under your eye bag). This provides a valley next to the mountain (your eye bag). I would recommend a fat transposition (move the existing fat downward to fill some of that hollowness) possibly with adding more fat (fat transfer) that is harvested from another part of your body. Generally since this fat is placed deep about half of it survives.

Robert Schwarcz, MD
New York Oculoplastic Surgeon
4.5 out of 5 stars 23 reviews

Lower Blepharoplasty Alternatives

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I agree with the others that a conservative lower lid blepharoplasty is the right approach if you do undergo surgery. If you are hesitant, it would also be reasonable to consider 2 other nonsurgical treatments such as the use of hyaluronic acid (HA) fillers such as restylane or juvederm to fill in the tear troughs, and possible a skin resurfacing treatment such as a fractionated CO2 laser to help slightly tighten and brighten the lower lid skin.

This approach offers some advantages to surgery by retiring voluming and improving the appearance of the skin.

Jon E. Mendelsohn, MD
Cincinnati Facial Plastic Surgeon
4.8 out of 5 stars 128 reviews

Conservative fat removal avoids hollowness after belpharoplasty

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Like all things, the quality of the result depends on a degree of artistry and experience in removing the right amount of fat to balance lid position. Not too much (hollow) or too little (persistent bulging). Hollowness can be treated if it occurs, but a carefully performed procedure by an experienced surgeon has a low risk of hollowness.

Lawrence Bass, MD
New York Plastic Surgeon

Blepharoplasty for early 30s and tired look

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A conservative fat removal trans- conjunctival approach lower blepharoplasty will give the best results. It's important to give a natural result that is long-lasting. For many examples, please see the link below to our eyelid surgery photo gallery

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

Risk of hollowing after lower blepharoplasty

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Hollowing is usually the result of overly-aggressive fat removal. Conservative fat removal and, possibly, fat repositioning can minimize this risk. Seek a highly experienced blepharoplasty surgeon. I hope this information is helpful.

Stephen Weber MD, FACS

Great candidate for blepharoplasty

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With the availability of fat transposition blepharoplasty and fat grafting techniques, you should be able to get an excellent result that will last you a long time with minimal risk of developing a hollowed appearance.

Make sure your surgeon is comfortable with these techniques as subtle differences in indications between patients would require different surgical treatments.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 42 reviews

Under eye fat deposits

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You appear to have significant fat bags. These can be conservatively treated to soften the look. If the tear trough is an issue after this, then it can be gently filled to camouflage the area.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

You have a fair amount of fat prolapse for you age.

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However, you may benefit from some filler in the tear trough first. This will help to mask the fat, and make a smooth transition from lower lid to cheek. IN this area, the filler often lasts for at least a year. If you want to do a surgery, you may benefit from a fat repositioning blepharoplasty. In this surgery the fat is moved inferiorly from a trans-conjunctival approach, so there is no external scar. By preserving the fat, there is much less chance of hollowing. If you do have some residual hollowing you could do a fat transfer.

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 31 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.