With each passing year I find myself performing less 'invasive' lower lid surgery (i.e a formal lower blepharoplasty) and more lower lid rejuvenation by means of structural fat grafting. The reality of aggressive lower lid surgery - which involves some combination of skin excision, fat pad reduction and/or fat pad transposition, orbicularis (muscle) redraping and excision, and canthal support (to hold up the lateral aspect of the lower lid while everything heals) - can easily create an 'operated' appearance. Every experienced blepharoplasty surgeon understands quite well that the lower lid can be very unforgiving, and that an 'operated' appearance can be produced despite the best efforts of even the most skilled hands.
Some patients absolutely require an aggressive approach to the lower lids: those with bulging fat pads, marked skin and muscle redundancy, and obvious lower lid laxity. Many patients with mild to moderate aging changes, on the other hand, can obtain youthful and natural-appearing results by means of structural fat grafting - to fill in the tear trough, and to blend the contour at the lower lid / cheek junction. This can be especially useful for patients with a hollow or gaunt appearance at the junction of the lower lid and cheek, and for those with poorly projecting cheekbones that provide minimal support for the lower lid. If this area is inherently hollow, then the last thing a surgeon should do is remove fat from behind the lower lid, as doing so will only serve to aggravate the hollow appearance and will actually accelerate the apparent aging of the eye area.
Patients with full cheekbones and excellent lower lid support usually do very well with a traditional lower blepharoplasty, although if I feel that I can produce an equivalent result by means of fat grafting and a modest amount of skin excision I will certainly choose the less invasive (and quicker recovery) fat grafting option. Patients with poorly projecting, flat cheekbones in which lower lid support is lacking, on the other hand, are at significant risk for post-blepharoplasty complications and that obvious 'operated' lower eyelid appearance. These patients are often best served by structural fat grafting to camouflage the hollowness and create some lower lid support.
Adding fat definitely improves lower lid support, and it often reduces the amount of lower lid skin excision that is required to produce an improved lower lid appearance and a blended lower lid / cheek junction. I frequently see patients who have previously undergone a blepharoplasty procedure in which an excessive amount of upper and/or lower lid fat has been removed, and they invariably report that since that surgery they feel that they look tired, older, and even ill. For patients with post-blepharoplasty hollowness, the only way to restore a healthy and more youthful appearance is to restore the missing soft tissue volume, and this can reliably be accomplished by means of structural fat grafting.
Structural fat grafting is a procedure in which small amounts (less than 0.1 cc at a time) of fat are carefully introduced in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each micrograft, new blood vessels are able to grow into the grafted fat, allowing it to persist indefinitely. If this process of blood vessel ingrowth (neovascularization) does not occur, then the transferred fat cannot truly be considered a 'graft' and is instead just another temporary 'soft tissue filler' that is broken down and reabsorbed over several weeks. Fat grafting requires specialized training and specialized surgical instruments, as well as patience and meticulous attention to detail on the part of the surgeon. When performed properly, permanent and natural-appearing aesthetic enhancements can be achieved.
Because the lower lid tissues tend to be quite thin, a conservative approach is an absolute necessity for fat grafting of this area. If one overfills the lower lid /cheek junction, and most of the fat persists, then the patient ends up with unnatural fullness that needs to be corrected. I tell patients that our plan will be to add fat until an ideal contour is achieved and then we have to let it heal and see how much persists. Because the amount of fat that survives is variable, some patients require a second and rarely even a third fat grafting procedure to reach the desired endpoint of improvement. As fat grafting can be performed as an office procedure under mild oral sedation, and fat grafting recoveries are brief compared to traditional lower blepharoplasty surgery, supplemental fat grafting procedures are easily accomplished.
The safest and most effective treatment for lower eyes is going to vary and patients should look at the following factors:
-patient anatomy- thinner skinned patients will look at thinner products and thicker skinned patients may look at alternative products
-product longevity- fat transfer or repositioning may offer a better long term solution but an appropriate filler may offer an adequate answer as well
-physician training- surgically trained physicians such as facial plastic surgeons and oculoplastic surgeons and plastic surgeons will look at the lower eye area with more potential tools including surgery to offer a broader scope of options for patients
This is one of the toughest problems in facial plastic surgery in my opinion. We have tried to make it look simple with the recent trend of injecting hyaluronic acid. However as many of us have noted the rate of problems in this area can be as high as 10% including prolonged swelling, bruising, or irregularities and lumpiness. On the other hand these problems can be even worse with fat injection to the area. And of course there are even the rare cases of blindness that have been reported with injections of any material in this area. Other procedures including mid-face lifting also have potential risks and problems so I guess I am urging caution. Make sure you select a conservative surgeon with lots of experience and someone who is a master of all of the above.
Dear ckone78:In Canada, I use Teosyal Redensity II to treat hollowness around the eyes. It is the only filler approved by Health Canada for this area of treatment. The treatments outcomes have been great which correlated with patient satisfaction. You need a thorough exam, which by an expert injector to ensure that you are a good candidate for this treatment. All the best.
Belotero is the safest and most effective treatment for under eye hollows. Because the area under the eyes is very delicate and easily bruises you cannot inject something like Juvederm because it is too thick and can cause swelling and lumps and a bluish hue. Belotero is a unique fine filler that is especially designed for this under eye area. For the best results please consult a board certified dermatologist with a great deal of experience with this type of facial injection.
My personal preference for filling the undereye area is to use a product Belotero, which is a HA filler similar to juvederm and restylane. The reason I prefer it is because it does not cause a tindle effect, which is a blueish hue underneath the eye when the product is used superficially. Although Belotero does not last as long as restylane or juvederm, most patients prefer this tradeoff.
Treating the hollow area under the eyes requires a great deal of skill. However, many patients get excellent results with the correct treatment.
Any filler will add volume under the eyes. The issue is which type of volume enhancement is the best option. In my opinion the best option for under the eyes is Restylane.
There are various reasons why under eye treatments get less than 100% positive results,
- Lower eyelid skin tends to be very thin and sits directly over the bone. For that reason it is very easy to see the filler if it is not placed correctly
- Lower eyelids swell very easily. Hyaluronic Acid fillers tend to attract fluid so swelling can be a problem (especially if you have allergies, or your eyes swell a lot in the morning.
- Some patient have hollow areas under their eyes, but also have areas of excess fat. Fillers will help the hollows and mask the excess fat, but not if there is really too much fat.
Restylane is the best filler for under the eyes for two reasons.
- It is reversible. No matter how talented the cosmetic surgeon, there are times when adjustments need to be made after the treatment. Restylane can easily be dissolved with an injection of Hyaluronidase, so adjustments are easy.
- Restylane is better then Juvederm (for under the eyes) because it tends to swell less. Many patients get excellent results under the eyes with Juvederm, but fewer patients swell with Restylane (once again, for under eye treatments).
The most important step is to see an experienced cosmetic surgeon who will help you decide if this treatment is right for you.
I prefer to use volbella under the eye area/tear trough area. It is a "thin" filler that minimizes the chances of lumpiness and light based bluish effects. If it feels lumpy it can easily be massaged. Minimal quantities are needed usually no more than 0.5 cc per tear trough.
the best, safest, and most effective treatment for hollow eyes would
rest on several factors that you may need to consider. Some of these
Anatomy: Information about your facial anatomy will be useful to your
doctor in terms of determining which treatment will best suit you.
You will need to be assessed and evaluated thoroughly to get accurate
data and so that a precise treatment plan can be developed. For
instance, if you have sunken hollow eyes due to an abnormality on
your bony orbit, you may have a condition commonly referred to as
enophthalmos. In this case, filler injections would have little to no
effect in resolving hollow eyes. Surgical correction would be best in
this case, as this will entail major work on the skeleton of your
Desired Result: Do you want it temporarily? Do you want it
permanently? What exact results are you expecting? If you are looking
for temporary results, dermal fillers may be best for you since they
work pretty well and are reversible.
this light, you will do well to first initiate a visit with your
selected board certified surgeon so proper assessment can be done and
then proper treatment options can be given to you.
Thank you for your question. In my opinion, there are 2 ways to approach under eye hollows. Surgical vs non-surgical.
Surgical is by fat repositioning and or redraping.
Non-surgical is by using a cannula and depositing a low viscosity filler in the hollow itself deep on the bone.
I hope this helps. Best wishes! (Dr. Salameh, Plastic Surgeon, Bowling Green, KY)