Safest and Most Effective Treatment for Hollow Eyes?

I have hollow eyes (from missing fat) which causes the dark eye circles and makes me look tired all the time. I'm seriously considering plastic surgery but want to make the safest, most effective decision. I've heard Juvederm and Restylane injections are best. but then some say fat transfer is another good option. Will there be surgical incisions to insert the fat vs. laser? I'm so confused.

Has anyone actually gotten these procedures done, and have recommendations on which has worked for them? What would doctors that recommend on which ways are the most safest and long-lasting? HELP!

Doctor Answers 21

Safest and Most Effective Treatment for Under Eye Hollows

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.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 118 reviews

Tough Problem to Correct

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.

S. Randolph Waldman, MD
Lexington Facial Plastic Surgeon
4.9 out of 5 stars 18 reviews

Safest and Most Effective For Hollow Eyes

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

Anil R. Shah, MD
Chicago Facial Plastic Surgeon
4.8 out of 5 stars 159 reviews

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Safest and Most Effective Treatment for Hollow eyes

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.

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There are many options available for treating your eyes. The nice thing about dermal fillers is that they work well, c and can be reversed. The downside is that they are only temporary. I would recommend an examination to see if you are a candidate. I hope my answer helps you.

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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.

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Restylane: Safe and Effective for Under Eye Hollows

Under eye hollows can be familial, and create a tired look, even after a great nights sleep. This change in the under eye area is due to a combination of factors: fat loss, change in the supporting tissue in the periorbital area, and changes in bone structure. The use of fillers has been proven to be both safe and very effective in correcting this loss of volume. The point I would like to make is that this is not a permanent solution, but it tends to last for 1 year, and you do not have to worry about committing to something that you may not be happy about in the future, such as fat transfer procedures. A Restylane injection can be reversed by a selective enzyme that can dissolve the product, which is a nice option to know is possible. The under eye area is one of the most challenging areas and best left to be injected by a more skilled injector.

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Surgery versus fillers

Surgery for under eye hollows usually provides the best longest lasting results.  However, if you have good skin laxity and minimal to no fat bulging under the eyes, then fillers like Restylane is a great option.  I would look for an experience injector who is also a board certified plastic surgeon who can help assess your individual needs and discuss the pros/cons of your options.

Young R. Cho, MD, PhD
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Surgical Correction Likely Needed

The vast majority of patients with sunken hollow eyes have underlying abnormalities of the boney orbit. These patients often have enlarged boney orbits which cause the eyeball to look small, sunken and hollow. This condition is known as enophthalmos.
Under these circumstances, injectable fillers would have very little effect on hollow eyes. In fact in some cases they might actually make the problem worse by burying the eyeball.
Surgical correction of this problem would involve major work on the facial skeleton. This type of procedure wouldn’t be justified because of the risk benefit ratio. In this situation, it’s probably reasonable to leave well enough alone.

Richard J. Bruneteau, MD
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I recommend belotero to the tear trough

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. 

David P. Rapaport, MD
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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.