Hollow Under Eyes - Fillers or Fat Grafting?

Question

Hi drs I suffer from hollow dark under eyes, i have researched both fillers and fat grafting but still unsure. im worried the filler will leave lumps.with fat im concerned it will be non reversible if it goes wrong.I prefer idea of fillers as less recovery time. Im only 25yrs (female) but have lost alot of volume under my eyes. i look foward to ur expert opinions. thanks Nora

Larry S. Nichter, MD, MS, FACS · Answer

Your thought process is on the right track. For many of my patients and this might apply to you, I recommend if they are unsure of what they may look like afterwards is to have fillers placed in the cheek/lower lid junction. The advantage is that you get to try out your new look. If you like it then next time around go for a more permanent fix with fat transfer.

Ron Shelton, MD · Answer

The hollowness may be helped by injecting Restylane or Juvederm underneath the muscle. Darkness of lower eyelids is difficult to treat. Some attempts have been made with skin lightening creams, vitamin K creams to change the iron deposits from sluggish red blood cells and other creams that effect a change in the iron deposits and blood flow. Unfortunately we don't have consistent results with any treatment for this darkness.

Michael Law, MD · Answer

A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed. is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.

	In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.

	In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.

	As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.

	In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.

	Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

	Structural Fat Grafting of the Lower Lid

	As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.

	In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.

	In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.

Khaled El-Hoshy, MD · Answer

Fat is a type of filler!! If you need fillers on cheeks , or other ares , fat would probably be a good option. It depends on your dermatologist, or plastic surgeon experience what kind of filler he or she would recommend. All fillers should give excellent results, if done properly.

Brooke R. Seckel, MD, FACS (retired) · Answer

Thank you for your question. My answer is likely controversial as many physicians are using filler injection around the eyes today. A perfectly placed filler injection can correct the depression beneath the lower eyelid called the dark circle or nasojugal fold which is different from the Hollow Eye which is caused by lack of orbital fat. The problems with filler injection in this area are:

	
		Many physicians with no training or experience in eyelid surgery are using this technique-often the filler is placed incorrectly or the eyelid muscle pushes the filler out of the depression and makes the dark circle worse-I also do not like the idea of repeated injections with a needle into a very delicate important functional area
	
		A true hollow eye-depressed eyelid caused by lack of fat requires volume replacement into the orbit where very vital structures are located-I would not blindly place a needle and inject into this area-blindness following filler injection into the eyelid has been reported in England-the filler was injected into a blood vessel
	
		Fillers are temporary and must be repeated-repeated injections into the eyelid can cause scarring and possibly damage to the eyelid


	I use Composite Fat Grafting NOT Fat Injection or Fat Transfer. Composite Fat Grafting utilizes a whole piece of fat which is harvested from the pubic area and transplanted into the depression beneath the puffy lower eyelid or dark circle. My reasons are:

	
		A composite Fat Graft survives better than injected fat
	
		If the graft takes or survives-about 80-90% of the time-the correction is permanent unlike fillers
	
		Injections into the eyelid are avoided
	
		The fat can be accurately surgically placed into the proper position
	
		Transconjunctival incision for graft placement allows for release of the Arcus Marginalis which allows proper placement where volume is needed
	
		For a true Hollow Eye, fat can safely be placed into the orbit to add volume


	I hope this helps

Kevin F. Hagan, MD (retired) · Answer

Hollow areas beneath the eyes can be caused by a lack of fat in the upper portions of the face.  It is most commonly seen in older patients, in which case a mid-face lift is often the best and most permanent solution.  In a young person such as yourself, some type of local volume replacement is usually the preferred treatment.

	This can be done with HA fillers such as Restylane or Juvederm, or with fat grafting.  Here are the pros and cons of each method:

	      Fillers (Restylane, Perlane, Juvederm, etc.)

	Advantages:  These are temporary, lasting usually 6 to 18 months. Therefore, if you don't like the result, it will get better with time.  If you REALLY don't like the results, it can easily be reversed with an injection of hyaluronidase.  Also, because these products are fairly thin and are injected through small needles, a smoother and more precise result can usually be obtained if the person injecting is skilled.

	Disadvantages: These are temporary, so if you like the result, re-treatment will be necessary in 6 to 18 months.  If large volumes of the product are necessary, a bluish discoloration of the skin  may sometimes result.

	         Fat Grafting

	Advantages: Fat can be a more permanent solution.  Once the injected fat is "accepted" by your body, it becomes permanent.  It will even enlarge if you gain weight!

	Disadvantages:  Only a portion of the fat that is injected will "take", and the remainder will be absorbed by your body.  The amount that takes is unpredictable, and it is therefore necessary to over-correct, injecting more fat than is necessary to compensate for the absorption.  Fat is also much more difficult to inject smoothly, and lumpiness is more common and is very difficult to correct.  Fat grafting is usually more expensive than fillers in the short term, and the area where the fat is harvested from will be tender for a few days.

	In your case, because of your age, I would recommend that you try the fillers first to see how you like the look. If you are pleased with the result but want a more permanent solution, then you can always try fat grafting at a later time.

	The darkness of the skin (blepharomelasma) is a different issue.  If you can't cover it with makeup easily, you might try using 4% hydroquinone cream, available with a prescription

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