Problematic under eye area - What is wrong with my midface? (Photo)

Question

It looks like really bad underlying bone structure which makes my face look like its melting . The eye area is very problematic

Ali Sajjadian, MD, FACS · Answer

Thanks Brave75808 for your question! What you are seeing is a very common, highly treatable anatomical variation in the midface and periorbital (under-eye) region. Your face isn't melting; rather, a few specific structural transitions are creating shadows that read as tiredness or sagging. The primary issue causing that disconnected or hollow look under your eyes is the presence of distinct tear troughs (the groove closest to your nose) and palpebromalar grooves (the continuation of that hollow extending across the upper cheek).
This is caused by a tight retaining ligament (the orbicularis retaining ligament) that binds the skin down to the underlying bone.  When this ligament is tight, it creates a physical indentation. Light hits the upper cheek and the lower eyelid, but gets lost in this groove, casting a dark shadow. That shadow is often mistaken for hyperpigmentation or "melting" skin, but it is purely a trick of light and volume transition. While your actual cheekbones (zygoma) appear to have a normal shape, there is a mild lack of anterior (forward-facing) projection right under the eye socket.
When there isn't quite enough soft tissue or forward bone support right at the rim of the eye, the lower eyelid fat pads can transition abruptly into the cheek rather than blending smoothly. This abrupt transition exacerbates the look of the tear trough.
To correct this, the goal isn't to change your bone structure, but rather to blend the transition between your lower eyelid and your cheek so that light bounces off the area evenly. Your face has great symmetry and strong features. To address this specific shadow, consider scheduling a consultation with a board-certified plastic surgeon. Ask them to evaluate your tear trough ligament tightness and your medial cheek volume—they will easily see exactly how to smooth out that transition for you.
Hope this was helpful!
Best wishes,
Dr Ali Sajjadian

Sang W. Kim, MD · Answer

From the photo, this patient seems to have scleral show and negative vector with associated tear trough and midface hollow. There is a spectrum of options for management of this, but I would always recommend less-invasive options, especially for younger patients. For nonsurgical option, I would recommend filler or fat graft to orbital rim, tear trough, and midface to convert the negative vector to neutral/positive, providing volume support beneath the lower lid. 
Surgical approaches range from a transconjunctival lower blepharoplasty combined with fat transposition/grafting. Some surgeons may also advocate for canthopexy or canthoplasty for lid tightening, although for this particular patient, I would likely start with less invasive options as described above.

David Hill, MD · Answer

You have a slight lateral canthal tilt, where the eyes are turned a bit downward at the outer edges. You also may have a slight eyelid ptosis although this is incompletely assessed since your pupils are not visible in this photo. One way to improve the "tired" or "sad" look is to do a canthopexy, which pulls the outer edge of the eye upwards. While this does change the appearance of the eye, it can also greatly change how you see yourself or the character of your face, which is a double-edged sword.

Semih Yildiz, MD, FEPOBRAS · Answer

The photo is cropped, so only the upper midface and lower eyelid area can be judged. In the visible area, the concern looks more like tear-trough hollowing/shadowing and limited lower-lid-to-cheek support than simply bad bone structure. Lighting, brow position, and facial expression can also make this area look more severe.

Treatment depends on an in-person exam and skin quality. Mild cases may improve with very conservative tear-trough or cheek filler, but filler in this area must be done carefully to avoid puffiness or a bluish shadow. Other options can include fat grafting, lower blepharoplasty, or a midface/cheek-lift type procedure if there is true tissue descent.

A full facelift is usually not the first step for an isolated under-eye concern. An exam with an oculoplastic or facial plastic surgeon can help separate whether the main issue is skin, fat pads, ligament/cheek support, or bone projection.

Problematic under eye area - What is wrong with my midface? (Photo)

Answers (4)

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