Can I fix my under eye area without surgery? (Photos)

Question

I‘ve always had significant hollows under my eyes and would like to improve them non-surgically, if possible. I have a slight bulge of the fat pad under my right eye which I know may be more appropriately addressed through surgery, but I’m not ready to take that leap. I recently visited a highly regarded NYC Derm who did not want to inject my tear troughs because she felt it wouldn’t remain in place due to a ligament. She also apologized that she couldnt help because “they look terrible.” Based on the pictures, is her assessment correct, or is it a matter of finding the right doctor for the treatment? Thank you for your advice.

Nelson Lee Novick, MD · Answer

First, let me say that I am very sorry for that regrettable evaluation you received. 
Since the upper cheeks are a major support for the under-eye regions, volume deficit in the upper cheeks contributes significantly to the formation of under-eye hollows. At least from the photos, it appears that there is indeed some deficit in the cheeks. If this is so, then the use of a robust HA Filler appropriately injected to restore more youthful cheek volume can secondarily improve the under-eyes and less Hollowness. In my own practice, this is a routine procedure that yields consistently gratifying results. You would be wise to consult with an experienced, board certified cosmetic dermatologist filler injector and best of luck.

Anna Chacon, MD, FAAD · Answer

I’m sorry you had that experience. Having a physician tell you that your under-eyes “look terrible” is understandably upsetting, and I want to reassure you that significant tear trough hollows are very common, especially in people who have had them for most of their lives. What you’re describing sounds more like a structural anatomical issue than a reflection of something being “terrible.”

From your description, I can understand why the dermatologist was cautious. Tear trough filler is one of the most technically demanding areas to treat, and in some patients it can create puffiness, irregularities, or a result that looks worse rather than better. A prominent tear trough ligament can indeed limit how well filler blends the hollow, so her assessment was not necessarily wrong.

That said, I don’t think this is simply a matter of “nothing can be done.”

When I evaluate under-eyes like yours, I usually think about three separate components:

True hollowing along the tear trough
Midface or cheek volume support
Fat pad bulging, which you’ve noticed more on the right side

If there is even a small amount of lower eyelid fat protrusion, placing filler directly into the tear trough can sometimes make the bulge appear more prominent by adding volume around it. In those situations, experienced injectors often get a better result by treating the upper cheek and lid-cheek junction rather than injecting deeply into the trough itself.

For someone who wants to avoid surgery, the non-surgical options that may be worth considering include:

Midface/cheek filler to provide structural support and soften the shadow indirectly.
Collagen-stimulating treatments such as radiofrequency microneedling if thin skin contributes to the hollow appearance.
Platelet-rich fibrin (PRF) or similar regenerative treatments, which may modestly improve skin quality, though they will not dramatically fill a significant hollow.
In carefully selected patients, very conservative hyaluronic acid filler placed by an injector with extensive tear trough experience.

The fact that your hollows have been present for as long as you can remember is actually an important clue. Congenital or long-standing tear troughs often respond better to structural support in the cheek than people expect, because the shadow is created by the transition between the lower eyelid and the midface rather than by a simple “empty space” that can be filled.

Your right-sided fat pad bulge does make the situation a bit more complex. Surgery (lower blepharoplasty with fat repositioning) is generally the most definitive treatment when both hollowness and fat protrusion are present together, because it can redistribute the existing fat rather than adding new volume. However, not being ready for surgery is completely reasonable, and many patients choose to pursue more conservative measures first.

Based on your description, I would not interpret the consultation as evidence that non-surgical improvement is impossible. I would interpret it as evidence that the dermatologist was being appropriately conservative about direct tear trough filler. In my opinion, the more useful question is whether you are a candidate for indirect support of the under-eye area through the midface, which is often a safer and more natural-looking approach in patients with a strong tear trough ligament and early fat pad bulging.

So, I don’t think the takeaway should be that your under-eyes are untreatable. Rather, the challenge is choosing a treatment that respects the underlying anatomy and avoids the common pitfall of placing filler directly into a trough that may not hold it well or may accentuate the existing bulge. A thoughtful, anatomy-based approach can often produce a noticeable softening of the hollow appearance without committing to surgery.

Camille Cash, MD · Answer

I'm sorry for the experience you had.  The under eye hollowness that concerns you is very common.  Using fillers in this area and the adjacent cheek often creates better balance and improves facial contours.  We also recommend using medical grade skin care products like Transform MD and wearing sunscreen every day.  I've included a video I hope you find helpful.

Can I fix my under eye area without surgery? (Photos)

Answers (3)

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