Safe Sunken Eyes Treatment for Thin Skin?

I am a 28 year old woman with dark, sunken looking eyes. I have used Botox around the brow and to eliminate crows feet. When I retain water, my eyes look great due to the extra volume, so I am guessing that a filler of some kind would be in order. I am concerned about the type of filler though, as my skin is thin and pale. What would be the best procedure?

Doctor Answers 18

Nice handle-microbiologist I presume?

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Despite your thin lower eyelid skin, Restylane filler is the way to go.  Don't have Juvederm in this area.  The smooth characteristic of that products also makes it a little runny and it tends not to hold in a precise way which is a problem for under eye treatment.  The under eye fillers are now so good that I strongly discourage most people from having lower eyelid surgery unless they have very particular findings that make this a more reasonable choice.  Fat is also not a great option for this very thin eyelid area because of the tendency of the fat to heal irregularly.  The nice thing about the hyaluronic acid fillers is that they can be adjusted.  Please recognize that this material cannot be just slammed into the face.  It has to be sculpted.  Not every doctor has the same artistic sense or skill.  You need an artist and enough filler.  Never allow someone to place permanent fillers into this region.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Sunken Lower Lids

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Many patients with mild to moderate aging changes 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.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Lower eyelid filler

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I would recommend hyaluronic acid for filling the lower eyelids and Restylane works very well in this location.  Thin skin is not a contraindication if the filler is placed below the muscle, and done in small amounts per pass.  Fat transplantation is also a good alternative for filling hollow lower eyelids, but again, it has to be placed below the muscle and not just under the skin.

Keith A. LaFerriere, MD (retired)
Springfield Facial Plastic Surgeon

Silikon-1000 may be used by experienced physicians to fill lower eyelid hollows. Video attached.

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Silikon-1000 is an off-label filler for permanent results. This is my personal preference for filling lower eyelid hollows. Your results from Silikon-1000, good or bad, are permanent so you must choose a physician familliar with the microdroplet, serial-puncture technique. Your lower eyelid area is delicate and unforgiving, so the experience of your surgeon is of utmost importance.

I hope this is helpful for you.

Regards from NJ:

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 435 reviews

Fillers are great for treating tear troughs

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Deep tear troughs are a common problem, one which makes people look tired even if they are well rested.  I have used most fillers for treating this area (Restylane, Perlane, Juvederm, Radiesse, and the volume enhancer Sculptra).  My preferred treatment isRadiesse as the clear colored hyaluronic acid fillers can cause this area to darken slightly.  That being said, I think all of the fillers are good for treating the tear troughs and I would suggest that you see a physician who is skilled with a variety of fillers.

Jonathan Sonne, MD
Naples Facial Plastic Surgeon

Radiesse for the tear trough areas

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I prefer judicious use of Radiesse ,0.1- 0.2 cc,  for your condition. Juvederm may leave a Tyndall effect, or a bluish hue, which can accentuate the pre-existing discoloration. Building the area slowly over time is preferred.

Edward J. Gross, MD
Orlando Facial Plastic Surgeon
4.8 out of 5 stars 35 reviews

Fat transfer to lower eye area...

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I would suggest fat transfer to that area.  With Juvederm you can have swelling that is prolonged and Restylane will last for only a short period of time.  A fat transfer will have longer lasting affects, averaging 2-3 years, sometimes longer, and is the safest treatment being that you are using your body's fat instead of a filler to such a sensitive area.  Having a few sessions throughout the year will help you achieve results that will look wonderful and natural, giving you the fullness and volume you desire.  Be sure the plastic surgeon you will see is experienced with this procedure and is board certified. 

Andrew Miller, MD
Edison Facial Plastic Surgeon
4.8 out of 5 stars 222 reviews

Best Treatment for Lower Eyelid Hollows

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Hi Helio,

Restylane is best for your lower eye hollows.  It must be injected conservatively.  Make sure that you choose your injecting physician most carefully in this most delicate and unforgiving area.  In some patients, Sculptra is an excellent choice.

Good luck and be well.

Dr. P

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 39 reviews

Juvederm or Restylane for sunken eye fillers

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I would recommend a hyaluronic filler like Juvederm or Restylane either one of these would be a good choice. I would stay away from Radiesse in this area as I see a lot of unhappy patients from other surgeons who have had this injected into the tear trough and have had lumpiness and other complications. Fat transfer is another option however I would try one of the other fillers first and make sure you are happy with the aesthetic result. A good surgeon should be able to advise you of your options upon examination. Best regards!

Michael Elam, MD
Orange County Facial Plastic Surgeon
5.0 out of 5 stars 218 reviews

Short term vs Long Term solution

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Hyaluronic acid [Restylane or Juviderm] is probably your best short term [6-9 months] solution and is a great first time option. They are also reversible if you do not feel your results are what you expected.

Although Radiesse has been used successfully in this region, the risks are greater as it is a more permanent filler. A highly experienced surgeon/injector might be comfortable with this product, but I would research heavily.

Finally fat injections have been used quite successfully in this region as well. Again, as this is a permanent filler [your own tissue], experience counts, so do your homework.

And please do not be mislead. Though board certified plastic surgeons are highly qualified physicians, they do not have a monopoly on expertise and safety. Many of these techniques have been pioneered and perfected by hightly qualified and well-trained Oculoplastic surgeons, facial plastic surgeons, as well as dermatologist. So individually research your cosmetic surgeon, and make the decision that is right for you.

Best of luck.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 42 reviews

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.