Surgery Instead of Botox Bleph?

Is there a more-permanent solution to the "botoxing" of the under-eye's "orbicularis muscle"? My PS has said that I am not in need of a lower blepharoplasty at all; but rather that it is this muscle, as enlarged as it is in me (and it is, apparently, very thick in me), that is what creates the hollow look I carry under my eyes.

Is there a surgical solution to weakening this muscle? Botox only lasts me three months!

Doctor Answers 9

Redraping of the orbicularis muscle

Botox works well in the outer corner of the orbicularis muscle. The hollow look will likely need redraping of the orbicularis muscle and blending of the eye lif cheek junction.

More specific advice will require pictures. Your board certified plastic surgeon will be able to help. Hope that helps!

Orange County Plastic Surgeon
5.0 out of 5 stars 19 reviews

It would help to post a picture

I have many patients that I treat for "crows feet" or wrinkles of the lateral eye area. These patients are usually too young to need a blepharoplasty. At the point where there continues to be excess skin wrinkling despite Botox, then a blepharoplasty with skin removal needs to be considered. It is interesting that you state that you have a "hollow" look under your eyes. Although obicularis hypertrophy or enlargement is possible, I suspect there are other issues at hand such as midfacial descent or loss of lower lid/cheek fat. Tough to tell without a picture.

Christopher L. Hess, MD
Fairfax Plastic Surgeon
4.4 out of 5 stars 34 reviews

Limited orbicularis reduction can be successful

We have had good results in a very limited reduction of the orbicularis oculi muscle through a limited incision. Use of the Carbon Dioxide laser or radiofrequency scalpel is useful for better results. The may be combined with filers or fat under the lower parts of the muscle to even the contour. The result takes a long time to see because slight swelling may persist until wound healing is complete.

Richard D. Gentile, MD
Youngstown Facial Plastic Surgeon
4.4 out of 5 stars 36 reviews

A hollow look under the eyes can be corrected with surgery

To mbalta,

Hi! Of course I don't know how old you are or exactly what you look like. But the goal is to have a smooth surface between the cheek and the under eyes, so you cannot tell where one ends and the other one begins. From the lashes down should be a smooth, full curve (like in a young attractive face). In general, this can be achieved with sophisticated surgery.

The problem is that this is very tricky surgery. Without a real expert, complications are not rare. Consult with an oculoplastic surgeon. If Botox is helping you, even for just 3 months, you might want to stick with it.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
4.8 out of 5 stars 9 reviews

Possible surgical solutions

Without examining you in person, it is hard to make specific recommendations. You mentioned the enlarged orbicularis oculi muscle causing a hollow look under the lower eyelid. That is not the usual place to inject Botox and while the enlarged or hypertrophic muscle can produce a baggy look, you should have a detailed analysis of the hollowness to see if it is a true hollowness (due to loss of fat or soft tissue or hypoplasia of infraorbital rim or malar complex) or a relative hollowness due to the excessive muscle or fat. Hypertrophic muscle can be trimmed surgically to lessen the bulkiness.

If the Botox is mainly affecting the crow's feet result of orbicularis oculi hyperactivity, surgical incison, weakening, or partial excision of this portion of the muscle can be done. Be very specific about the anatomical contributions to your appearance.

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 11 reviews

Botox does not work well on some people's eyelid muscle

Botox does not work well in some people-about 3-5% of people with thicker muscles.

If you have thick bulging eyelid muscles you may need a special lower blepharoplasty called a skin muscle flap blepharoplasty during which some of the excess muscle can be removed.

I do not use any injections beneath the lower eyelid-fat or fillers. Injections beneath the thin lower eyelid skin often leave lumps and can cause permanent discoloration of the skin.

I use a technique called the arcus release and fat grafting to plump hollows and dark circles under the eyes.

See before and after pictures of the arcus release and fat grafting below (april photo #11)

Best to stick with Botox

In your situation, it would be best to stick with Botox. If you include some pictures, we may be able to give you more specific advice. However, surgically removing part of the orbicularis muscle or some other procedure would not be warranted when Botox can do the same thing less invasively. Good luck.

David Shafer, MD
New York Plastic Surgeon
4.9 out of 5 stars 77 reviews


Strong orbicularis is very unusual. If Botox injections works for you it will better than surgery.If you have other problems like herniated fatty pocket then surgery will help. During surgery your surgeon will remove some fatty tissue and also remove some of the muscle.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 124 reviews

There are many options

Many options exist for enhancing a hollow look in the eye area. These include blepharoplasty, botox, fillers, and even some topical products. Some fillers, like Sculptra, can last several years. However, a treatment that lasts a long time is great if you like the results.... but if you are unhappy with the results you may be stuck.

If your PS thinks botox can help, it is cheap, temporary, and worth a try.

Jeffrey Ellis, MD
Long Island Dermatologic Surgeon
5.0 out of 5 stars 1 review

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.