Lower Blepharoplasty for Under-Eye Hollows

What Causes Under-Eye Hollows?

Under-eye hollowing can arise from several overlapping causes, and understanding which is dominant in each patient shapes the surgical approach.

Cause

Description

Surgical Solution

Tear trough ligament prominence

The ligament attaching the eyelid to the bone creates a visible groove

Release of the ligament and fat repositioning

Volume loss in the tear trough

Age-related fat atrophy beneath the orbital rim

Fat repositioning or fat grafting

Fat prolapse above creating a shadow

The bag above the hollow casts a shadow that deepens the apparent hollow

Fat repositioning addresses both simultaneously

Midface descent

The cheek falls away from the lower eyelid

May require midface lift in severe cases

Genetic predisposition

Some patients have naturally deep tear troughs from a young age

Fat repositioning or fat grafting

What is Lower Blepharoplasty for Under-Eye Hollows?

Lower blepharoplasty for under-eye hollows is a surgical procedure that addresses the tear trough depression through one of two primary methods: repositioning existing lower eyelid fat over the orbital rim into the hollow, or grafting fat harvested from elsewhere in the body into the tear trough area.

The choice between these two approaches depends on how much fat is available in the lower eyelid compartments and whether there is also a fat bag present that can be usefully redirected.

Approach Options

Approach

When It Is Used

Key Advantage

Fat repositioning

Fat bag present alongside the hollow

Addresses both bag and hollow simultaneously

Fat grafting

Hollow without significant fat prolapse

Adds volume where none is available to reposition

Combined approach

Partial repositioning with additional grafting

Used when repositioned fat alone is insufficient

The Surgical Tools Used

Arcus Marginalis Release

• Fine scissors or Colorado needle for releasing the arcus marginalis precisely
• Loupe magnification to work safely at the orbital rim
• Periosteal elevator to create the pocket for the repositioned fat

Fat Grafting Instruments (where used)

• Harvest cannulas for collecting fat from a donor site such as the abdomen or flank
• Centrifuge to process and purify the harvested fat before injection
• Fine injection cannulas for precise placement of fat in the tear trough

Fixation

• Fine absorbable sutures to secure repositioned fat to the periosteum
• Multiple fixation points to ensure the fat lies flat and smooth without bunching

Is Lower Blepharoplasty for Under-Eye Hollows Right for You?

Who Makes a Good Candidate?

• Men and women with a clearly visible tear trough depression causing a tired or sunken appearance
• Those who have had repeated filler treatments in the tear trough and want a more permanent solution
• Patients with both a fat bag and a hollow who are seeking a single procedure to address both
• Individuals with a genetic predisposition to tear trough hollowing who have had this concern since their twenties or thirties

What to Expect: Recovery Week by Week

Days 1 to 3: Immediate Recovery

• Swelling and bruising around the eyes and into the cheek area
• Cold compresses and head elevation are essential
• Lubricating eye drops as directed
• The treated area may feel firm and appear over-corrected initially, which is normal

Days 4 to 7: Early Progress

• Bruising begins to fade and swelling reduces
• The lower eyelid area begins to settle
• Sutures removed if a transcutaneous approach was used

Week 2: Returning to Normal

• Most patients return to work and social activities
• Makeup can be applied from around day ten
• The improvement in the tear trough area begins to become apparent

Weeks 3 to 4: Resuming Daily Life

• Light exercise can be reintroduced
• The repositioned or grafted fat begins to integrate
• The hollow appears progressively less visible

Months 2 to 6: Final Results

• Fat repositioning results are fully integrated and stable
• Fat grafting results settle as any reabsorption of grafted fat reaches equilibrium, typically at three to six months
• The smooth lid-cheek transition is clearly established

Clinical Outcomes: What to Expect Long Term

• Fat repositioning: Produces a permanent correction as the patient's own tissue integrates fully at the orbital rim
• Fat grafting: The surviving fat is permanent, though some reabsorption occurs in the first three to six months, which is why slight overcorrection is planned for
• Natural appearance: Using the patient's own tissue avoids the risk of migration, Tyndall effect, or the artificial appearance associated with repeated filler
• Satisfaction: High, particularly in patients who have struggled to achieve lasting improvement with injectable treatments

Potential Risks and Considerations

Common and Temporary

• Swelling and bruising around the eyes and upper cheek
• A feeling of firmness or slight overcorrection in the tear trough area that resolves as swelling settles
• Temporary dry eye or altered tear production

Less Common Risks

• Asymmetry between the two sides if fat volume is not equal
• Lumpiness or irregularity in the tear trough if fat grafting is not placed smoothly
• Reabsorption of a greater than expected proportion of grafted fat, requiring a second session

Rare Risks

• Vascular occlusion from fat grafting in the periorbital area, extremely rare but requiring immediate assessment
• Haematoma within the orbit

Financial Considerations

• Fat grafting involves harvesting from a donor site, adding to the procedure time and cost
• A second fat grafting session may be needed if reabsorption is significant
• Time off work, typically one to two weeks
• Follow-up appointments to monitor integration and symmetry

Lower blepharoplasty for under-eye hollows offers a permanent, natural solution to one of the most common and difficult-to-treat concerns in the lower eyelid area. When the correct technique is matched to the patient's anatomy, the result is a smooth, rested lid-cheek junction that looks entirely natural and lasts without maintenance.

Struggling with hollows beneath your eyes that filler cannot fully resolve? Book a consultation to explore your surgical options.