How to Correct Under Eye Bags and Hollow Lower Eyelids

The Liquid Eyelid Lift

Under eye bags and hollowing (sometimes called a tear trough deformity) are common problems. They are usually due to aging but can sometimes be seen in younger patients. Oculoplastic surgeons are frequently consulted for evaluation and treatment of under eye bags and hollowing.

Why do people get under eye bags and hollowing?

Lower eyelid bags are usually due a combination of the aging process and a patient’s unique anatomy. A youthful appearing lower eyelid typically has minimal bulging and a smooth transition to the cheek. As we age, several changes occur that cause lower eyelid bags and hollowing. First, the fat from the inside of the eye socket (orbital fat) begins to protrude forward. This is due to weakening of a structure called the orbital septum, which normally holds the orbital fat inside the eye socket. This process is responsible for “eyelid bag” formation. Second, there is loss of fat and volume in the cheek. This causes the cheek to deflate and descend slightly away from the lower eyelid. Hollow appearing lower eyelids can result (also called a “tear trough”). Finally, a ligament like structure called the arcus marginalis, also referred to as the orbital retaining ligament or orbito-malar ligament, separates the lower eyelid tissues from the cheek tissues. The arcus marginalis is strong, and does not change much while the other structures around the eye and cheek do. This enhances age related changes around the eye. All together, these changes cause the junction between the lower eyelid and cheek to be very abrupt, rather than a smooth and youthful transition. Some people are genetically predisposed to having lower eyelid bags or a prominent tear trough. These people will have bags or hollowing from a young age due to their natural anatomy.

How can filler correct lower eyelid bags and hollowing?

Fillers are an excellent option to correct mild to moderate lower eyelid hollowing and mask the appearance of lower eyelid bags. There are two main ways to accomplish this, and often a combination of both is used. The goal of treatment is to fill the hollow area under the eyes and smooth out the junction between the lower eyelid and cheek. Injecting filler into the hollowed tear trough can replace lost volume and smooth the lid-cheek junction. Due to thin eyelid skin and a complex anatomy, injecting under eye filler is considered an advanced technique, and an expert should perform treatment. It is extremely important to place the filler deep (just on top of the bone), distribute it smoothly, and avoid blood vessels in the area. The type of filler used is also very important. Fillers that are “thinner” and more moldable are ideal for this area. As of writing this, Belotero Balance and Restylane are the two most popular choices, although technically all fillers are used “off label” for tear trough injections. Restylane silk is gaining popularity for tear trough injections as well. Replacing volume in the cheek can also help correct the appearance of sunken or baggy lower eyelids. By replacing lost volume, the cheek will “re-inflate” and also smooth the junction between the lower eyelid and midface. As with tear trough injections, the filler placement and type used are extremely important and an expert injector should perform the treatment. Cheek filler should be placed directly on top of the bone and smoothly distributed in order to re-create what is known as an “ogee curve”. Blood vessels must be avoided. Fillers that are considered “thicker” and give more “lift” are preferred for cheek injections. The two most popular choices currently are Juvederm Voluma and Radiesse. Some patients have both hollowing of the lower eyelid and loss of cheek volume. For these patients, placing filler in both tear trough and cheek gives the best results.

What is the injection process like?

Lower eyelid and cheek filler injections are performed in the office. The typical treatment takes less than 15 minutes, although the entire appointment may take up to an hour. Numbing cream is applied to the injection site and given time to take effect. The area is cleaned and the injections are performed. The results are immediately seen. Cool gauze may be applied for a few minutes after treatment. Pain is usually minimal. There may be a mild amount of swelling or bruising that resolves in a few days. Strenuous activity should be avoided for a day or two.

Who is a candidate for lower eyelid filler?

Most people who have puffy or hollow lower lids are candidates. The best results are seen with patients who have problems but are not yet candidates for a lower lid blepharoplasty. Many patients who are ideal surgical candidates can get improvement from lower eyelid filler, although their results may be less than that of blepharoplasty. Even so, some patients who would benefit more from lower eyelid surgery choose to have filler instead due to their minimal downtime and relative safety.

Are there any people who should not get lower eyelid filler?

Anyone who has an allergic to any of the filler products should not be treated with them. Luckily, this is extremely rare. Also, some patients have more advanced lower eyelid changes that require surgical correction. These patients can still get improvement with fillers; however lower blepharoplasty possibly with fat repositioning or transfer may be a better option.

What are the possible risks of lower eyelid filler?

First, the level of patient satisfaction after lower eyelid and cheek filler is extremely high. While risks and complications can occur with any filler injection, they are very rare when performed by an expert injector. Most risks and complications are minor and can be corrected or reversed. These include lumpiness, puffiness, or a bluish color under the eyes. Tear trough filler can be dissolved if any of these issues develop. Serious risks are extremely rare, and include allergic reaction, infection, and occlusion of a blood vessel. An expert lower eyelid injector will be aware of these possible risks and take all possible measures to avoid them.

How can I find a surgeon or physician who is an expert at lower eyelid filler?

The lower eyelid, tear trough, and lid cheek junction is a complicated area to treat. Using filler to correct lower eyelid hollowing and bags is an advanced technique that requires extensive training and experience. An oculoplastic surgeon specializes in cosmetic and reconstructive surgery of the eyelids and surrounding area of the face and skull. Oculoplastic surgeons are eyelid surgery experts and commonly use filler to correct lower eyelid hollows and bags. Some plastic surgeons, dermatologists, or other injectors may have experience with treating these areas as well.

If you have any questions regarding lower eyelid filler, or any eyelid or facial cosmetic or reconstructive surgery, please feel free to contact Dr. Vidor at his Newport Beach office at any time.

Image set 1. – Pre and post injection – tear trough filler

Image set 1. – Pre and post injection – tear trough filler

Left – Before – Notice the appearance of puffy lower eyelids with hollowing in the tear trough. This is due to insufficient tear trough volume and accentuates the puffiness and lid-cheek junction.

Right – After – Belotero Balance injected into the tear trough. The lid cheek junction is smooth, no tear trough is visible, and the lower eyelid bags are masked.