Hollow under-eyes and sunken upper eyelids: filling them with fat grafting

Why does the area around the eyes look hollow?

Aging of the lower eyelid results from changes in the skin, the orbital fat, the muscle around the eye (orbicularis oculi), the soft tissue of the midface, and the tear trough acting together ^[1]. The extent of these changes varies from person to person, and they are described as developing against a background of overall volume loss in the face ^[1].

When the upper eyelid looks hollow, this is called a sunken upper eyelid (sunken superior sulcus), and more people are said to be seeking correction for it ^[3]. The loss of volume around the eyes with age may not be fully addressed by traditional eyelid surgery alone, so fat grafting is also being discussed ^[5].

Eyelid surgery that preserves volume

A 2016 review explained that both upper and lower eyelid surgery have shifted toward preserving volume and sometimes adding it ^[2]. In upper eyelid surgery, excess skin is removed but fat is reduced cautiously so that the upper eyelid does not become sunken, and volume can be added with fat grafting or fillers when needed ^[2].

In lower eyelid surgery, bulging fat is addressed through an approach from either the skin side or the conjunctival side (the inside of the eyelid), and methods are used that release ligaments to smooth the junction between the under-eye area and the cheek while moving or grafting fat ^[2]. Another review also described a skin incision approach that moves fat to preserve volume, and presented the transconjunctival approach and autologous fat grafting as alternatives ^[1].

The author of a 2021 review of fat grafting around the eyes considered that traditional eyelid surgery does not always address age-related volume loss and may even harm the appearance of the eyes, and presented fat grafting as an important alternative ^[5]. It should be kept in mind that this review strongly reflects the author's own perspective.

Evidence on treating sunken upper eyelids

A 2016 review analyzed 12 publications covering 680 cases of sunken upper eyelid correction. All were case series, and there were no randomized controlled trials ^[3]. Five used surgery to restore volume, four used hyaluronic acid fillers, one used micro autologous fat grafting, and two combined fat grafting with correction of a drooping eyelid (ptosis) and upper eyelid surgery ^[3].

Overall, complications occurred in about 7.2% (49 of 680 cases), 4.3% required revision surgery, and no serious complications were observed ^[3]. These figures combine several treatment methods and are not specific to fat grafting. The authors stated that the clinical features need to be examined carefully and classified into types in order to make a specific treatment plan ^[3].

Hollows under the eyes and dark circles

The causes of darkness under the eyes are divided into pigmentation, structural, vascular, and mixed types ^[4]. A 2021 systematic review of 39 studies summarized that fillers and autologous fat grafting are effective for dark circles caused by volume loss, and eyelid surgery for cases with a lot of loose skin ^[4]. However, it stated that because high-quality evidence is lacking, these recommendations should be applied selectively ^[4].

There is also a study that used a gel-like form of fat, mechanically processed so that it retains abundant stromal vascular fraction cells and extracellular matrix, to correct under-eye bags and the tear trough ^[6]. It was used alone or together with transconjunctival removal of under-eye fat, and high satisfaction and relatively few complications were reported, but the research summary does not give specific figures ^[6].

Risks and points of caution

Complications of upper eyelid surgery are described as generally few when skin is removed conservatively and volume is preserved ^[2]. On the other hand, lower eyelid surgery can lead to serious complications such as an abnormal eyelid position (eyelid malposition), so it should be approached with great caution ^[2]. Absolute and relative contraindications to the skin incision approach were also discussed ^[1].

Because the skin around the eyes is thin, grafted fat that does not settle evenly can become visible on the surface, and this is generally named as a point to be careful about. Results and recovery vary from person to person.

What to check during your consultation

Even when the hollowness looks the same, the right method differs depending on whether the cause is volume loss, sagging skin, or a pigment or blood vessel problem. It is a good idea to first identify the cause with the specialist who examines you in person and then decide on the method.

• The main cause of the hollowness, and whether sagging or pigmentation is also involved
• Which of fat grafting, fat repositioning, or fillers is being considered, and why
• If lower eyelid surgery is done at the same time, the risk of an abnormal eyelid position
• The plan for correction if the volume decreases or becomes uneven