Background: The shape of the eyes is determined by many anatomic factors including the amount of fat under the eyelid skin. One undesired aesthetic look of the eyes is a deep depression underneath it. Known as lower eyelid hollows, this is when the lower eyelid skin indents beneath the lashline and lower lid margin. This creates a shadowing effect which lends to a tired or aged appearance.
Lower eyelid hollows are a reflection of the underlying anatomy. It could be due to a natural lack (congenital) of or age-related atrophy of fat, a weak or deficient infraorbital bony rim, a bulging eye (rare) or some combination. The most common cause of lower eyelid hollows, however, is almost always skeletal-based due to the projection of the lower bony rim. Fat deficiency may also be present but is not often the sole source of the problem.
Treatment of lower eyelid hollows requires augmentation which can be done by two basic approaches. The non-surgical injection approach is the simplest using either synthetic (hyaluronic acid-based) fillers or fat injections. A trial with synthetuc fillers is a good first step to confirm whether any type of augmentation will be effective. Fat injections offer a potential long-term solution but there is the risk of lumps or irregularities and its retention is not completely assured. Implants of the infraorbital rim offer an assured permanent solution but it is a surgery that is very technique-sensitive.
Case Study: This 47 year-old male did not like the appearance of his lower eyes. He felt they were sunken in, particularly in the tear trough area. He was not interested in fat injections and had had a prior experience with an injectable filler that left him bruised and irregular over a year ago. He not only wanted the bony rim built up but also wanted some malar augmentation as well.
Under general anesthesia, a lower blepharoplasty (subciliary and lateral canthal extension) incisional approach was used. The bony rim was exposed and subperiosteal elevation done from the medial edge of the rim to the cheek area. The infraorbital nerves were identified in the course of the dissection. Using Medpor infraorbital-malar implants, they were applied to both sides making sure there was not a elevated step-off in the tear trough area. The implants were secured with self-tapping 1.5mm screws into two locations for each implant. The lower blepharoplasty incisions were closed by orbicularius muscle suspension and lateral canthopexies.
His postoperative course had the usual amount of swelling of the lower eyelids and cheeks that took three weeks to completely go away. Despite the swelling, the lower eyelids never experienced any sag or ectropion. His final result as seen at 8 weeks after surgery showed elimination of the lower eyelid tear trough/hollows and some cheek augmentation as well. On his right side, he did have some cheek and upper lip numbness which had completely resolved by three months after surgery.
Synthetic implants can be successfully used for improvement of lower eyelid hollows, which is often deepest in the medial tear trough area. Their placement is just an extension of a lower blepharoplasty procedure which is very similar to the dissection needed for a midface lift. There are specific implants designed for this purpose that produces good results when properly placed.
1) Tear troughs or lower eyelid hollows can be permanently improved by orbital rim implants.
2) Orbital rim implants are placed through a lower eyelid (blepharoplasty) incision.
3) Precise placement of the implants on the infraorbital rim and secured by small screws is necessary to prevent implant migration and edge palpability.
Dr. Barry Eppley