Is My Undereye Hollowness A Bone Or Soft Tissue Problem?

Q: Dr. Eppley, I am writing to inquire about infraorbital hollowness and under-eye discoloration.I have moderate under-eye hollowness with dark circles that has been present since my mid-teens. I have a lean build with thin periorbital skin. I recently consulted with a surgeon about fat grafting to the infraorbital area (placed on the bone), and while he felt it could improve the hollowness and discoloration, I want to understand the degree to which my issue is skeletal versus soft tissue before committing to any procedure.

I have attached three photos:

∙ Front-facing (hair pulled back)

∙ Side profile

  • Close-up of the under-eye area showing the hollowness and discoloration

My questions:

1. Based on an initial assessment, does my infraorbital hollowness appear to be primarily a bony deficiency (infraorbital rim recession) that would be best addressed by custom infraorbital/ saddled infraorbital-malar implants, or could this be a soft tissue issue where fat grafting may provide a meaningful result?

2. If I proceed with fat grafting first as a less invasive step, would this complicate future custom IOM implant design or surgical placement in any way?

3. What type of scan do you require for a full assessment — would a CBCT from a dental clinic be sufficient, or do I need a full medical 3D CT scan? 

4) I am also considering MARPE for palatal expansion. I understand this should ideally be completed before any midface implant work, as it changes the maxillary anatomy.

Thank you for your time. I look forward to hearing from you.

A:Thank you for your inquiry and sending your pictures. What you have is a classic negative orbital vector which is always indicative of a significant skeletal issue, lack of adequate infraorbital – malar projection. This is an assessment that can clearly be seen in your pictures as your corneal projection lies well in front of the infraorbital rim. This can only be addressed by infraorbital – malar implant augmentation.

In answer to your other questions:

1) There certainly is little harm in doing fat injections although this will prove to be an ineffective maneuver. While complete resorption of the fat is the most likely outcome in a young thin patient there is always the risk of potentially creating fat collections in areas where you don’t want them that will be impossible to remove. But that issue aside it most certainly will not interfere with secondary implant placement

2) The purpose of the 3-D CT scan is to serve as the platform on which the implants are built. They will also only confirm that what is seen on the outside is evident on the bone. In short you don’t really it for a diagnosis. You would only get it because it would be needed for implant design.

3) Any form of palatal expansion is not going to interfere or change what needs to be done to the bone well above it.

Dr. Barry Eppley

Plastic Surgeon