If a sunken socket is the result of hereditary influences on the normal aging process, there is really little one can do to interfere with the expression of such gentically-encoded changes.

On the other hand, aggressive eyelid surgery is a preventable cause that continues to go unappreciated by many patients and even some surgeons. Most "classic" approaches to blepharoplasty call for the removal of substantial quantities of tissue.

Blepharoplasty has been described by some doctors as a "routine" or "simple" operation. This photo of a (unfortunately, not rare) patient referred after overdone fat, skin, and muscle resection by a Board-certified plastic surgeon demonstrates that such statements are dangerously naive.

To compound the problem, many patients have come to expect (and demand) aggressive upper eyelid surgery to raise the crease and create a high platform of exposed skin on which to apply cosmetics.
Others may be dissatisfied if even the slightest remnant of noticeable fat remains after treatment of their lower eyelid bags and request a "touch-up". Under such pressure, it is not surprising that many obliging surgeons are unwittingly contributing to an epidemic of post-blepharoplasty hollowness.

The most common missteps involve excessive removal or manipulation of the fat, muscle, skin and brow. • Fat Some bulging of normal upper or lower orbital/eyelid fat develops in many people with advancing age. Judicious thinning of clearly excess fat by an experienced practitioner with a tender touch is unlikely to cause noticeable hollowing. Using newer techniques, it is even possible to return bulging fat to the orbit by repairing a weak orbital septum. Aggressively excising fat or repositioning fat into the tear trough, on the other hand, will almost predictably cause immediate or late-appearing depletion of orbital volume. Adequate eyelid inflation from deep orbital fat is a vital sign of youth. Take it away and the face radiates an aura of "illness" and "age." Not uncommonly, the lower eyelid may undergo spontaneous "spotty" absorption of orbital fat accompanied by gradual thinning of the overlying skin, changes that serve to "unveil" any remaining islands of normal intact fat. Such eyelids demonstrate areas of apparent (but false) bulging. If this little remaining normal fat is misdiagnosed as excessive and removed during blepharoplasty . . .

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