Hollowness below the eyelid (that is, beginning just beneath the rim of the bony socket and below the red dots) is most typically due to upper cheek fat loss with secondary sagging of the cheek's upper muscles ("midface descent") and/or inadequate development and forward projection of the bone of the upper cheek ("bony hypoplasia").

Where the Eyelid Ends and the Cheek Begins
1. Woman faintly smiling to accentuate the demarcation between the eyelid and the upper cheek. When smiling, the eyelid closing muscle contracts and draws the skin just above the orbital bone inward so that the transition is easier to see.	2. The area above the red dots is considered 'eyelid'. Deep orbital volume influences the fullness in only this area. 3. The area at and below the red dots is considered 'cheek'. Orbital volume does not influence the fullness in this area. Most "dark circles" below the eyes are thus not helped by pearl fat grafting.
Exaggerated under-eye hollowness in the area between the rim of orbital bone and the side of the nose is sometimes referred to as a "tear trough." Technically, the tear trough is the "nasojugal fold," a normal anatomic indentation. If it becomes noticeably deepened, it is often called a "tear trough depression."
	When upper cheek hollowness is more widespread, this state is described as a "suborbital volume deficiency." As with a tear trough depression, this is a cheek phenomenon located below the eyelid.
In contrast to the other types of hollowness discussed in this section of our web site, tear trough and suborbital volume deficiencies are not caused by a shortage of orbital fat and so are not helped by orbital fat grafting. This is a common point of confusion. The easiest way to distinguish between upper cheek and true orbital hollowness is to look in a mirror and push your finger against the depression. If you encounter bone, the hollowness is on your upper cheek. If you feel the eyeball, the hollowness is orbital. Of course, if the hollowness developed only after lower blepharoplasty, it is likely orbital in origin. Examples of patients with true lower orbital hollowness If an upper cheek depression becomes overly deep with time, augmentation may be partially accomplished using methods summarized below:

While relatively safe commercial filler substances may be injected into the tear trough, most disappear within a matter of months. Longer lasting fillers introduce the risk of persistant lumpiness if misplaced or overdone.

Injection of liposuctioned fat aspirate (autologous fat transplantation) works similar to commercial fillers. The tissues in the area of the tear trough are extremely thin and so any flaws in technique will be readily apparent. Fat injections placed too superficially may quickly disappear while too much injected fat injected may result in visible lumpiness that is not easy to remove.

While more invasive, repositioning of bulging lower orbital fat into an area of mild upper cheek hollowness offers the theoretical advantage of employing intact fat with an attached blood supply. Improvement, however, is typically subtle at best. In more than mild cases, any filling effect may be too small to be noticeable. Unintended hollowing of the lower lid is not rare. While previously popular, we no longer use this technique.

Placement of synthetic orbital implants (tear trough and suborbital cheek implants) may offer the best remedy, especially if insufficient cheek bone and not just fat loss is the primary factor causing hollowness along the upper cheek. Synthetic implants may sometimes show during smiling or squinting.

For marked cheek hollowing due to advanced midface descent, mulitple cheek implants accompanied by midface lift may offer the only effective approach.