Under-Eye Hollowing & Tear Trough Deformity

To understand why under-eye hollowing occurs—and why certain treatments work—you need to understand the anatomy:

The Tear Trough Ligament This is a fibrous band that attaches the skin directly to the orbital rim (bone). It's the reason the tear trough groove exists—the skin is literally tethered down at this point.

Orbital Fat Pads Three fat compartments sit above the tear trough ligament (in the lower eyelid). With age, these pads shrink and descend. When they herniate forward, they create 'bags.' When they simply shrink, they create hollowing.

SOOF (Sub-Orbicularis Oculi Fat) This deeper fat pad sits below the tear trough ligament, in the cheek area. When SOOF volume is lost, the tear trough deepens because there's less support from below.

The Orbital Rim The bone itself resorbs with age, particularly the maxilla (cheekbone) and orbital rim. This further reduces structural support, making hollows more prominent.

Why This Matters for Treatment Treatments work by either: (1) thickening the skin to hide underlying structures, (2) replacing lost fat pad volume, or (3) providing structural support where bone has resorbed. Your specific anatomy determines which approach—or combination—is right for you.

Under-eye hollowing is clinically graded using the Barton Tear Trough Scale:

Grade 1 — Mild Subtle groove visible only in certain lighting. Minimal shadow. The transition from eyelid to cheek is slightly less smooth than ideal. Treatment approach: Regenerative (Polynucleotides, PRP, Skin Boosters)

Grade 2 — Moderate Clear groove visible in most lighting. Noticeable shadow creating a 'tired' appearance. The tear trough is obvious but skin quality remains reasonable. Treatment approach: Regenerative or mild volumising (EZ Gel, light HA filler)

Grade 3 — Significant Deep groove with prominent shadowing. Clear demarcation between lower eyelid and cheek. May have early signs of fat pad prominence (mild bags). Treatment approach: Volumising (EZ Gel or HA filler), possibly combined with regenerative treatments

Grade 4 — Severe Severe hollowing often combined with significant fat pad herniation (bags) and/or skin laxity. The combination of hollows AND bags creates a complex presentation. Treatment approach: Often requires surgical consultation (blepharoplasty). Injectables alone may worsen appearance in some cases.

During your consultation, we'll assess your specific grade and recommend the most appropriate treatment pathway.

If you've tried every eye cream, serum, and home remedy but your under-eye hollowing refuses to improve, here's why:

Hollowing Is a Structural Problem

Under-eye hollowing is caused by volume loss—shrinking fat pads, bone resorption, and loss of structural support. No topical product can replace lost volume. It's like trying to fill a pothole by painting over it.

What Eye Creams CAN Do

• Temporarily plump the skin surface (hyaluronic acid)
• Reduce puffiness from fluid retention (caffeine)
• Improve skin texture over time (retinoids)
• Protect against further collagen loss (antioxidants, SPF)

What Eye Creams CANNOT Do

• Replace lost fat pad volume
• Lift descended tissue
• Fill the tear trough groove
• Reverse bone resorption

The Reality

Meaningful improvement in under-eye hollowing requires treatments that address the structural cause: either thickening the skin significantly (Polynucleotides, Sylfirm X), or physically replacing lost volume (fillers, EZ Gel). Skincare has a role—particularly retinoids for maintaining skin thickness and SPF for preventing further damage—but it's supportive, not corrective.

This isn't marketing—it's anatomy. Understanding this helps you invest your time and money in treatments that can actually make a difference.

Important: This guide is for educational purposes. Treatment recommendations are made only after face-to-face assessment by a GMC-registered doctor, taking into account your anatomy, medical history, and goals.

• Polynucleotides + PRP — Can thicken skin and provide subtle improvement, but won't fill deep structural hollows
• EZ Gel Biofiller — Technically a 'filler' but 100% your own material—no synthetic HA
• Sylfirm X — Builds collagen, thickens dermis—good for vascular shadows but won't replace volume

Our philosophy: We recommend what works for YOUR anatomy, not what's most popular or profitable. Many patients benefit from a combination approach.

If you've had under-eye filler and noticed a blue, grey, or purple tint that wasn't there before—you're likely experiencing the Tyndall Effect. This is one of the most common complications of tear trough filler, and understanding it can help you avoid it.

What Is the Tyndall Effect?

The Tyndall Effect occurs when hyaluronic acid (HA) filler is placed too superficially in thin skin. The filler particles scatter light, creating a bluish discolouration—similar to why the sky appears blue. In the under-eye area, where skin is extremely thin (just 0.5mm), this risk is heightened.

Why Does It Happen?

• Superficial placement — Filler placed too close to the skin surface rather than deep on the bone
• Wrong filler type — Using a dense, volumising filler instead of one designed for the delicate tear trough
• Overfilling — Too much product pushing upward toward the skin surface
• Thin skin — Patients with naturally thin periorbital skin are at higher risk

Can the Tyndall Effect Be Fixed?

Yes. The filler can be dissolved using hyaluronidase, an enzyme that breaks down HA. This is a straightforward in-clinic procedure. Once dissolved, the blue tint resolves and the area can be re-treated with proper technique if desired.

How We Avoid It

At PRP London Clinic, we prevent the Tyndall Effect through:

• Deep placement — Filler is placed on the bone (supraperiosteal), not superficially
• Appropriate products — We use fillers specifically engineered for the tear trough (Teosyal Redensity II, Juvederm Volbella)
• Cannula technique — Allows precise, deep placement with less trauma
• Conservative volumes — We under-fill rather than over-fill; you can always add more
• Alternative options — For very thin skin, we may recommend EZ Gel Biofiller or Polynucleotides which carry zero Tyndall risk

If you're experiencing the Tyndall Effect from treatment elsewhere, we can assess and advise on correction options.

Not everyone is a candidate for under-eye filler—and understanding why is crucial. Two conditions in particular can be made worse by injectable treatments: malar edema and festoons.

What Is Malar Edema?

Malar edema is chronic fluid accumulation in the cheek/under-eye area, causing persistent puffiness that's worse in the morning or after salty foods. It's different from fat pad herniation (bags)—it's fluid, not tissue.

Why filler makes it worse: Adding volume to an area with poor lymphatic drainage traps more fluid. Many patients have had filler elsewhere that triggered or worsened malar edema—and then seek more filler to 'fix' the problem, creating a vicious cycle.

What Are Festoons?

Festoons are hammock-like folds of lax skin and muscle that hang below the orbital rim, over the cheekbone. They're caused by weakened orbicularis oculi muscle and sun damage, not volume loss.

Why filler doesn't help: Festoons are a tissue laxity problem, not a volume problem. Filler cannot tighten loose skin—it can actually make festoons more prominent by pushing the lax tissue outward.

How We Screen for These Conditions

During your consultation, we specifically assess for:

• Fluid fluctuation (worse in morning vs evening)
• Response to gentle pressure (fluid displacement vs solid tissue)
• Skin laxity and muscle tone
• History of previous filler treatments
• History of allergies or sinus issues (associated with malar edema)

What We Recommend Instead

If you have malar edema or festoons, we'll be honest: filler isn't the answer. Depending on severity, we may recommend:

• Lymphatic drainage techniques and lifestyle modifications for mild malar edema
• RF treatments (Sylfirm X) for mild skin laxity
• Surgical consultation for significant festoons—we provide referrals to trusted oculoplastic surgeons
• Dissolving existing filler if previous treatments are contributing to the problem

Had a bad experience with filler elsewhere? We see many patients seeking correction. Honest assessment is the first step—book a consultation and we'll tell you what's actually going on.

The under-eye area is one of the most delicate and complex zones to treat. Here's why patients trust us:

Diagnostic-First Philosophy We don't sell treatments—we diagnose patients. Every consultation starts with anatomical assessment using the Tear Trough Grading Scale. We identify what's actually causing your concern before recommending any treatment.

Dual-Modality Expertise Our practitioners are trained in BOTH synthetic fillers AND regenerative medicine. This means we can offer the full spectrum of options—from HA fillers to EZ Gel to Polynucleotides—and recommend what's actually right for you.

GMC-Registered Medical Team All treatments are performed by GMC-registered doctors with specialist training in periorbital rejuvenation. The under-eye area is too complex for non-medical practitioners.

Safety-Focused Techniques We use micro-cannula techniques wherever appropriate to minimise bruising and protect the delicate vascular anatomy around the eye. Periorbital mapping ensures safe, natural-looking results.

Honest Referrals When surgery is the better option—for Grade 4 hollowing with significant bags or skin laxity—we'll tell you honestly and provide a referral to trusted oculoplastic surgeons. We won't recommend injectables when they're not appropriate.

Premium Products Only We use FDA-approved HA fillers (Teosyal Redensity II, Juvederm Volbella) and Class IIB medical devices (T-Lab PRF system). No compromises on quality.