Concerns / Mid Face / Under-Eye Hollows
Hollow under eyes: what causes
them and what does not
A hollow under the eye is a groove running from the inner corner of the eye diagonally outward toward the cheek. Clinically it is called the tear trough.
The reason it looks dark is not usually what people assume, and the reason it forms is not usually one thing. Both matter, because they determine whether anything can be done and what kind of thing that would be.
Dr Ibrahim Hawli
MBBS · Registered Medical Practitioner
In short
Hollows, bags and dark circles are three separate problems that look similar and need different answers. A hollow is a depression that casts a shadow. A bag is orbital fat pushing forward. A dark circle can be shadow, pigment, or visible blood vessels. Most under-eye darkness is shadow rather than pigment, which is why skin products rarely change it. The groove itself is anchored to bone by a genuine ligament, which is why it holds its line.
01 / The Distinction
Hollows, bags and dark circles
are three different things
This distinction is the whole subject, and getting it wrong is the most common reason people spend money on something that could never have worked.
Finding one
A hollow
Reads as “in”
A depression sitting below the orbital rim. It produces shadowing because light does not reach into the groove. The area looks sunken.
Finding two
A bag
Reads as “out”
A protrusion. Orbital fat herniates forward through a weakening septum, the wall that holds fat behind the eye. Worse in the morning, after salty food, or when tired.
Finding three
A dark circle
A discolouration
At least four possible causes: shadowing from a hollow, pigmentation from sun or genetics, blood vessels visible through thin skin, or chronic inflammation.
It is entirely possible to have all three at once, and many people do. They are not stages of the same process. They are separate findings, and each one responds to something different.
02 / The Confusion
Why the darkness is usually
shadow, not pigment
When the fat compartments beneath the eye are full and well positioned, the transition from lower eyelid to cheek is smooth and gradual. When volume reduces, that transition becomes abrupt and a groove forms.
Light then catches the depression differently from the fuller skin around it, and a shadow is cast. That shadow is what most people are describing when they say their under-eyes look dark. It exists independently of melanin. The skin in the groove may be exactly the same colour as the skin beside it.
A shadow produced by a contour cannot be lightened by a product applied to the surface. Equally, genuine pigmentation in the skin will not be improved by changing the contour. Establishing which one is present is the difference between an approach that can work and one that cannot.
03 / Causes
What actually creates
a hollow under eye
Several changes contribute, and they compound. Most people have more than one, and the mix determines what is realistic.
01
Volume reduction
As the fat filling the area between lower lid and cheekbone reduces, the smooth transition is lost and the groove becomes visible.
02
Ligament behaviour
The central portion of the orbicularis retaining ligament is the weakest, and distends more with age, allowing greater exposure of the fat pad behind it.
03
Midface descent
As the midface descends, the orbicularis muscle stays tethered over the tear trough by the retaining ligament. Tissue over the groove thins and the groove becomes more prominent.
04
Position of the eye
With age the globe descends within the orbit and infraorbital fat is displaced forward. That bulge casts a shadow downward, making the hollow look deeper than it is.
05
Skin thinning
The skin here is among the thinnest on the body. As the dermis loses collagen, the contour beneath shows through and vessels become more visible.
06
Inherited anatomy
Some people have a visible tear trough in their twenties with no volume loss at all. A shallow bony rim produces the same appearance as age-related change.
04 / Anatomy
The tear trough is anchored
by a real ligament
This is worth understanding because it explains why the groove holds such a precise line.
The tear trough is not simply a fold in loose skin. It is anchored by a true ligament running from the bone of the orbital rim to the skin above it. Ligaments of that type hold their position, which is why the groove follows the same diagonal path in almost everyone and does not drift or soften the way a crease would.
It also explains why the hollow can appear deeper without anything having been lost. If the tissue above the ligament changes position, or the tissue below it thins, the anchored line becomes more visible without the ligament itself changing at all.
05 / What Responds
How to fix under eye hollows:
what works on what
Being specific here is more useful than being encouraging. Each finding responds to something different, and some respond to nothing that is offered in a cosmetic setting.
Shadow from a genuine depression
Responds to a change in contour. If the darkness is shadow, changing the contour changes the shadow.
Pigmentation in the skin
Does not respond to a change in contour. It is not a volume problem.
Blood vessels visible through thin skin
Does not respond to a change in contour either.
Orbital fat herniation
Does not respond to creams, massage or lymphatic drainage. A bag is structural and progressive.
Significant fat prolapse, excess skin, lid laxity
May need a surgical opinion rather than a cosmetic one. Surgery is not performed at this practice, and referral is the appropriate recommendation.
Skin quality, thickness and pigmentation
Responds to skin-directed care over months rather than weeks, with daily sun protection the single most useful measure.
The periorbital skin is among the least reliably protected areas of the face, because sunscreen application usually stops short of the orbital rim.
06 / Try This Now
A self-test you can
do right now
This will not replace an examination, but it will tell you which category you are probably in, and it takes seconds.
The method
Sit in front of a mirror in even light. Place a fingertip on the skin just below the hollow and pull gently downward, stretching the skin without pressing into the eye.
Hollow reduces
The appearance is largely volume and contour related.
Hollow unchanged
Something other than a simple contour deficit is producing it, most often pigmentation or vessel visibility.
Puffy ridge above
Fat herniation is part of the picture, particularly if worse in the morning. That changes the assessment considerably.
Bring what you observed to your consultation. It is genuinely useful information and it is the sort of thing patients are rarely asked about.
07 / A Specific Risk
When a hollow and a bag
occur together
This combination is more common than most people realise, and it carries a specific risk worth knowing about before you book anywhere.
Fat herniation creates a puffy ridge above the orbital rim. Volume loss creates a hollow groove below it. Both can be present in the same eye at the same time.
The risk is this. Addressing the hollow without accounting for the fat above it can make the puffiness look more pronounced, because the contrast between the two is reduced from below rather than from above. The result can be an eye that looks fuller overall and puffier at the same time.
A practitioner assessing this region should tell you whether fat herniation is present, and if it is, should explain how that changes what is appropriate. If it is not raised at all during an assessment, the assessment is incomplete.
08 / Medical First
When under eye hollows
are a medical question
Some causes of under-eye change are not cosmetic, and they should be assessed before anything else is considered.
See a general practitioner first if you have
- Sudden change in the appearance of one or both eyes
- Swelling that varies day to day, or is worse on waking and does not settle
- Associated nasal congestion, itching or a seasonal pattern
- Any change in vision, eye discomfort, or pressure behind the eye
- Known thyroid disease, or symptoms suggesting it
- Unexplained fatigue alongside the change
Rapid or asymmetric change in this region in particular deserves a medical opinion rather than a cosmetic one. Any practitioner who does not take a medical history before examining this area has not completed the assessment.
09 / Assessment
What an under eye hollows
treatment assessment covers
Photographs may be taken as a clinical record in standard front and side views, and are not used for advertising.
- Depth and extent of the groove, and whether it is a true depression or an apparent one
- Whether the darkness is shadow, pigment, vessel visibility, or a combination, assessed under direct light
- Presence and degree of orbital fat prolapse
- Skin quality, thickness and laxity, and whether vessels are visible through it
- Lower lid tone and position
- Cheek volume and contour, since midface support directly influences how the groove reads
- Whether the midface has descended, and whether that is contributing
- Symmetry between sides, which is very common to differ and frequently unnoticed
- Medical history, including thyroid disease, allergy and any recent change
- Whether anything is clinically appropriate, including the option of nothing, and whether a surgical or medical referral is the better course
10 / Before You Decide
What to know before
your consultation
Every option carries potential risks as well as potential benefits, and no cosmetic medical procedure is risk free. This region carries particular considerations: the skin is among the thinnest on the face, the area is rich in blood vessels, and it sits immediately beneath the eye.
Bring a list of your current medications, and a photograph from several years ago if you have one. For this region an older photograph is particularly useful, because it distinguishes inherited anatomy from acquired change.
Assessed at consultation
Factors that may make an approach inadvisable
- Pregnancy or breastfeeding
- Active infection or inflammation of the eyelid or surrounding skin
- Significant orbital fat prolapse, where a surgical opinion is the appropriate course
- Marked skin excess or lower lid laxity
- Pre-existing dry eye disease
- Certain autoimmune, bleeding or connective tissue conditions
- Certain medications, including blood thinning medication
- Undiagnosed swelling or asymmetry, which should be medically assessed first
- Expectation that pigmentation will improve through a change in contour
- Unrealistic expectations about achievable change
Individual results vary. Not all people are suitable candidates. In some cases the appropriate recommendation is that nothing be undertaken, or that a different practitioner is the right person to see.
11 / What Happens
What happens at your consultation in Glenroy
Appointments run 30 to 45 minutes. A consultation fee applies and is confirmed when you book. No referral is required to attend.
01
Discussion
What you have noticed, when it changed, whether it varies through the day, allergy and thyroid history, medical history, current medications and previous cosmetic work.
02
Assessment
The region is examined in front and side views under direct light, with the skin stretch test performed, assessment of fat prolapse, skin thickness, lid tone and cheek support.
03
Information
Which of the three findings you have and in what combination, what is clinically appropriate, expected timeline, risks, alternatives, and whether referral is the better course.
04
Decision
You are not asked to decide on the day. Time to consider information is part of informed consent.
12 / Service Area
Assessment for patients across Melbourne's northern suburbs
The clinic is on Glenroy Road, close to Glenroy Station and the Pascoe Vale Road corridor. Patients attend from Glenroy, Hadfield, Fawkner, Oak Park, Gowanbrae, Pascoe Vale, Coburg North, Broadmeadows, Campbellfield and Craigieburn.
13 / Common Questions
Questions patients
ask
If your question is not answered here, ask it at your consultation. There is time set aside for exactly that.
Reduction of the fat compartments between the lower lid and cheekbone, weakening of the retaining ligament, descent of the midface, forward displacement of fat within the socket, and thinning of very thin skin. Some people have a visible groove from their twenties because of inherited bony anatomy rather than any loss.
No. A hollow is a depression that casts a shadow. A dark circle is a discolouration, which can come from that shadow but can equally come from pigmentation, from blood vessels visible through thin skin, or from chronic inflammation. They need different answers.
Stretch the skin below the hollow gently downward with a fingertip. If the darkness reduces noticeably, it is largely shadow. If it stays the same, pigment or vessel visibility is more likely. Direct examination confirms it.
No. A shadow cast by a contour cannot be lightened from the surface. Skin-directed care can improve skin quality, thickness and genuine pigmentation over months, and daily sun protection to the orbital rim is worthwhile regardless. It will not change a depression.
No, and this is important. A bag is orbital fat pushing forward through a weakened septum. It is structural and progressive, and it does not respond to creams, massage or lymphatic drainage. Where a hollow and a bag coexist, addressing the hollow alone can make the puffiness look more pronounced.
Asymmetry here is very common. Bony rim contour differs between sides, fat compartments are rarely identical, and habitual sleeping position contributes. It is often unnoticed until it is pointed out.
If the change was sudden, if swelling varies a lot day to day, if there is any change in vision or eye discomfort, if you have thyroid disease or symptoms of it, or if there is an allergic pattern with nasal symptoms. Those need a medical assessment first.
A consultation fee applies and is confirmed when you book.
Related concerns
The midface is assessed as a whole
Written and clinically reviewed by
Dr Ibrahim Hawli, MBBS
Level 1 Certification, American Academy of Aesthetic Medicine. Advanced training in non-surgical nasal work with Aesthetic Intelligence.
Last reviewed: [insert month year] · Next review due: [insert month year]
Your first step is
an assessment.
This page provides general information about cosmetic medical consultations and does not constitute medical advice. Any cosmetic medical procedure carries risks. Individual outcomes vary and not all people are suitable candidates. Surgery is not performed at this practice. Any decision follows an individual consultation and assessment with a registered medical practitioner.