Under-Eye Hollows: Causes, What Skincare Can't Fix, and What Fillers and Surgery Show
Start with our pillar guide: Dermal Fillers for Ozempic Face: What the Evidence Shows (and Doesn't), or browse all Aesthetic Treatments articles.
Under-eye hollows are mostly an anatomy-and-aging problem: volume loss in the deep fat pads under the eye, plus thinner, less elastic skin and the ligament that forms the tear trough. Skincare can't replace that volume. Hyaluronic acid filler is the most-studied fix, lasting 8 to 12 months in a systematic review, with rare but serious risks. Evidence: Limited.
This guide covers cosmetic hollowing only. It separates what studies measured from what is clinic convention, and it explains what can go wrong with filler. For PRP and PRF in detail, see our PRP vs PRF under eyes comparison. For whole-face filler after weight loss, see filler options after GLP-1 weight loss.
Key takeaways
- A 2025 review attributes under-eye hollowness to deep fat-pad volume loss, including the sub-orbicularis oculi fat (SOOF) and malar fat, plus skin thinning and lost elasticity (Hong et al., 2025).
- A 2022 systematic review of 23 articles on tear-trough filler found high patient satisfaction and an effect lasting 8 to 12 months (Trinh et al., 2022).
- The topical trials we found measured wrinkles, not volume. Two 4-week split-face trials (n=42 and n=35) improved periorbital roughness, not hollows (Kaczvinsky et al., 2009).
- A systematic review of 52 published cases of delayed tear-trough filler complications found an average onset of 16.8 months, with swelling the most common reaction (Trinh et al., 2022).
- An 18-cadaver study described infraorbital danger zones and a possible route for retrograde embolism, a clot of filler traveling backward in an artery (Hufschmidt et al., 2019).
What are under-eye hollows?
Under-eye hollows are a sunken groove or depression below the lower eyelid, often called the tear trough or infraorbital hollow. A 2025 review describes them as common aging-related changes that give a "sunken and tired appearance" (Hong et al., 2025).
"Tear trough deformity" is the clinical term. A 2012 review notes that it can appear with lower eyelid bags or on its own (Stutman & Codner, 2012). Hollows can also read as dark circles. A review classifying dark circles lists "shadowing" as one recognized type, alongside vascular, pigment-related and constitutional types (Pissaridou et al., 2020).
This page covers cosmetic hollowing. If your eyes look suddenly sunken or you feel unwell, see a doctor.
Evidence: Limited (reviews).
What causes under-eye hollows and sunken eyes?
Reviews point to 3 structural causes: shrinking deep fat pads, thinning and less elastic skin, and the ligament-and-muscle structure of the tear trough itself. A possible bone component is expert opinion only.
- Fat-pad volume loss. Hong and colleagues attribute hollowness to "progressive loss of volume in the deep fat pads," naming SOOF (a fat layer under the eye's ring muscle) and malar fat (cheek fat) (Hong et al., 2025).
- Skin changes. The same review lists skin thinning and decreased elasticity.
- Trough anatomy. Stutman and Codner describe the tear trough as made of ligamentous structures and the orbicularis, the ring-shaped muscle around the eye (Stutman & Codner, 2012).
- Bone. A surgeon's paper states that midfacial aging "also has a skeletal component" but gives this as background, not a finding (Bitik, 2023).
Hollows aren't only an aging issue. One fat-injection series treated 102 people with tear trough deformity whose average age was 25.9 (Su et al., 2022). The abstract doesn't say what caused the hollows in these younger patients, and we found no study in our review that tests lifestyle causes.
Evidence: Limited (reviews and expert opinion).
Is it a hollow, an eye bag or a dark circle?
They can overlap, and the cause decides the fix. Studies match volume loss to filler or fat, bulging fat with excess skin to surgery, and pigment to topicals or peels. Puffiness from fluid is a different problem than a hollow; for that angle, see lymphatic drainage massage face.
Jiang and colleagues sorted 78 tear-trough patients into 3 classes (Jiang et al., 2016). A 39-study systematic review of dark circles reached similar matches but warned of a "scarcity of high-quality evidence" (Michelle et al., 2021). In a 34-patient private-practice study in the UK and India, people with tear troughs or hollow eyes responded well to fillers, while those with loose, wrinkled skin responded to CO2 laser (Kounidas et al., 2022).
| What you see | What studies call it | Option studies matched it to |
|---|---|---|
| Groove or hollow, no bulging fat or extra skin | Class I tear trough (Jiang 2016) | HA filler or fat injection |
| Hollow plus mild to moderate bulging fat | Class II (Jiang 2016) | HA filler or fat injection |
| Severe bulging fat plus excess lower-lid skin | Class III (Jiang 2016) | Fat repositioning, sometimes with fat grafting |
| Dark circle from volume loss or shadow | Structural / shadowing (Michelle 2021; Pissaridou 2020) | Fillers or fat grafting |
| Loose, crepey skin | Skin laxity (Michelle 2021; Kounidas 2022) | Blepharoplasty or CO2 laser |
| Brown pigment | Pigment-based (Michelle 2021) | Topical creams, chemical peels, lasers |
Kounidas found no statistically significant difference between its filler, laser and combined groups, and 82% of patients rated their improvement as excellent. That figure is self-rated, and the abstract doesn't report follow-up length or funding.
Evidence: Limited.
Can skincare fix under-eye hollows?
No. Skincare doesn't add volume, and the topical trials we found measured wrinkles and roughness, not hollows.
The best-designed topical data come from 2 double-blind, randomized, split-face trials by Kaczvinsky and colleagues in women aged 30 to 70 with moderate to distinct periorbital wrinkles (n=42 and n=35) (Kaczvinsky et al., 2009). Participants applied 0.5 g of a product to half the face twice daily for 4 weeks, and the other side got no treatment. The products contained niacinamide, the peptides Pal-KT and Pal-KTTKS, and carnosine. One wrinkle treatment also contained retinyl propionate, a mild vitamin A derivative.
Results were mixed product by product. In Study 1, the eye cream improved crow's-feet smoothness but did not beat no treatment on Rz (average maximum roughness). Pooled data showed all 3 pooled products beat no treatment on both roughness measures. The abstract lists non-government research support but doesn't name the funder.
An older growth-factor cream study reported that 83% of participants improved their eye-area wrinkle score after 60 days of twice-daily use (Gold et al., 2007). It had no control group, the abstract doesn't give the sample size, and the authors themselves call for a placebo-controlled trial.
Neither study measured volume. For what topical peptides can do for lines, see our peptide ingredients ranked by evidence and what peptides do for your skin. Tretinoin isn't covered in our sources here; see does tretinoin help with wrinkles. If what you're seeing is tiny white bumps rather than a hollow, those are more likely milia; see our guide to milia around the eyes.
Evidence: Early / preliminary (wrinkles only; no topical volume data).
Does filler work for under-eye hollows?
Hyaluronic acid (HA) filler, a gel made from a sugar molecule found naturally in skin, is the most-studied option for under-eye hollows. Results are consistent but come from uncontrolled studies, not trials against an untreated group.
- Systematic review. Trinh and colleagues analyzed 23 articles on tear-trough filler. Patient satisfaction was high, the effect lasted 8 to 12 months, and Restylane was the most-used product. The authors declared no conflicts (Trinh et al., 2022).
- Single product study. Hevia and colleagues treated 49 people with Belotero Balance, an HA filler, with a blinded grader scoring photos. Hollowness scores improved at 2, 6 and 10 months (P<.001), with no serious adverse events. Of 46 who finished, 27 of the 31 participants who were not retreated still showed at least 1 point of improvement at 10 months (Hevia et al., 2014; observational, single-arm, funding not reported).
- Consensus. An interdisciplinary consensus describes HA results as "long-lasting, but not permanent" and says outcomes depend on anatomical knowledge, assessment, technique and product choice (Anido et al., 2021).
- Reviews. Hong calls HA filler the "preferred" treatment (Hong et al., 2025), and another review says fillers can "camouflage" tear trough deformity (Barbee, 2024).
| Trinh 2022 (systematic review) | 23 articles | Varied | Mostly Restylane HA filler | High satisfaction; effect 8 to 12 months; mild side effects |
| Hevia 2014 (observational) | 49 | 10 months | Belotero Balance HA; touch-up at 2 weeks if needed (protocol) | Improved at 2, 6, 10 months; 27 of 31 not retreated still improved at 10 months |
| Jiang 2016 (clinical series) | 78 | Not reported | HA or fat (Class I/II); fat repositioning (Class III) | Improvement on photos; complications all resolved |
| Su 2022 (case series) | 102 (mean age 25.9) | 13.2 months average | Fat injection with ligament release | Improvement maintained; no major complications; 58.8% very satisfied |
| Kounidas 2022 (3-group) | 34 | Not reported | Filler, laser or both | All effective; no difference between groups; 82% rated excellent |
| Kaczvinsky 2009 (2 split-face RCTs) | 42 and 35 | 4 weeks | 0.5 g twice daily, peptide/niacinamide products | Improved periorbital roughness vs no treatment; wrinkles only |
Trinh 2022 (systematic review)
Result: High satisfaction; effect 8 to 12 months; mild side effects
PRISMA review of tear-trough filler studies. No conflicts declared.
Hevia 2014 (observational)
Result: Improved at 2, 6, 10 months; 27 of 31 not retreated still improved at 10 months
Single-arm, blinded photo grading. Funding not reported.
No study here compares a treatment with an untreated control group for hollows.
We make no claim about the US regulatory status of any filler for this area. Ask your injector what the specific product's labeling covers.
Evidence: Limited (systematic review of uncontrolled studies).
How safe is filler for under-eye hollows?
Most side effects in published studies are mild and short-lived. Delayed reactions and rare vascular injuries are documented, but no source in our review gives a rate for serious events.
Common, mild effects. The 23-article review lists bruising, edema (swelling), blue-gray discoloration and contour irregularities (Trinh et al., 2022).
Delayed reactions. A second systematic review by the same group pooled 52 published cases of delayed complications from 28 articles. Of the patients, 51 of 52 were women, with an average age of 48.3, and HA was the most-reported product (37 of 52). The average onset was 16.8 months: xanthelasma-like reactions (yellowish plaques) appeared soonest, at a mean of 10 months, and discoloration latest, at a mean of 52 months. Most swelling came from HA, while semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more linked to lumps (Trinh et al., 2022). PLLA and CaHA each made up 4 of the 52 cases; for how those products differ, see Sculptra vs Radiesse.
Show data table
| Complication | Number of cases (of 52) |
|---|---|
| Swelling | 22cases |
| Lumps or nodules | 13cases |
| Xanthelasma-like reaction | 9cases |
| Migration | 4cases |
| Discoloration | 3cases |
These counts show which problems get written up, not how often they occur in people who get filler.
Vascular risk. In 18 fresh cadavers, Hufschmidt and colleagues found that branches of the infraorbital artery sit in common injection areas and connect with arteries near the nose and eye. They describe a possible route for retrograde embolism leading to "blindness and stroke" (Hufschmidt et al., 2019). This is anatomy, not a clinical outcome study. In a living patient, a case report describes a 60-year-old woman who developed double vision after HA filler in the tear trough, attributed to vascular injury of the infraorbital artery. It resolved with hyaluronidase (an enzyme that breaks down HA) and oral steroids (Santiago Díaz et al., 2024; no financial interests declared). The report's background notes that central retinal artery occlusion is a significant risk.
A disagreement on depth. The 23-article review says injections generally placed filler pre-periosteally, just above the bone covering. The cadaver study says injecting into the periosteal layer for tear-trough correction "is not advised." The abstracts don't make clear whether these describe the same plane. We report this as an open question, not technique guidance.
Filler gone wrong. A review of periocular filler complications flags migration and the Tyndall effect, a bluish tint from filler placed too superficially. It says hyaluronidase "generally is effective" for HA overcorrection or migration (Wang et al., 2021; 2 authors report royalties and 1 holds Revance shares). In a 22-patient series of filler-caused deformities, HA and unknown fillers were dissolved with hyaluronidase, and non-HA or undissolved fillers were located with MRI and removed surgically. 90.9% were satisfied or highly satisfied (Kang et al., 2024; level IV evidence).
Under-eye filler is a medical procedure. If you go ahead, choose a qualified, licensed injector who can explain the product and its reversal options.
Evidence: Limited (case pools, cadaver anatomy and case reports; no incidence data).
Under-eye filler timings: what's study-based and what isn't
- 2 weeksTouch-up (study protocol only)
One study allowed a touch-up at 2 weeks if needed. That was its protocol, not a recommendation.
- 6 monthsPRF gains often fade
A 14-study review found PRF improvements often diminished by 6 months.
- 8 to 12 monthsTypical HA filler duration
Range reported in a 23-article systematic review.
- 10 monthsLongest single-study check
27 of 31 participants not retreated still improved.
- 16.8 months (mean)Delayed complications
Average onset across 52 published cases; range spans 10 to 52 months by type.
- Other day countsClinic convention
When swelling settles, when to judge results and re-treatment intervals are not set by studies in our review.
What about PRP or PRF for hollow eyes?
PRP (platelet-rich plasma) and PRF (platelet-rich fibrin) are made from your own blood. A systematic review found texture gains with PRF and pigment gains with PRP but reported no volume outcomes.
Sollitto and colleagues reviewed 14 studies. PRF was linked to better skin texture, wrinkles and crepiness, and PRP showed stronger evidence for hyperpigmentation. PRF improvements often faded by 6 months, and neither proved superior (Sollitto et al., 2025; no conflicts declared). For protocols and the full comparison, see PRP vs PRF under eyes.
Evidence: Limited.
When are fat grafting or surgery better for under-eye hollows?
More pronounced under-eye hollows with severe bulging fat and excess lower-lid skin "are often better served" by fat repositioning, with or without fat grafting, according to a 78-patient series (Jiang et al., 2016).
- Fat injection. In Su's series of 102 young patients, fat injection with ligament release maintained improvement over an average 13.2-month follow-up with no major complications. 58.8% were very satisfied, 38.2% satisfied and 2.9% neutral (Su et al., 2022; uncontrolled).
- Blepharoplasty with fat relocation. A review of lower-lid surgery notes a trend toward relocating fat from inside the eye socket to correct inferior orbital hollowing. The approach depends on whether skin needs removing (Bhattacharjee et al., 2020; no conflicts).
- Midface lift. In 82 nonconsecutive cases from 1 surgeon, the infraorbital hollow did not recur in any patient, and 0 of 58 primary patients developed ectropion, an outward-turned lower lid (Bitik, 2023; retrospective).
Surgery isn't simple. Stutman and Codner say every tear-trough procedure "should be considered more complex" than standard lower blepharoplasty and carries additional complications (Stutman & Codner, 2012).
| Option | What studies measured | Evidence |
|---|---|---|
| Skincare | Wrinkles and roughness only | Early / preliminary |
| PRP / PRF | Texture and pigment, no volume | Limited |
| HA filler | Hollowness, 8 to 12 months | Limited |
| Fat injection | Tear-trough improvement, ~13 months | Early / preliminary |
| Surgery | Photo outcomes, single-surgeon or review data | Limited |
Evidence: Limited (case series and reviews).
Can weight loss or GLP-1 medicines make your eyes look sunken?
No study in our review looks at this directly. The aging mechanism above is fat-pad volume loss, but whether medication-related weight loss affects the same under-eye pads hasn't been studied in our sources.
For what is known about facial changes on these drugs, see how to fix Ozempic face and dermal fillers for Ozempic face. Don't stop or change your medication over a cosmetic concern; talk to your prescriber.
Evidence: Limited. No study tests this for under-eye hollows specifically.
Where the evidence stops
- No controlled trials. No study compares any treatment with an untreated control group for under-eye hollows.
- No incidence data. Case pools and case reports show that serious events happen but not how often.
- No topical volume data. Cream trials measured wrinkles only.
- Technique is unsettled. A systematic review and a cadaver study describe the deep plane differently.
- No GLP-1 data for the under-eye area.
- Short follow-up. The longest single filler study ran 10 months.
FAQ
Can you fix under-eye hollows without filler?
Not with skincare, because the topical trials we found measured wrinkles and roughness, not volume. Non-filler options studied for hollows include fat injection and surgery such as fat repositioning during lower blepharoplasty. PRF has been linked to texture and crepiness gains, but no study in our review shows it fills a hollow.
How long does under-eye filler last?
A 2022 systematic review of 23 articles reported that the effect of tear-trough filler lasted 8 to 12 months. In a 49-person observational study, 27 of the 31 participants who were not retreated still showed at least 1 point of improvement at 10 months.
Is tear-trough filler dangerous?
Most side effects in published studies were mild, such as bruising, swelling, blue-gray discoloration and contour irregularities. Delayed swelling, lumps and other reactions have been reported an average of 16.8 months after injection. Rare vascular injuries, including a case of double vision, are documented, but our sources give no figure for how often they happen.
Can under-eye filler be dissolved?
A review of periocular filler complications says hyaluronidase injection is generally effective at reducing overcorrection or migration of hyaluronic acid filler. In a 22-patient series, non-HA fillers and unknown fillers that failed to dissolve were assessed with MRI and removed surgically.
Do peptide eye creams help hollow eyes?
In two small 4-week split-face trials, products containing niacinamide, the peptides Pal-KT and Pal-KTTKS and carnosine improved periorbital roughness compared with no treatment. Those trials measured wrinkles, not hollows, and no study in our review shows a cream restores under-eye volume.
Does Ozempic cause sunken eyes?
We found no study that looks at under-eye hollowing on GLP-1 medicines directly. Don't stop or change your medication over a cosmetic concern; talk to your prescriber.
Is PRP or PRF better than filler for under-eye hollows?
No head-to-head study of PRP or PRF against filler is in our review. A 2025 systematic review of 14 studies linked PRF to texture, wrinkle and crepiness gains that often faded by 6 months and PRP to pigment gains, and it reported no volume outcomes.
Can you get under-eye hollows in your 20s?
Yes. One fat-injection study treated 102 people with tear trough deformity whose average age was 25.9. The abstract does not explain what causes hollows in younger people.
References
- Hong GW, et al. Anatomical-Based Filler Injection Diagnosis to Treatment Techniques: Infraorbital Groove and Hollowness. Life (Basel). 2025. Review; authors declare no conflicting interest. https://pubmed.ncbi.nlm.nih.gov/40003646/
- Stutman RL, Codner MA. Tear trough deformity: review of anatomy and treatment options. Aesthet Surg J. 2012. Review. https://pubmed.ncbi.nlm.nih.gov/22523096/
- Bitik O. Intraorbital Fixation Midface Lift. Aesthet Surg J. 2023. Retrospective review, 82 nonconsecutive cases, single surgeon. https://pubmed.ncbi.nlm.nih.gov/36342769/
- Pissaridou MK, et al. Periorbital Discolouration Diagnosis and Treatment: Evidence-Based Review. J Cosmet Laser Ther. 2020. Literature review. https://pubmed.ncbi.nlm.nih.gov/34078228/
- Michelle L, et al. Treatments of Periorbital Hyperpigmentation: A Systematic Review. Dermatol Surg. 2021. Systematic review, 39 studies. https://pubmed.ncbi.nlm.nih.gov/32740208/
- Jiang J, et al. Tear trough deformity: different types of anatomy and treatment options. Postepy Dermatol Alergol. 2016. Clinical series, n=78; follow-up not reported. https://pubmed.ncbi.nlm.nih.gov/27605904/
- Kounidas G, et al. Decoding infraorbital dark circles with lasers and fillers. J Dermatolog Treat. 2022. 3-group private-practice study, n=34; duration and funding not reported. https://pubmed.ncbi.nlm.nih.gov/33272039/
- Kaczvinsky JR, et al. Efficacy of anti-aging products for periorbital wrinkles as measured by 3-D imaging. J Cosmet Dermatol. 2009. 2 double-blind randomized split-face trials vs no treatment, n=42 and n=35, 4 weeks; non-government research support, funder not named in abstract. https://pubmed.ncbi.nlm.nih.gov/19735523/
- Gold MH, et al. Efficacy of novel skin cream containing mixture of human growth factors and cytokines for skin rejuvenation. J Drugs Dermatol. 2007. Uncontrolled multicenter trial, 60 days; n not reported in abstract. https://pubmed.ncbi.nlm.nih.gov/17373178/
- Trinh LN, et al. Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review. Facial Plast Surg. 2022. Systematic review, 23 articles; no conflicts declared. https://pubmed.ncbi.nlm.nih.gov/34192769/
- Hevia O, et al. Safety and efficacy of a cohesive polydensified matrix hyaluronic acid for the correction of infraorbital hollow: an observational study with results at 40 weeks. J Drugs Dermatol. 2014. Observational single-arm, n=49, 10 months; funding not reported. https://pubmed.ncbi.nlm.nih.gov/25226002/
- Anido J, et al. Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler. J Cosmet Dermatol. 2021. Interdisciplinary consensus. https://pubmed.ncbi.nlm.nih.gov/32844581/
- Barbee PH. Periorbital Rejuvenation. Atlas Oral Maxillofac Surg Clin North Am. 2024. Review; no conflicts or funding. https://pubmed.ncbi.nlm.nih.gov/38307635/
- Trinh LN, et al. Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review. Facial Plast Surg. 2022. Systematic review, 28 articles, 52 cases; no conflicts declared. https://pubmed.ncbi.nlm.nih.gov/34666405/
- Hufschmidt K, et al. The infraorbital artery: Clinical relevance in esthetic medicine and identification of danger zones of the midface. J Plast Reconstr Aesthet Surg. 2019. Cadaver study, n=18. https://pubmed.ncbi.nlm.nih.gov/30327185/
- Santiago Díaz A, et al. Injection-related Visual Compromise. Plast Reconstr Surg Glob Open. 2024. Case report, n=1; no financial interests. https://pubmed.ncbi.nlm.nih.gov/38250204/
- Wang Y, et al. Complications of Periocular Dermal Fillers. Facial Plast Surg Clin North Am. 2021. Review; authors report royalties and Revance shareholding. https://pubmed.ncbi.nlm.nih.gov/33906766/
- Kang Y, et al. Static and Dynamic Filler-Associated Tear Trough Deformities: Manifestations and Treatment Algorithm. Aesthetic Plast Surg. 2024. Case series, n=22, level IV evidence. https://pubmed.ncbi.nlm.nih.gov/38727846/
- Sollitto CF, et al. A Systematic Review of Platelet-Rich Plasma Versus Platelet-Rich Fibrin for Periorbital Rejuvenation. J Cosmet Dermatol. 2025. Systematic review, 14 studies; no conflicts declared. https://pubmed.ncbi.nlm.nih.gov/41190633/
- Su Y, et al. Corrective treatment for tear trough deformity in a young population utilizing two-dimensional fat injections. J Cosmet Dermatol. 2022. Uncontrolled case series, n=102, mean follow-up 13.2 months. https://pubmed.ncbi.nlm.nih.gov/34971470/
- Bhattacharjee K, et al. Lower eyelid blepharoplasty: An overview. Indian J Ophthalmol. 2020. Review; no conflicts. https://pubmed.ncbi.nlm.nih.gov/32971612/
Disclosure: This article is for general information only. It is not medical advice. Peptide Skincare has no affiliate links in this article and received no payment from any manufacturer mentioned. Under-eye filler is a medical procedure; see a qualified, licensed injector or oculoplastic surgeon, and seek urgent care for vision changes or severe pain after any filler.