Skip to content

Treating Concurrent Under Eye Puffiness and Hollowness

In our office, we see a lot of people who are concerned about under eye puffiness and hollowness. While they appear to be diametrically opposite situations, they can be concurrent in certain circumstances. I’ll go over how I evaluate patients who have concerns about their lower eyes, and how I develop treatment plans for them.

As a cosmetic oculoplastic surgeon, I specialize in primary upper and lower eyelid cosmetic surgery, non-surgical eyelid treatments such as the use of injectable fillers, neuromodulators, and lasers, and the correction of complications from eyelid surgery performed by other doctors. Every day, I help people with under eye puffiness, as well as hollow eyes and discoloration of the lower eyelids.

eye bag surgery before and after
eye bag surgery before and after

Patients who come to me after having their under eye bags treated elsewhere frequently express concern about a lack of volume under their eyes, also known as appearing hollow. We frequently see patients who have had treatment for hollowness by another doctor and come to see me because they have eye bags.

What Causes Puffy and Hollow Under Eyes?

There are several conditions that can cause both puffy eye bags and hollowness at the same time. The most common example is when the elevation of under eye bags causes the lower eyelid to appear hollow. This is analogous to a mountain next to a valley, where the height of the puffiness makes the adjacent area appear relatively hollow. 

In such cases, people frequently only notice hollowness, not realizing that the hollowness is caused by eye bags. In these cases, sculpting and reducing the fat that causes the eye bags can significantly improve the patient’s perception of a hollow appearance.

Treating Concurrent Under Eye Puffiness and Hollowness before and after
before and after Treating Concurrent Under Eye Puffiness and Hollowness

Under Eye Puffiness Treatment

When I treat under eye bags surgically, I sculpt the fat to create a natural appearance, with the goal of making you appear as if you never had eye bags. In contrast to the more common transcutaneous blepharoplasty, I perform this type of lower eyelid surgery using a technique called transconjunctival blepharoplasty.

tranconjunctival blepharoplasty incision illustration

The fat pockets responsible for the eye bags are accessed from behind the eyelid during transconjunctival blepharoplasty, so no external or outside incisions are made on the lower eyelid. My patients can see themselves with a more natural appearance after I perform this technique, as if they never had eye bags. I’m also able to avoid the common complications of an external incision.

before and after lower eyelid blepharoplasty female patient
before and after lower eyelid blepharoplasty female patient
The delicate lower eyelid support structures are often compromised in people who have undergone the outside incision or transcutaneous method to access the fat pockets, and the eyelids become pulled down, resulting in a rounded appearance. To treat wrinkles, many doctors combine the transcutaneous method with skin removal, which only contributes to more rounding due to an eyelid skin shortage.
Complications from lower eyelid skin removal to treat wrinkles

Under Eye Puffiness and Wrinkles

When my patients want to improve the appearance of wrinkles under their eyes, I generally do not remove skin, but rather improve the eyelid skin quality with non-surgical treatments such as platelet-rich plasma, or PRP, to thicken the skin, improve texture, and stimulate collagen, and laser treatment to improve the superficial and deeper layers of the skin.

Related: Read Why Laser for Under Eye Bags Don’t Work for Puffy Under Eye Bags

upper and lower blepharoplasty before and after performed in Prasad Cosmetic Surgery Manhattan office
upper and lower blepharoplasty before and after performed in Prasad Cosmetic Surgery Manhattan office

Hollow Under Eyes Treatment

When the fat pockets are large enough, the underlying hollowness in the tear trough and cheek is hidden. Although some doctors advocate for procedures such as fat transposition into the tear trough, I consider these to be imprecise and unpredictable. After treating the under eye bags, I advise my patients that volume enhancement of the tear trough and cheek can be done safely and predictably with hyaluronic acid fillers.

bags under eyes treatment before and after fillers
under eye filler before and after

Under Eye Puffiness and Lack Cheek Bone Projection Treatment

Another scenario is when there are significant puffy eye bags as well as a lack of cheek bone projection. This is common with facial aging. There is a progressive loss of bone, muscle, and fat in the face as we age.
best surgical treatment for bags under eyes before and after results
cosmetic surgery bags under eyes treatment and cheek filler before and after results

I approach volume correction on the cheek bones a little differently than most doctors. I employ a technique known as Structural Volumizing, in which the filler is placed beneath the muscle layer at the bone level. When placed in this area, the filler becomes much more stable and provides solid structure and definition to the cheeks, creating a natural, youthful appearance.

I use fillers that last longer, such as Juvederm Ultra Plus or Juvederm Voluma. More traditional methods of filler placement in the cheeks right under the skin frequently result in the filler migrating and appearing soft and doughy.

y lift before and after performed by Dr Prasad NYC
y lift before and after performed by Dr Prasad New York City


When treating puffiness under the eyes and hollowing, it is critical to consider the entire face. I frequently tell my patients that the sum of their parts is greater than the sum of their parts. Addressing puffiness and hollowness on the face gives it a more balanced, refreshed, and youthful appearance.

Appointment Request