Sunken eyes: assessing the orbit and fat

"My eyes are sinking." The phrase may describe a normal phenomenon of aging, the effect of rapid weight loss, a family anatomical trait or, more rarely, a clinical sign to be investigated. A sunken eye changes the expression of the whole face: an appearance of tiredness, illness, sadness. The assessment needs to tell these scenarios apart before any plan.

This page guides the assessment of the orbit and fat, shows the reach of orofacial harmonization (HOF) and indicates when to refer. For the area, see periorbital and tear trough.

Why does the eye look sunken?

The sunken-eye look comes from the relationship among three elements: the skeleton of the orbit, the fat that fills it and the soft tissues around it. A change in any of them alters how the eye reads.

Bone resorption is part of facial aging. See facial bone loss and facial bone resorption and planning.

When a sunken eye is a medical issue

Recession of the eyeball, called enophthalmos, is an ophthalmologic finding. It can have a traumatic cause (orbital fracture), result from diseases that reduce orbital contents or come from other conditions. Signs that require referral before any procedure:

• recent, rapid or progressive sinking;
• a clear difference between the two eyes that was not there before;
• double vision, pain, changes in the eyelid or pupil;
• previous facial trauma;
• associated general symptoms.

In these cases, the aesthetic plan comes second. Referral to an ophthalmologist is part of the care. See referring patients in HOF and asymmetric eyes.

What HOF can do

When the sinking is part of aging or fat loss, HOF works on the surrounding soft tissues, without touching the eyeball. The possible approaches, always at the professional's discretion, include:

• Tear trough and groove: discreet volume to soften the step and the shadow. See tear trough filler.
• Temple: restoring temporal volume improves the frame of the gaze. See temple filler and hollow temples.
• Cheekbone: midface projection reduces the apparent depth of the orbit. See sunken eyes and low cheekbones.
• Upper eyelid: in selected cases, volume can soften the sinking, with risk. See sunken upper eyelid.

What is not done: trying to "push" the eyeball outward or restore the deep fat of the orbit. What is done is composing the surroundings. In general, treating the temple and the cheekbone before the tear trough gives a more natural frame.

When weight loss is the reason

People who lose a lot of weight, fast or with medication, lose facial fat globally, and the eyes look more sunken. The plan changes: the loss tends to be diffuse, and the final volume should be thought out in stages. See facial volume loss after weight loss, gaunt face after weight loss and planning HOF for rapid weight loss.

How to organize the plan

1. Rule out a medical cause and record the history.
2. Treat the context: temple, cheekbone and, afterward, tear trough, with conservative volumes.
3. Reassess with standardized photography before any addition.
4. Avoid excess volume in the eyelid, which gives a puffy look.
5. Agree on the expectation: a softer frame, eyes in the same place.

See also cheekbone and tear trough: combining in the plan and temples and cheekbone: combining in the plan.

Common mistakes

The first mistake is filling the tear trough without looking at the whole of the orbit, temple and cheekbone. The second is promising the patient that the eye will "go back into place," when what changes is the frame. The third is ignoring weight loss: a patient who lost a lot of weight may need a different, more gradual plan, and perhaps a pause to stabilize weight before investing in volume. The fourth is using too much product in the upper eyelid, which can look puffy and raise the risk. In all of these scenarios, minimal volume, good photos and reassessment are the best protection for the patient and for the professional.

Simulation and expectations

Harmy simulates Tear Trough, Temple and Cheekbone. The image below shows the effect of volume in the tear trough on the fictional person. The projection does not change the position of the eyeball or the deep orbital fat, and the patient should be told this.

Summary for the decision

Sunken eyes call for history, comparison with old photos and an exam before any plan. Rule out a medical cause, accept that the orbit and deep fat are beyond the reach of HOF, treat the surroundings with conservative volumes and remember the vascular risk of the area. Everything at the discretion of the qualified professional, in line with the rules of their professional council in Brazil, without promising results.