Why do some people regret under-eye correction?
Under-eye correction for dark circles and puffiness can be addressed through surgical methods (transconjunctival Hamra technique, lower eyelid fat removal, Hamra technique) and non-surgical methods (hyaluronic acid filler, PRP, laser). Because the optimal treatment differs depending on the cause, an inaccurate diagnosis or incorrect choice of procedure can lead to regret.
5 Common "Failure" Patterns
① Hollowing (sunken appearance)
Removing too much fat can cause the area under the eyes to become sunken, producing the counterproductive effect of looking "more aged." The amount of fat must be carefully adjusted, as over-removal makes revision surgery extremely difficult.
② Dark circles did not improve
Dark circles include "brown circles (pigmentation)," "blue circles (blood flow)," "black circles (shadow/sagging)," and "red circles (inflammation)," each requiring a different treatment approach. Fat removal has no effect on brown or blue circles. An accurate diagnosis is essential.
③ Lower eyelid retraction (ectropion)
With procedures that involve incising the lower eyelid (such as the external Hamra technique), the eyelid may be pulled outward, resulting in a "drooping lower eyelid" condition (ectropion). Because this is an anatomically complex area, the surgeon's experience is critical.
④ Bluish show-through after hyaluronic acid filler (Tyndall effect)
With non-surgical hyaluronic acid filler, injecting too superficially into the thin skin beneath the eyes can cause the filler to appear as a bluish tint — known as the "Tyndall effect." Injection at an appropriate depth is necessary.
⑤ Prolonged swelling and bruising
Because the lower eyelid has abundant blood flow and thin skin, post-operative swelling and bruising tend to be noticeable, and it may take several weeks to several months to see the final result. It is important to receive a thorough explanation of the downtime before surgery.
Treatment Options by Dark Circle Type
- Black under-eye circles (sagging/shadows): Transconjunctival Hamra technique · lower eyelid fat removal · hyaluronic acid (tear trough filling)
- Brown under-eye circles (pigmentation): Laser · peeling · whitening care (surgery is not suitable)
- Blue under-eye circles (visible blood vessels): Laser · lifestyle improvement (fat removal is not suitable)
- Red under-eye circles (visible orbicularis oculi muscle): Hyaluronic acid · PRP, etc. (first examine the cause carefully)
Checklist for Choosing a Trustworthy Clinic
- Whether the type of under-eye condition is accurately assessed during the consultation
- Whether options other than "fat removal" (such as filler or laser) are also presented
- Whether the policy for adjusting the amount of fat removal is explained
- Whether the risk of post-operative hollowing is explained in advance
- Whether the system for revision surgery is clearly stated
The Zetith Clinic Approach
Accurate Diagnosis of Dark Circle Type
During the consultation, we carefully determine your dark circle type and recommend the most suitable approach from surgical, non-surgical, or combination treatments. We do not make hasty judgments such as "removing fat will fix it."
Conservative Fat Management Combined with Filler
We take a "conservative" approach of not removing too much fat, and where necessary, combine fat repositioning (Hamra technique) or filler to maintain a natural volume.
Attentive Post-Operative Follow-Up
We regularly monitor the progress of swelling and bruising, and respond promptly to any complications that may arise.
Revision Surgery Consultations from Other Clinics Are Welcome
If you have concerns following a procedure at another clinic — such as hollowing after lower eyelid fat removal or bluish show-through from hyaluronic acid filler — please feel free to consult us.
Lower Eyelid Fat Removal & Fat Repositioning (Transconjunctival Approach) Outcomes
Source: Extended Transconjunctival Lower Blepharoplasty (PRS 2025, n=1803) / MAFT study
Under-eye correction surgery (transconjunctival approach) complication rates
Source: Extended Transconjunctival Lower Blepharoplasty (2025) / MAFT study (mean follow-up 60.2 months)
By Under-Eye Dark Circle Type — Appropriate Treatments and Precautions
Patient Satisfaction with Hyaluronic Acid Filler Injections (Tear Trough / Under-Eye Correction)
Source: Use of Hyaluronic Acid Fillers in Treatment of Periorbital Dark Circles (2021), Satisfied or above total 95%
Complication and Revision Rate Data for Under-Eye Correction from Clinical Literature
One of the most important aspects of choosing aesthetic medicine is understanding both the expected outcomes and the potential risks at the same time. At Zetith Clinic, we believe that sharing data from peer-reviewed medical literature transparently leads to decisions our patients will not regret. Below is a summary of key clinical research data on lower eyelid (under-eye correction) treatments.
① Transconjunctival Approach + Tear Trough Ligament Release + Free Fat Grafting (Surgical Treatment)
A clinical study of 200 cases reported an exceptionally high patient satisfaction rate of 198/200 cases — 99.0% for transconjunctival lower blepharoplasty combining tear trough ligament release with free fat grafting. Long-term follow-up showed lower eyelid positional abnormality (0%) and scleral show (0%), with no significant visible deformities observed.
On the other hand, there are negative data points that must be communicated honestly. Fat necrosis occurred in 3.5% (7 cases), indicating that transplanted fat does not always survive. Additionally, chemosis (skin discoloration) occurred in 3.0% (6 cases), minor delayed bleeding in 1.5% (3 cases), mid-lamellar scarring in 1.0% (2 cases), and revision surgery was required in 1.0% of cases due to residual under-eye bags. Although the incidence rates are low, these are complication that should be understood in advance.
② Transconjunctival Fat Repositioning (Large-Scale Data of 1,803 Cases)
A study with 1,803 cases — a remarkably large sample size by international standards — evaluated the effectiveness of transconjunctival fat repositioning for tear trough deformity. Using the Hirmand classification, the tear trough resolution rate was 87.4% in the primary surgery group and 85.3% even in the revision surgery group, demonstrating high technical reproducibility. Bilateral surgery time was approximately 50 minutes.
Patient-reported outcomes (FACE-Q) showed improvement in lower eyelid dissatisfaction scores from 54.2±10.0 preoperatively to 34.3±20.2 postoperatively (lower scores indicate higher satisfaction). Preoperatively, 85.4% of patients felt they "looked tired" and 76.1% felt they "looked older." Postoperatively, the proportion of patients with complete tear trough resolution increased from 0% to 20.8%. Notably, 34% of patients still had moderate or greater residual tear trough deformity after surgery, which is important information indicating that a single procedure does not always achieve complete improvement. The satisfaction score for the decision to undergo surgery was 78.2±18.7 (out of 100).
③ Hyaluronic Acid Filler Injection (Non-Surgical Treatment)
A study of hyaluronic acid filler treatment (60 cases) targeting periocular hyperpigmentation (dark circles) caused by shadows from tear trough deformity found that 80% of patients rated their satisfaction as "satisfied" or above (VAS ≥ 7), consisting of "very satisfied" (25%) and "satisfied" (55%). Particularly, patients with Grade 1 (mild) tear trough showed the best results, with 83.3% achieving VAS ≥ 7, demonstrating that filler tends to be more effective when the tear trough deformity is mild.
Regarding complication, immediate post-injection edema and erythema occurred in 33% (20 cases), though most were temporary. Prolonged postoperative swelling occurred in 8.3% and mild bruising in 6.6% (4 cases), all of which resolved within approximately one week. 5% of patients (3/60 cases) were dissatisfied, indicating that satisfactory results cannot be guaranteed for everyone.
④ Risks for Patients with Prior Filler History Undergoing Surgery (Important)
This study presents data that requires particular attention when considering under-eye correction treatment. Among 48 patients with a history of hyaluronic acid filler injections to the infra-orbital area who underwent lower blepharoplasty, 83.3% (40/48 cases) experienced some form of adverse event.
Specifically, malar edema (chronic cheek swelling) was observed in 25.0%, abnormal intraoperative tissue findings in 37.5%, and prolonged postoperative edema requiring additional intervention in 43.8%. In 60.4% of cases, filler had been placed anterior to the orbital septum (pre-septal), and in 12.5% there was suspicion of filler extending posterior to the septum. Furthermore, residual filler was confirmed in 10.4% of patients even six or more years after injection, meaning the assumption that filler "naturally dissolves over time" is not always accurate.
Hyaluronidase (dissolving injections) was administered preoperatively in 45 patients, with 5 cases requiring multiple dissolution procedures. If you have a history of filler injections and are considering surgery, please be sure to inform your physician in advance.
⑤ Micro-Autologous Fat Transplantation (MAFT Method)
A long-term follow-up study of 205 cases over a mean of 60.2 months (approximately 5 years) evaluated the efficacy and safety of MAFT (Micro-Autologous Fat Transplantation) for periorbital aging. "Very satisfied" was reported by 76% (156 cases) and "satisfied" by 19% (39 cases), with a combined satisfaction rate of 95% (195/205 cases). The mean satisfaction score on a 5-point Likert scale was 4.702, indicating a high level of satisfaction.
Regarding complication, transient lower eyelid retraction occurred in 2.0% (4 cases), all of which resolved within one month. 94% of patients (193 cases) achieved completion with a single procedure, and only 4.4% (9 cases) requested secondary revision surgery. The confirmed long-term stability of fat survival is a significant advantage of treatments using autologous tissue.
What the Data Tell Us
While satisfaction rates across all treatment options are high, it is also true that a certain percentage of complication and revision cases exist. The following three points are particularly important:
- The milder the tear trough deformity, the more reliably improvement can be expected (Grade 1 showed the best outcomes with fillers, and a similar trend is seen with fat repositioning)
- A history of prior filler injections significantly increases surgical risk (adverse event rate of 83.3%), making accurate disclosure of treatment history essential
- No treatment offers a "100% guarantee," but risk can be minimized by carefully selecting the surgical approach and improving the accuracy of preoperative assessment
At Zetith Clinic, during consultation we carefully explain the risks and benefits for each individual patient based on this data. "Knowing" is the first step toward a decision you will not regret.
References
- Extended Transconjunctival Lower Blepharoplasty with Tear Trough Ligament Release and Free Fat Grafting — Transconjunctival lower blepharoplasty with tear trough ligament release and free fat grafting (200 cases). Reports patient satisfaction of 99.0%, fat necrosis of 3.5%, and revision surgery rate of 1.0%.
- Transconjunctival Fat Repositioning Blepharoplasty for Tear Trough Deformity — Transconjunctival fat repositioning for tear trough deformity (1,803 cases). Reports tear trough resolution rate of 87.4% and patient-reported outcomes via FACE-Q.
- Use of Hyaluronic Acid Fillers in Treatment of Periocular Melanosis Induced by Shadow Effect of Tear Trough Deformity — HA filler treatment for periocular hyperpigmentation caused by tear trough deformity (60 cases). Reports VAS ≥ 7 satisfaction rate of 80%, with 83.3% in Grade 1 cases.
- HA Filler-Related Complications in Patients Seeking Lower Blepharoplasty — Study of complication in lower blepharoplasty patients with prior filler history (48 cases). Reports adverse event rate of 83.3% and prolonged postoperative edema of 43.8%.
- Micro-Autologous Fat Transplantation (MAFT) for Periorbital Rejuvenation — Long-term study of MAFT for periorbital aging (205 cases, mean follow-up 60.2 months). Reports patient satisfaction of 95% and transient lower eyelid retraction of 2.0%.
Summary: Understanding Your Dark Circle Type Is the First Step to Avoiding Regret
Most regret following under-eye correction stems from "misdiagnosis" and a "mismatch in procedure selection." The most important step is to accurately identify your dark circle type and choose a treatment suited to it. At Zetith Clinic, we alleviate your concerns through thorough examinations and a satisfying consultation.