Why You Look Tired When You Are Not: A Practitioner’s Guide to Understanding and Treating Hollow Eyes

By Alice Henshaw, RN, NMP, Founder and Medical Director, Harley Street Injectables

There is a sentence I hear in my consultation room more than almost any other. It is not a request for a specific treatment. It is not a question about a product or a price. It is this:

“I look tired all the time, but I am not.”

It comes from clients in their thirties who are sleeping perfectly well. From executives in their forties who exercise, eat well, and feel genuinely energised, yet catch their reflection in a bathroom mirror and see someone who looks like they have not slept in days. From women in their fifties who say their friends keep asking if they are okay.

That disconnect between how you feel and how your face communicates what you feel is one of the most distressing things a person can experience about their appearance. And it almost always comes down to the eyes. Specifically, to what is happening beneath them.

If you have searched for “hollow eyes treatment” or “tear trough filler” or “dark circles that will not go away,” you have probably found dozens of articles telling you that the solution is a syringe full of hyaluronic acid or, more recently, a course of polynucleotides. Some of those articles are perfectly fine. But almost none of them start where they should: with the question of why your under-eye area looks the way it does in the first place.

That diagnostic question, the one that happens before anyone picks up a needle, is what I want to talk about here. Because the under-eye area is the most misunderstood, most over-simplified, and most frequently mis-treated part of the face. And getting it wrong does not just waste your money. It can make things look worse.

The Under-Eye Area Is Not What You Think It Is

Most people think of the area under their eyes as a simple surface: skin that is either smooth or not, dark or not, hollow or not. But anatomically, it is one of the most complex regions of the face. Understanding why requires a quick tour of what is actually going on beneath what you see in the mirror.

The skin under your eyes is the thinnest on your entire body. Research published in the Journal of Clinical Medicine using high-frequency ultrasound confirms that the periorbital region is among the thinnest on the face, with the thinnest skin found in recessed areas such as the eyelids and under-eye zone. Some measurements place periorbital skin at approximately 0.5mm thick, compared to roughly 2mm on most of the face. Beneath that paper-thin skin sits a delicate network of blood vessels, a thin layer of muscle (the orbicularis oculi), fat pads that provide cushioning and volume, and the bony orbital rim, the edge of your eye socket.

When you are young, all of these layers work together harmoniously. The fat pads are plump and well-positioned, the skin is thick enough to conceal the blood vessels beneath, and the transition from lower eyelid to cheek is smooth and uninterrupted.

As you age (and this can begin as early as your mid-twenties for some people) multiple things change simultaneously. Fat pads shrink and descend. Bone resorbs, making the eye socket literally wider and deeper. A landmark review in Aesthetic Plastic Surgery confirmed that the orbital aperture increases with age in both area and width, with the superomedial and inferolateral aspects of the orbital rim being most susceptible to resorption. Collagen degrades, causing the skin to thin further. The ligaments that tether the skin to the underlying bone become more visible as the tissue around them deflates.

The result is what most people call “hollowing.” But here is the critical point that almost nobody explains: hollowing is not one condition. It is the visible endpoint of several different underlying problems, and each one requires a different approach.

This is where I see the most mistakes being made, both by clients self-diagnosing online and, frankly, by practitioners who treat every under-eye complaint with the same tool.

The Five Faces of Under-Eye Hollowing

In over a decade of treating the under-eye area at Harley Street Injectables, I have come to think of under-eye hollowing as having five distinct presentations. They can overlap (and they often do) but recognising which ones are dominant in a particular client is what separates a good outcome from a mediocre or even harmful one.

1. True Volume Loss (The Sunken Trough)

This is the classic tear trough: a groove that runs from the inner corner of the eye diagonally toward the cheek. It is caused primarily by the loss of fat and soft tissue beneath the skin, often combined with bone resorption in the orbital rim. Research in Aesthetic Plastic Surgery (2025) using MRI imaging of 236 subjects confirmed that lower orbital fat increases in volume at both the anterior and posterior compartments, while orbital cavity volume expands through bony resorption, contributing to the sunken, enophthalmic appearance associated with ageing. The hallmark of true volume loss is a shadow that is structural, meaning it does not change depending on how rested you are or how much water you have had. It looks the same whether you slept for four hours or ten.

This is the presentation that responds best to tear trough filler: the careful placement of hyaluronic acid gel to restore the volume that has been lost. But even within this category, not every case is straightforward. Some clients have volume loss only in the trough itself, while others have lost volume across the entire mid-face, meaning the trough is really a symptom of broader deflation. Filling the trough alone without addressing the cheek can create a ridge or an unnatural transition that looks worse than the hollow did.

This is why I often assess the under-eye area in the context of the whole mid-face. Sometimes the most effective thing I can do for a client’s tear trough is to place cheek filler to lift and support the tissue above, which reduces the depth of the trough without needing to touch the under-eye area directly. It is a counterintuitive approach, but it frequently produces the most natural result.

2. Skin Thinning and Transparency (The Vascular Shadow)

Some clients have under-eye darkness that is not caused by a hollow at all. It is caused by the skin becoming so thin that the underlying blood vessels and muscle show through. The colour is typically blue, purple, or reddish, and if you press gently on the area, it briefly blanches before the colour returns. As dermatological research has documented, the thinness of the periorbital skin, combined with a lack of subcutaneous fatty tissue, gives this region its characteristic translucency, making the accumulation of melanin or vessel dilation easily visible.

Filling this with hyaluronic acid filler is often a mistake. Adding volume beneath already-thin skin can create a puffy, waterlogged look (the dreaded “filler shelf”) because hyaluronic acid attracts water, and the tissue under the eyes is particularly prone to fluid retention.

This is precisely the presentation where polynucleotides have become transformative. Rather than adding volume, polynucleotides work biologically to thicken and regenerate the skin itself, improving its quality from within. A systematic review published in the Journal of Cosmetic Dermatology (Lampridou et al., 2025) concluded that polynucleotides offer a natural, effective, and safe option for skin rejuvenation, with their capacity to promote collagen production, tissue repair, and improved skin quality. They stimulate fibroblast cells to produce new collagen and elastin, increase hydration at a cellular level, and essentially give the skin more substance so that the blood vessels beneath are less visible. It is not an overnight fix (results build over two to four sessions) but the improvement in skin quality can be remarkable, and importantly, it looks completely natural because you are working with the body’s own regenerative processes rather than placing a foreign substance.

3. Fat Pad Herniation (The Puffy Bag)

This is the one that catches people out most often. Some under-eye “hollowing” is actually an optical illusion created by the fat pads behind the orbital septum pushing forward, creating a bag. The hollow beneath the bag is just the contrast between the bulging fat above and the relatively flat cheek below.

Injecting filler into this presentation is one of the most common errors I see in corrective work: clients coming to me after someone else has tried to fill their way around a bag, resulting in more puffiness, more bulk, and a heavier-looking eye. The filler has added volume to an area that already had too much volume in the wrong place.

For these clients, the answer often is not an injectable at all. It might be a skin-tightening treatment to improve the tissue above, or in more pronounced cases, a referral for a surgical consultation for lower blepharoplasty. I know that as the founder of a non-surgical clinic, recommending surgery might seem counterproductive. But I would rather lose a client to a surgeon who can give them the right result than keep a client by giving them the wrong one.

4. Pigmentation (The True Dark Circle)

Genuine under-eye pigmentation, as opposed to shadows caused by hollowing, is a dermal or epidermal discolouration that does not change with volume correction. It is particularly common in clients with darker skin tones and has a strong genetic component. You can tell the difference from a shadow by looking at the skin surface: pigmentation sits in the skin itself, while a shadow cast by a hollow will shift when you change the angle of the light.

Neither filler nor polynucleotides alone will resolve true pigmentation. At our clinic, we would typically look at topical treatments, skincare protocols, or specific energy-based treatments depending on the depth and type of pigmentation. I mention this because I have seen countless clients spend thousands on tear trough filler for what was actually a pigmentation issue, and the disappointment is significant. Accurate diagnosis before treatment is not a luxury. It is a clinical necessity.

5. The Combination Presentation (The Real World)

In practice, most clients sitting in front of me have a combination of two, three, or even all four of the presentations above. Their tear trough has volume loss and their skin has thinned and there is a mild bag forming and they have some genetic pigmentation darkening the whole picture.

This is why the under-eye area demands a layered, phased treatment approach rather than a single-visit fix. We might begin with polynucleotides to improve the skin quality and thickness, then reassess after two or three sessions to see how much of the apparent hollowing has improved just from skin regeneration. We might then add a small amount of tear trough filler to address any remaining structural volume loss. We might combine this with mid-face support from cheek filler. And we might layer in a Thermage FLX treatment for the surrounding skin to tighten and lift.

This phased approach requires patience from both the practitioner and the client. But it consistently produces better, safer, more natural results than trying to solve everything in one appointment.

Tear Trough Filler: When It Is Right and When It Is Not

I want to be clear: I am not against tear trough filler. I perform it regularly at Harley Street Injectables, and when it is done well, on the right candidate, it is one of the most transformative treatments I offer. A client can walk in looking exhausted and walk out looking ten years more rested, in under thirty minutes.

But the key phrase there is “on the right candidate.”

The ideal candidate for tear trough filler typically has clear structural hollowing with minimal puffiness, skin that still has reasonable thickness and elasticity, adequate mid-face volume to support the correction, and realistic expectations about what a small amount of product can achieve.

The list of people I would steer away from tear trough filler is equally important: those with prominent fat pad herniation where filler would make things worse, very thin or crepey skin where the filler would be visible or create an irregular texture, a tendency toward facial oedema or puffiness where the water-attracting properties of hyaluronic acid could exacerbate swelling, and anyone expecting filler to resolve pigmentation or fine lines that are really skin-quality issues.

The under-eye area is the most unforgiving part of the face when it comes to filler. Everywhere else, a slightly imperfect result can be relatively forgiving. Under the eyes, even a fraction of a millilitre too much, or product placed even a millimetre too superficially, is immediately visible. The skin is too thin to hide anything. This is why tear trough treatment should only be performed by practitioners with specific, advanced experience in this area. It is not a beginner procedure, and it is not something you should choose based on price.

At our clinic, we use a cannula technique for the majority of tear trough treatments. A cannula is a blunt-tipped, flexible tube that glides through tissue rather than piercing through it the way a needle does. This significantly reduces the risk of bruising and, more importantly, minimises the risk of vascular complications in an area rich with blood vessels. We typically use a single entry point on each side and place the product deep, beneath the orbicularis muscle, so it sits on the bone where it provides structural support without creating puffiness in the superficial layers.

The product choice matters too. Not all hyaluronic acid fillers are appropriate for the under-eye area. We use products specifically designed for this delicate region: soft, cohesive, and with a low tendency to attract excessive water. The wrong product under the eyes can result in persistent swelling that lasts for months.

Polynucleotides: The Treatment That Changed How I Think About Eyes

I have been practising aesthetics for over a decade, and I can count on one hand the number of treatments that have genuinely changed how I approach a particular area of the face. Polynucleotides for the under-eye area is one of them.

For years, tear trough filler was essentially the only non-surgical option for under-eye hollowing. If filler was not appropriate, the alternatives were limited: surgery, concealer, or acceptance. But polynucleotides have opened up a middle ground that did not exist before, and they have become one of our most popular treatments at the clinic for good reason.

Polynucleotides are fragments of DNA, typically derived from salmon, that when injected into the skin trigger a cascade of regenerative activity. Published research confirms that PDRN (polydeoxyribonucleotide) stimulates collagen synthesis in a dose-dependent manner, a property not seen with hyaluronic acid alone. A comprehensive review in Biomaterials Research (2025) concluded that PDRN and PN have shown significant potential in skin regeneration and rejuvenation due to their capacity to stimulate cellular repair and tissue regeneration, by promoting fibroblast activity, collagen synthesis, and angiogenesis. They improve microcirculation. They hydrate the tissue from within. And crucially, they do all of this without adding bulk or volume.

For the under-eye area specifically, this means polynucleotides can improve skin thickness in a region where thinning is a primary driver of both darkness and visible hollowing. They can reduce the vascular shadowing that makes eyes look dark without filling them with a product that attracts water. And they can improve the overall texture and resilience of the periorbital skin, creating a foundation that makes any subsequent filler work look better and last longer.

A survey of 235 board-certified Korean dermatologists published in Journal of Cosmetic Dermatology found that infraorbital fine lines were the second most common indication for polynucleotide injection, with 88% of the dermatologists surveyed using polynucleotides in their practice. This reflects a growing professional consensus around the role of polynucleotides in periorbital treatment.

I typically recommend a course of two to four sessions, spaced three to four weeks apart. The results are gradual: you will not walk out of the first appointment with a dramatic change. But by the end of a course, the cumulative improvement in skin quality is usually significant. Clients often describe it as their eyes looking “brighter” or “more awake” rather than looking like they have had a specific treatment. That is exactly the kind of feedback I want to hear.

I am also increasingly using polynucleotides as the first phase of a combined treatment plan. We start by improving the skin quality, then reassess after two or three sessions. In many cases, the skin improvement alone reduces the apparent hollowing enough that the client is happy without any filler at all. In cases where filler is still indicated, the improved skin quality means it integrates more naturally, looks smoother, and the overall result is more refined.

The Combination Approach: My Current Thinking

If you had asked me five years ago how I would treat a client with moderate under-eye hollowing, I would probably have said tear trough filler and possibly some cheek support. It was a good approach and it produced good results.

But my thinking has evolved considerably. The arrival of polynucleotides and our deeper understanding of the under-eye area as a multi-layered problem (rather than just a hollow that needs filling) has shifted me toward a more nuanced, phased approach.

My current framework for under-eye treatment at Harley Street Injectables typically looks something like this.

Phase one: Skin regeneration. For most clients, I now start with polynucleotides. This addresses skin thinning, improves hydration and microcirculation, and gives us a better baseline from which to assess what structural correction, if any, is still needed. Two to three sessions over six to nine weeks.

Phase two: Reassess. This is the step most clinics skip, and it is arguably the most important one. After completing a course of polynucleotides, we bring the client back for a thorough reassessment. How much has the skin quality improved? Has the apparent hollowing reduced? Is there still a structural volume deficit, or has the skin improvement been sufficient? Does the mid-face need support? This honest reassessment prevents us from over-treating, which in the under-eye area is a far greater risk than under-treating.

Phase three: Structural correction if needed. For clients who still have a meaningful tear trough after skin quality has been optimised, we then consider tear trough filler, placed conservatively, deep to the muscle, using a cannula. Because the skin above is now thicker and healthier, the filler integrates more naturally and the risk of visible irregularities is lower.

Phase four: Maintenance. I recommend polynucleotide maintenance sessions every six to nine months to sustain the skin-quality improvements, and tear trough filler top-ups as needed, which, with the polynucleotide foundation, tends to be less frequently than with filler alone.

Not every client needs all four phases. Some only need polynucleotides. Some are ideal filler candidates from the start. Some need a completely different approach: a skin-tightening treatment, a surgical referral, or a skincare protocol. The framework is not a rigid formula; it is a way of thinking that ensures we are treating the actual problem rather than applying a one-size-fits-all solution.

The Mistakes I See (And How to Avoid Them)

Having performed corrective work on clients who have had under-eye treatments elsewhere, I have developed a fairly clear picture of where things commonly go wrong. These are the patterns I see repeatedly.

Over-filling. The under-eye area requires tiny amounts of product. We are often talking about 0.3 to 0.5ml per side for filler, sometimes less. But the temptation to add more is strong, because a little filler makes a big difference and the assumption is that more filler will make an even bigger difference. It does not. It makes the area look swollen, heavy, and unnatural. And because hyaluronic acid attracts water, even a small excess can create persistent puffiness that clients then mistake for bags.

Wrong product. Using a filler designed for cheeks or lips in the tear trough is a recipe for problems. These products are typically more volumising, more hydrophilic (water-attracting), and too firm for the paper-thin skin under the eyes. The result is visible ridging, a bluish discolouration called the Tyndall effect, and persistent oedema.

Wrong candidate. Treating fat pad herniation with filler. Treating pigmentation with filler. Treating skin thinning with filler. These are all diagnostic errors that lead to disappointing or harmful outcomes. The treatment can only be as good as the diagnosis that precedes it.

No follow-up plan. Tear trough filler is not a one-and-done treatment. It requires ongoing assessment, maintenance, and sometimes adjustment. Clients who have filler placed once and then never return for review are the ones most likely to end up with accumulated product that gradually makes the area worse over time.

Ignoring the mid-face. The under-eye area does not exist in isolation. It sits on top of the cheek, and the cheek sits on top of the jawline. Volume loss in the mid-face directly contributes to the appearance of the tear trough: the tissue above has descended, deepening the groove below. Treating the trough without considering whether mid-face support is needed is like patching a ceiling without fixing the roof above it.

What I Want You to Know Before You Book Anything

If you are reading this because you are tired of looking tired, I want to leave you with a few thoughts that I hope will help you make a better decision, whether that decision involves our clinic or someone else entirely.

Start with a diagnosis, not a treatment. Do not walk into a clinic and ask for tear trough filler. Walk in and describe your concern. A good practitioner will examine your under-eye area, assess the underlying cause of what you are seeing, consider the context of your whole face, and then recommend the most appropriate treatment. If they go straight to a syringe without that assessment, find someone else.

Be wary of instant solutions. The under-eye area rewards patience and conservatism. A practitioner who promises dramatic results in a single session is either over-promising or over-treating. The best outcomes I achieve are built over time, with small, carefully considered interventions that compound into a significant improvement.

Ask about polynucleotides. If you have been told you are not a good candidate for tear trough filler (perhaps because of puffiness, thin skin, or a tendency toward oedema) polynucleotides may be an excellent alternative. They work differently from filler and address a different set of problems. Even if you are a good filler candidate, starting with polynucleotides to optimise your skin quality first can significantly improve the final result.

Look at the practitioner’s experience with eyes specifically. The under-eye area is one of the highest-risk zones for injectable treatments. Blood vessels, proximity to the eye itself, exceptionally thin skin: it all demands precision and experience. Ask how often they perform tear trough treatments. Ask about their complication management protocol. Ask what they would do if something went wrong. At Harley Street Injectables, our team are trained in emergency vascular protocols, and our CQC-registered clinical environment means we operate to the same safety standards as a medical facility, because this is medical treatment, regardless of how it is marketed.

Understand that the goal is not perfection. The under-eye area is the most honest part of the face. It will always show some evidence of your age, your sleep, your genetics, your life. The goal of treatment is not to erase all of that. It is to soften the disconnect between how you feel and how you look. To bring the two back into alignment. If the mirror reflects something closer to the energy you actually have, the treatment has succeeded.

A Note on the Emotional Impact

I said something in a recent article about lip filler that I want to repeat here, because it applies doubly to the eyes: these treatments are emotional.

The eyes are how people read you. They are the first thing others look at when they greet you, the feature that communicates warmth, energy, kindness, fatigue, sadness. When your eyes consistently communicate a message that is not yours (“I am exhausted,” “I am unwell,” “I am ageing badly”) it chips away at you over time. Not dramatically. Not all at once. But steadily, in the background, every time someone asks if you are feeling okay when you feel fine.

I have had clients cry with relief after a tear trough treatment. Not because the result is dramatic, but because for the first time in years, their face matches their feeling. That matters. It is not vanity. It is the very human need to be seen accurately.

At Harley Street Injectables, we take that seriously. The under-eye area is not a trend or a quick fix. It is one of the most rewarding areas I treat, because when it is done well, with the right diagnosis, the right approach, and the right amount of patience, it changes how a person experiences their own face, every single day.

If you would like to explore what is right for your under-eye area, I would encourage you to book a consultation with our team. We will assess you properly, explain what we see, and give you an honest recommendation, which might be filler, polynucleotides, a combination, something else entirely, or nothing at all. The conversation is where it starts. And it is always worth having.

About the Author

Alice Henshaw, RN, NMP, is the founder and medical director of Harley Street Injectables, the largest clinic on Harley Street dedicated exclusively to non-surgical aesthetic treatments. A qualified nurse prescriber registered in the UK, Australia, and New Zealand, Alice is a Key Opinion Leader for Allergan Aesthetics, was named Best Aesthetic Injector in London by the GHP Awards, and has been featured in Vogue, Tatler, Vanity Fair, and the Tatler Cosmetic Surgery Guide. The clinic is CQC registered and offers complimentary consultations with all treatments.

To book a consultation, visit harleystreetinjectables.com or call +44(0) 3455 485 658.

Sources referenced in this article:

1. Facial skin thickness mapping using high-frequency ultrasound, Journal of Clinical Medicine (2025). Confirmed the periorbital area as having the thinnest facial skin.

2. Mendelson, B. and Wong, C. “Changes in the Facial Skeleton With Aging,” Aesthetic Plastic Surgery (2012). Landmark review on orbital bone resorption.

3. “Decoding Periorbital Aging: A Multilayered Analysis of Anatomical Changes,” Aesthetic Plastic Surgery (2025). MRI study of 236 subjects confirming orbital cavity expansion and fat redistribution.

4. “Facial Bone Aging: An Update and Literature Review,” ScienceDirect (2026). Mechanotransduction hypothesis and region-specific facial bone remodelling.

5. Lampridou, S. et al. “The Effectiveness of Polynucleotides in Aesthetic Medicine: A Systematic Review,” Journal of Cosmetic Dermatology (2025). Systematic review confirming safety and efficacy.

6. “Versatile and Marvelous Potentials of Polydeoxyribonucleotide for Tissue Engineering and Regeneration,” Biomaterials Research (2025). Review of PDRN mechanisms including fibroblast stimulation and collagen synthesis.

7. Survey of 235 Korean board-certified dermatologists on polynucleotide usage patterns, Journal of Cosmetic Dermatology. Infraorbital area among top indications.

“Polynucleotides and polydeoxyribonucleotides in dermatology: A narrative review,” Journal of Cutaneous and Aesthetic Surgery (2026). Confirmed dose-dependent collagen synthesis from PDRN.