Sunken or hollow eye is not rare in patients with ptosis, elder age, or complication after upper blepharoplasty. It is quite prevalent for surgeons choose to graft patients with sunken eye, without differentiating the pathomechanism. For the best aesthetic results, we must understand the mechanism of sunken eye and treat it accordingly.

There are two major types of pathomechanism for sunken eyes. One is volume depletion, which can be seen in patients with orbital fat hernia as eye bag, or results of excessive removal of orbital fat during upper blepharoplasty. The other one is a dynamic sunkening caused by dehiscence of levator aponeurosis or mis-insertion of aponeurosis, which often combines with mild ptosis and brow raising when eyes are opening, and thus further exacerbates the sunkening.

Treatment of the sunken eye should be based on the etiology. For the volume depletion group with lower eyelid fat hernia, capsulopalpebral fascia repair is the choice of treatment. For the dynamic sunkening group, aponeurosis repair or treatment of ptosis is mandatory to successful management.

Surprisingly in author's clinical experience, the elder group of patients with hollow eyes present more with dynamic sunkening than with mere volume depletion. Misinterpretation of sunken eye probably explains why over grafting of fat is so commonly seen in current clinical practices.

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