Old Facial Fractures and Cosmetic Surgery: The Sunken Eye, the Flat Cheekbone, the Plates You Can Feel, and Why Filler Is Not Always the Answer

The patient is 38. Six years ago a pickup basketball game ended with an elbow to the left side of the face. The emergency department found a cracked orbital floor and a cheekbone fracture, a surgeon put in two small plates, and the swelling went down. Life moved on. Lately, though, the left eye looks smaller in photos, the left cheek looks flatter, and there is a ridge under the lower lid that can be felt with a fingertip. They have booked a consultation about old facial fractures and cosmetic surgery and are hoping to hear the word "filler."

It may be the right word. It may also be a way of decorating a problem that lives in the bone. A sunken eye after an orbital fracture is often not a missing-volume problem in the usual cosmetic sense. It can be a container problem: the bony socket got bigger, and the eye sank back into the extra space. Filler can blur that. It cannot shrink the socket.

This piece is about the people who carry an old injury into a cosmetic consultation: the eye that sits lower or deeper, the cheekbone that never quite came back, the numb patch, the palpable hardware, and the lower lid that has pulled down since the repair. It covers what is worth sorting out before anyone reaches for a syringe. The nose is its own subject, covered in our piece on broken noses and nasal fracture repair timing.

Why does an old orbital fracture make the eye look sunken?

The short answer: when the thin floor or inner wall of the eye socket breaks outward, the socket's volume increases, and the eye can settle backward and sometimes downward into that space, a change called enophthalmos that may not show until the swelling is gone.

The orbit is a cone of bone, and its floor (above the maxillary sinus) and inner wall are paper-thin. A blow to the eye can raise pressure inside the socket enough to crack those walls outward. Fat and tissue drift into the sinus. Right after the injury, swelling can hold the eye forward and hide the change. Weeks or months later, as the swelling resolves and some displaced fat scars or shrinks, the eye can look deeper set, the upper lid crease can climb and hollow, and the eye can look smaller on that side.

Published case reports describe a difference of 2 to 3 millimeters as detectable on examination and larger differences as clearly disfiguring. That is a description of what people notice, not a surgical rule. Some patients with a modest difference are bothered daily. Others never notice.

Here is what this means for a cosmetic consultation.

• A hollow upper lid after an orbital fracture is not the same as age-related hollowing. Filling the sulcus can soften the look, but it does nothing about where the eye sits, and it can make the area look heavy if the real issue is depth.
• Eye position should be measured, not eyeballed. An exophthalmometer reading, a comparison of old photos, and a CT scan of the orbits tell a surgeon far more than a mirror.
• Double vision is a medical finding, not a cosmetic one. If the eye no longer moves fully, or you see double in some directions of gaze, that belongs in front of an ophthalmologist or an orbital surgeon first.

It also helps to know what enophthalmos is not. A bulging eye from thyroid eye disease can make the other eye look sunken by comparison. Simple facial asymmetry, discussed in our piece on facial and breast asymmetry, can also do it. The injury history is a strong clue, but the measurement is what settles it.

Why do the first weeks after a facial fracture matter so much?

The short answer: bone and soft tissue are easiest to put back while the fracture is fresh, and once broken pieces heal in the wrong position (malunion), correcting them usually means rebreaking bone through larger incisions with less predictable results.

Much of the surgical literature distinguishes immediate repair (within hours, usually for a trapped muscle or a threatened eye), early repair (roughly within two weeks), and late repair. Many orbital floor fractures are watched for about two weeks while the swelling settles, because some double vision recovers on its own and not every fracture needs an operation. A 2014 systematic review in the International Journal of Oral and Maxillofacial Surgery found the evidence supported immediate repair when it was indicated, but was not strong enough to define an ideal window beyond that. Some reports describe poorer results when orbital floor repair is delayed past roughly two months.

The cheekbone follows a similar logic. A fracture of the zygoma (the zygomaticomaxillary complex, in surgical terms) can be repositioned and fixed with plates fairly directly in the first weeks. Clinical reviews describe successful delayed repair even months out, but once the bone has knit in a displaced position, the operation gets bigger.

For readers who were injured recently, this is the one practical point to take away: do not wait for a cosmetic surgeon to fix a fresh facial fracture months from now. If you were hit in the face and you have double vision, a numb cheek or upper lip, a flat cheekbone once the swelling eases, trouble opening your mouth, or teeth that no longer meet properly, get evaluated by a facial trauma surgeon now. Oral and maxillofacial surgeons, plastic surgeons, ENT facial plastic surgeons, and oculoplastic surgeons all treat these injuries. Sports injuries are a common route in, as with the athletes in our piece on cauliflower ear.

For readers who are years out, the window has closed, and that changes the menu. It does not empty it.

What does late correction of a sunken eye or flat cheekbone involve?

The short answer: true late correction means restoring the bone, usually by reconstructing the orbit with an implant to reduce its volume and, for a malunited cheekbone, cutting and repositioning the bone (osteotomy), which is real reconstructive surgery with real recovery and no guaranteed symmetry.

Secondary orbital reconstruction. For a sunken eye, the surgeon goes back into the orbit, frees scar tissue, and places an implant along the floor or inner wall to rebuild the socket's shape and push the eye forward. Surgeons increasingly plan these cases from CT scans, use the uninjured side as a template, and may use patient-specific implants or intraoperative navigation. A 2017 case series of late reconstruction with 3D-planned implants operated on patients two to four years after injury. Its authors also noted that timing, technique, implant choice, and indications for late cases remain debated. Translation: it can work, it has been done well years after the injury, and nobody should promise you a mirror image.

Cheekbone osteotomy. A zygoma that healed in the wrong place can be cut and moved back toward its proper position. Published series of late correction describe exposure through incisions in the scalp (a coronal incision), the lower eyelid, and inside the mouth. That is a significantly larger operation than the original repair would have been. It is the mirror image of cheekbone reduction surgery: the cuts are similar, the goal is the opposite.

The risks that come with going back in. These areas have been operated on before, so scar tissue is part of the job. The eyelid is part of the approach, so lower lid position is at stake. The infraorbital nerve runs through the injured bone, so sensation can change. And the eye itself is the neighbor. Double vision can improve, persist, or occasionally appear after secondary orbital surgery, and vision-threatening complications, while uncommon, are part of the consent conversation. This is not a weekend procedure.

"A sunken eye after an orbital fracture is often a container problem, not a volume problem. Filler can blur that. It cannot shrink the socket."

Who does this work? Ask about volume specifically: how many secondary orbital reconstructions or zygomatic osteotomies does the surgeon do in a year? A surgeon with a large cosmetic eyelid practice may not do many. Teams that handle complex facial trauma often do. Planning tools are worth asking about too. Our piece on 3D imaging in consultations covers what simulation can and cannot promise, and the limits are sharper when the plan involves moving bone. For a case like this, a second consultation is not a sign of distrust. It is standard practice.

Insurance is also more realistic here than most cosmetic patients expect. Correcting a post-traumatic deformity, especially one with double vision or functional problems, is often reconstructive rather than cosmetic. Coverage still varies by plan and documentation, as our piece on insurance and medical necessity explains. Keep the old operative report and imaging. They are evidence.

When are filler, fat, or an implant a reasonable shortcut?

The short answer: camouflage with filler, fat grafting, or a cheek implant is a legitimate choice when the problem is mild, when the eye works normally, and when the patient understands they are disguising a bony change rather than correcting it, but scarred, previously operated tissue changes the risk picture.

Plenty of people with an old fracture do not want a coronal incision and an orbital implant to correct a few millimeters. That is a reasonable decision. Camouflage can do a great deal for a flattened cheek or a modest hollow, as long as everyone is honest about what it is.

• Hyaluronic acid filler is reversible, which is a real advantage when the anatomy is unpredictable (see our piece on dissolving filler). Scar tissue can make filler spread unevenly or sit in odd shapes, and a scarred plane can behave differently from virgin tissue. Small, staged amounts are sensible. The periorbital area also carries a known risk of vascular occlusion, and altered anatomy is not a reason to be bolder. Our pieces on filler migration and biostimulatory fillers explain why permanent or semi-permanent products deserve extra caution in a face that may need more surgery later.
• Fat grafting can rebuild a flat cheek or a hollow lid and integrates with the tissue. Survival in scarred beds is less predictable, and our pieces on fat transfer to the face and fat graft survival cover why a second session is common.
• A cheek implant can restore projection over a flat zygoma without moving bone. It suits cases where the bone underneath is stable and the asymmetry is mostly forward projection. Our piece on cheek and jaw implants covers the general tradeoffs. After trauma, existing hardware and scar tissue complicate the pocket, and the surgeon needs the CT scan.

What camouflage should not do is mask an untreated functional problem. If the eye is deeper set and you also see double when you look up, filler is not a treatment. If the lower lid has been pulled down since the original repair, adding volume underneath will not lift it. It may make it worse.

What about the plates, the numb cheek, and the lower eyelid?

The short answer: titanium plates are usually left in permanently and rarely cause trouble, but they can be felt or seen under thin skin and can be removed; numbness from the infraorbital nerve often improves but sometimes persists; and lower lid changes from the original approach are a common, fixable source of cosmetic complaint.

The hardware. Most facial fractures are fixed with small titanium plates and screws, and most are left in for life. Titanium is not magnetic, so facial plates are generally compatible with MRI, though you should always tell the imaging team about them. Plates near the rim of the orbit or on the cheekbone can be felt, and in thin skin, especially as facial fat thins with age, they can become visible as a ridge. Cold sensitivity is sometimes reported. Plates can be removed once the bone has healed, which is a modest operation in most cases. Many surgeons would rather remove a symptomatic plate than try to hide it with filler, which can outline the edge rather than soften it. Plate removal can also be combined with other work if the timing makes sense.

The numb cheek. The infraorbital nerve supplies feeling to the cheek, side of the nose, upper lip, and sometimes the front teeth, and it runs right through the bone that breaks in orbital floor and cheekbone fractures. Numbness or tingling after these injuries is common. A 1990 study of 52 patients found earlier treatment was associated with better nerve recovery. Small later series report that many patients improve after repair, though a share keep some reduced sensation. If it has not changed in several years, it is unlikely to change much on its own. That matters for cosmetic planning in two ways. You may not feel an injection or a burn from a device on that side, so energy treatments and cold or heat therapies need care. And a numb lip can change how a smile moves. Our piece on numbness after plastic surgery explains how nerves recover in general.

The lower eyelid. Orbital floor repairs are often done through an incision in or just below the lower lid. Some patients are left with a slightly pulled-down lid (retraction), more white showing below the iris, or a lid that turns outward. Patients often notice this before anything else, and they often assume it is aging. A surgeon who reaches for a standard lower blepharoplasty on a lid like this can make it worse. The relevant playbook is the one in our pieces on lower lid retraction after eyelid surgery and on ectropion and lid support surgery: support the lid first, then refine it. Under-eye dark circles have similar overlap, covered in our piece on under-eye dark circles.

Jaw fractures are a cousin of this story. A mandible that healed with a slightly different bite can leave clicking, pain, or asymmetry. Those belong in the conversations in our pieces on TMJ disorder and facial surgery and orthognathic surgery versus jawline work, not in a filler appointment.

The honest summary

An old facial fracture changes the cosmetic conversation. The sunken eye after an orbital blowout is often a bigger socket, not lost fat. The flat cheekbone is often bone that healed in the wrong place. Neither is truly fixed by volume, though both can be softened by it.

Fresh fractures should be evaluated by a facial trauma surgeon promptly, because repair in the first weeks is far simpler than correction years later. For old injuries, true correction means secondary orbital reconstruction or a cheekbone osteotomy. These are reconstructive operations with real recovery and debated indications, and they belong with surgeons who do them often and plan from CT scans. Insurance may well apply.

Camouflage with filler, fat, or a cheek implant is a legitimate choice for mild changes in an eye that works normally, as long as it is labeled honestly and done conservatively in scarred tissue. Palpable plates can usually be removed. A numb cheek that has not changed in years is probably stable, and it calls for care with devices and heat. A lower lid that has drifted down since the repair needs support before it needs a blepharoplasty.

The first useful question in the consultation is not "how much filler?" It is "what exactly moved, and where is it now?" A surgeon who asks for the old scans before quoting a syringe count is doing the job properly.