Seeing an aesthetic procedure all over social media can breed a strange sort of FOMO. (Hey, we’re not immune.) Yet it may be difficult to distinguish for-the-’Gram fads from truly “Worth It” tweaks. Which is why we’re launching a new series on RealSelf: Everybody’s Doing It. Each month, we’ll explore all sides of an of-the-moment cosmetic procedure, to bring you the uncensored truth about its efficacy and safety so you can decide if it’s right for you. Here, in our latest installment, we’re demystifying the art of under-eye filler.
While their after shots are decidedly less flashy than pouty lips or chiseled jawlines, the lower eyelids have quietly become a favorite filler zone of late—in part because the problems plaguing this area tend not to discriminate.
That sunken, shadowy appearance that makes you look zonked even when you’re not—what doctors affectionately call a tear trough deformity—“spans ages and races, so there is no one demographic for under-eye filler,” explains Dr. Heidi Waldorf, a board-certified dermatologist in Nanuet, New York. “In fact, the under-eye is one of the most common starter areas for filler, for younger patients in my practice.”
Dr. David Funt, a board-certified plastic surgeon in Woodmere, New York, goes so far as to call tear trough correction a “universal treatment”—one that can benefit “young people who genetically have hollow eyes due to their bone structure” as well as “older folks as they start to get that V-shaped area of deficiency under their eyes.”
In other words, if we weren’t born with sleepy hollows, they’ll likely surface later in life. “It’s an aging change that occurs in everyone—the lower eyelid appears longer and distinct from the cheek,” he adds. The good news? Blurring that border can make the whole face look fresher.
Our experts’ go-to revolumizer for this part of the face is hyaluronic acid (HA); it’s temporary and can quickly be dissolved with an injectable enzyme called hyaluronidase, should something go awry or you simply not love the way it looks.
That sinking feeling: how our eyes change over time
With age, the bony socket of the eye recedes and elongates, and fat pads in the area deflate and drop as their surrounding ligaments relax. Once the overall support structure of the eye weakens, fat pads can herniate or protrude forward as puffy bags. Compounding matters, the inherently delicate skin of the lower lid thins and slackens as collagen and elastin production decline, putting all our under-eye frailties on full display.
The eyelid’s own evolving anatomy isn’t solely to blame for shadows, however. To the south sit the malar fat pads of the cheeks, which lend cherubic plumpness to the face in youth. Over time, they too shrink and sag, “making the demarcation between the lower lid and the cheek even more prominent,” adds Nashville board-certified oculoplastic surgeon Dr. Brian Biesman—so much so, he notes, that in many patients, replacing volume in the midface alone is enough to remedy tired tear troughs.
Related: The Surprising Reason I Tried Cheek Fillers for the First Time
Despite the broad appeal of this eye-brightening fix, tear-trough filler injections are not without controversy. One of the treatment’s most outspoken opponents is Dr. Raj Kanodia, a board-certified facial plastic surgeon in Beverly Hills, California, who’s taken to social media on more than one occasion to warn of its potential downsides.
“I am so against it,” he tells us. “I wouldn’t let anyone fill my under-eyes, and I won’t do it to anyone else. I probably lose close to $10,000-plus per week, but I am very firm in saying no, the under-eye should not be injected.” His reasons range from the rare risk of blindness (which can occur if filler enters and blocks the blood vessels feeding the retina) to the aesthetic eyesores that walk into his office daily. “I see people who were injected 10 years ago and they’re still suffering the consequences—they look like they have water balloons under their eyes,” he says.
While doctors debate the dangers inherent to the eye area—and we’ll delve into those shortly—they all agree that treating the under-eye requires finesse and expertise. “When I first started doing this, it was a specialized treatment that almost no one offered,” says Boston-based board-certified oculoplastic surgeon Dr. Mitesh Kapadia, who’s corrected roughly 5,000 tear troughs in the past 12 years. “Now injectors will take a weekend course and think they can fill under the eyes. But it’s definitely a complicated area to inject—there’s a lot less margin for error—and many providers simply lack the experience to get it right.”
According to Dallas board-certified plastic surgeon Dr. Rod Rohrich, success also hinges on the judgment of your injector, since “the key to excellent results in tear trough fillers is patient selection,” he explains. Hold up: Does that mean under-eye filler is maybe not so universal after all? Not necessarily. “Anybody who has a deficiency in the area will get improvement when it’s properly filled, so I don’t think there’s a group that we can’t treat,” says Dr. Funt. “But patients will get results of varying quality,” based on skin elasticity and other anatomical considerations.
Who’s the ideal candidate for under-eye filler?
“This is the million-dollar question,” says Dr. Sameer Bashey, a board-certified dermatologic surgeon who sees patients in New York City and Los Angeles. And nailing it requires not only years of experience but a deep understanding of the under-eye anatomy. Generally speaking, the best outcomes are enjoyed by those “who have good skin quality and true under-eye hollows, without significant eye bags or skin laxity,” explains Dr. Katie Beleznay, a board-certified dermatologic surgeon in Vancouver, British Columbia. Translation: young people with tight skin.
“If the skin is too loose, there’s nowhere to hide the filler,” says Dr. Kapadia. “You need tight skin to hold the filler back in place” and keep it from pooching out and looking lumpy.
Injectors are often tasked with improving not just hollows but also bags resulting from bulging under-eye fat—a much taller order, by all accounts. “I think there’s a mild to moderate amount of fat you can camouflage with filler, but if you have significant herniated fat, there’s no way we can put enough filler around it [to blend the bag] and have it look really good,” Dr. Biesman says.
Eyelid surgery—a lower blepharoplasty, specifically—tends to be a better option for conspicuous under-eye bags, yet most injectors will at least try to downplay the puff for patients who are reluctant to go under the knife. “We usually can soften the appearance of a bulging fat pad with filler,” says Dr. Funt (emphasis on the word soften). “Sometimes a subtle improvement is better than a perfect correction, because the correction may look odd but an improvement will look good.”
Interestingly, fat isn’t to blame for all varieties of under-eye bloat. According to Dr. Funt, “there’s a subset of patients, about 10% of the population, who have poor lymphatic drainage under the eyes—and when treated with filler, they accumulate fluid.” This condition, called malar edema, occurs when the filler compresses and stagnates the already sluggish lymphatic flow, causing a persistent puffiness right atop the cheekbones. “If there’s any question as to whether a patient will tolerate filler, because they have a hint of edema beforehand, I may treat them over more than one session, with very small volumes, to give the lymphatics a chance to adapt to the increased pressure on them,” he says. For those who don’t do well, hyaluronidase can dissolve the under-eye filler and resolve swelling.
The real risks of under-eye filler
Back to the juicy stuff.
Let’s start with the risk of vascular blockage or occlusion—the most dreaded under-eye filler complication, which can lead to skin death and irreversible blindness. This illustration of our vast vasculature makes it abundantly clear that the entire face is essentially a danger zone for filler. It’s hard to imagine plunging in a needle and not hitting a blood vessel.
That being said, certain arteries are more perilous than others. “The ones we generally worry about are the dorsal artery and the angular artery, which course along the side of the nose,” says Dr. Bashey. “But they’re pretty medial to where we’re injecting when correcting the tear troughs”—meaning those vessels are situated closer to the midline of the face. Of course, he concedes, actual human anatomy is rarely textbook perfect, and injectors have to account for vascular aberrations—rogue vessels that deviate from the norm.
However, Dr. Biesman insists that the under-eye, when filled properly, “is actually one of the safer areas to inject” and that “the relative risk of vascular compromise is surprisingly low.”
Dr. Beleznay, who has co-authored several studies on vascular compromise, confirms that while “there is a risk of vascular complications under the eyes, there are more reports [of blindness] from the glabella [between the brows], nose, forehead, and nasolabial folds.”
Still, Dr. Kanodia argues that blindness stemming from tear-trough injections may be underreported and that there’s really “no concrete data on blindness from under-eye filler [because] if it happens, it’s kept quiet,” he says.
As a medical advisor to filler manufacturers Allergan and Merz and someone charged with handling significant adverse events, Dr. Funt notes that “the under-eye does have communication with the angular artery, which connects with the dorsal nasal artery, which flows into the ophthalmic artery”—so while this area may not be as dicey as the nose, it does rank among the danger zones for blindness. He also reports having seen cases of inadvertent injection into the infraorbital artery, a large vessel with numerous circulatory connections that sits about seven millimeters below the bony orbital rim, directly in line with the pupil. A clog here could cut off blood flow to the skin or eyes. (Be sure your injector always has sufficient hyaluronidase on hand for emergency treatment. Vision loss tends to be permanent, but skin death can be prevented with a swift shot.)
While serious blood vessel injuries are exceedingly rare, aesthetic complications in the eye area are on the rise. “Poorly injected or overdone under-eye filler is the most common issue new patients come to me to fix,” Dr. Waldorf notes.
Related: 10 Concealers Almost As Good As Under-Eye Filler
The most ubiquitous symptoms of tear troughs gone wrong include a bluish tint under the eyes cast by HAs placed too close to the skin’s surface (aka Tyndall effect); temporary nerve injury; lumps; contour irregularities—and, perhaps the most vexsome of all, swelling, which can arise for myriad reasons, causing that water-balloon effect Dr. Kanodia described earlier.
Fluid fluctuations are part of what makes “fixing the under-eyes challenging for even the most seasoned injector,” says Dr. Bashey. The anatomy here is easily influenced by countless factors beyond the provider’s control, he explains—immune reactions, seasonal allergies, a history of eczema, salt intake, sleep patterns, medications, air travel, even changes in weather.
For most, recurrent swelling tends to wax and wane over the lifespan of the filler—typically a year or two, in this relatively immobile area—and can be largely controlled with antihistamines, steroids, and lifestyle adjustments.
But there are patients who see their tear trough filler (and related side effects) last much longer. Sometimes “years after an under-eye HA is successfully injected, patients will return complaining of new dark, puffy bags or circles,” says Dr. Waldorf. “The cause is unknown, but it appears that during metabolism, even two to five years after injection, some HA can migrate upward.” From this more superficial position just below the skin, “the HA can appear blue due to light reflection and cause swelling from water absorption,” she adds.
Bear in mind, “only a small percentage of people experience this forever-puffy filler look,” says New York City board-certified dermatologic surgeon Dr. Paul Jarrod Frank. “With the right filler and placement, the majority of people have good reactions and a normal metabolism of the product,” he says. For those in the minority? Hyaluronidase can usually melt any troubles away.
How pros avoid the pitfalls of under-eye injections
Knowledge is power—and crackerjack injectors, wise to complications, know precisely how to defend against them. Everyone we spoke to stressed the importance of choosing the right type of HA—a thin, soft gel that absorbs little to no water, like classic Restylane, Restylane Refyne, Restylane Silk, Belotero Balance, and Revanesse Versa. Dr. Biesman often finds a slightly denser HA, like Restylane Lyft, to be more effective in men with thick skin and a glaring lid-cheek divide. Several doctors warn against using Juvéderm fillers under the eye, asserting that these water-hoarding formulas are notorious for triggering and exacerbating swelling.
To keep under-eye fillers undetectable, injectors place HAs bone-deep along the lower rim of the eye socket, and slowly inject very minimal amounts. “I never use more than half a vial per side at one time,” notes Dr. Bashey.
The exact target for under-eye filler depends on the patient: is there an isolated hollow at the inner corner or a more widespread depression spanning the length of the lower lid?
“I think about filler in this area as improving the transition between anatomic margins—it’s like turning a deep canyon into a rolling valley and hillscape,” explains Dr. Waldorf. “It may be necessary to start injecting to the side or below the area first, to provide support, and then [we can] reduce the amount of filler required directly under the eye,” for a seamless effect.
One thing to absolutely avoid in every patient, she stresses, is “injections that blur the border between the cheek and nose,” creating the semblance of a snout.
An equally critical spot is the lateral canthus, or the outer corner of the eye where the upper and lower eyelids meet. Injectors tend to neglect this triangular divot, says Dr. Biesman, but “injecting it makes all the difference from an aesthetic perspective.”
When it comes to delivering the goods, some providers appreciate the precision of a needle for tear troughs, while others are loyal to bruise-reducing cannulas. There are also those who use both tools, basing their choice on the individual patient’s anatomy. Dr. Biesman, for instance, calls the cannula his workhorse, but notes, “there are times when I rely on needles too, like when I want to add just a couple drops at the lateral canthus,” he says.
In short, “there is no perfect tool,” Dr. Waldorf says. “What’s most important is the hand holding it.”
That’s the moral of pretty much every aesthetics story, is it not? When artfully injected, a hint of HA under and around the eyes can be transformative, waking up the face and filtering signs of aging. But filler in this area can sometimes behave unpredictably, so make sure your injector has the know-how to navigate the ups and downs.
