Treatment
Under-eye filler, and the harder question of whether you need it
Most people who ask for tear trough filler do not have a volume problem. They have a shadow, a pigment, a fluid or a skin problem — and filler makes three of those four worse. The assessment matters more here than anywhere else on the face.
- Appointment
- 40 to 60 minutes, including assessment
- Anaesthetic
- Topical; lidocaine is contained in the gel
- Onset
- Visible immediately; true result at 2 to 4 weeks
- Duration
- Commonly 9 to 18 months in this area
- Downtime
- Bruising possible for 3 to 7 days
What it is
The tear trough is the groove that runs from the inner corner of the eye along the orbital rim. Where it is genuinely hollow, a small quantity of a soft, low water-binding hyaluronic acid gel placed deep, on bone, beneath the orbicularis muscle, can restore the transition between lower lid and cheek. Quantities are small — often a fraction of a millilitre per side — and the technique is deliberately conservative.
Hyaluronic acid is used because it is reversible. Hyaluronidase dissolves it within hours if the result is not right. In an area this unforgiving, that reversibility is the entire argument for the material.
What is assessed
A dark or tired under-eye has at least five different causes, and they respond to completely different things. Injecting filler into all five is the single commonest mistake made in this area, and it is why so many corrected under-eyes look puffy, bluish or heavier than they did before.
- True hollowing — a real deficit over the orbital rim, best seen with the face lit from above. This is the only one of the five that filler treats well.
- Shadow from a projecting bag — herniated orbital fat casting a shadow. Filler here fills the valley below a hill and makes the whole area larger. Surgery, not injection, is the honest answer.
- Pigmentation — constitutional or post-inflammatory darkness of the skin itself, common in Middle Eastern and South Asian skin. No filler changes pigment.
- Fluid retention — morning puffiness that varies through the day, with salt, sleep and allergy. Hyaluronic acid binds water, so filler placed into a fluid-prone lid can hold onto it.
- Skin quality — very thin, crêped or lax lid skin shows any product placed under it. Thin skin is a reason to decline, or to treat the skin instead.
Midface support is assessed at the same time. A flat cheek drags the lid–cheek junction down, and in a good number of people the under-eye improves visibly when the cheek is restored and nothing is placed in the trough at all.
Who I decline
This is the treatment I say no to most often, and it is worth being direct about why. Turning down an under-eye is not caution for its own sake; it is the difference between a result you stop thinking about and one you spend a year trying to undo.
- Prominent fat pads with little true hollowing — a surgical problem being asked to behave like an injectable one.
- Malar oedema or a history of puffy lids — placing water-binding gel into a lid that already holds fluid is how long-lasting, difficult swelling starts.
- Very thin, translucent skin where any product will read as a bluish-grey line under the surface.
- Pigment as the main complaint — the shadow is in the skin, and moving the surface forwards will not lift it.
- Unresolved recent filler elsewhere in the midface that has not yet been accounted for.
In each of those cases there is usually something else worth doing, and I will tell you what it is even when it is not something I am the one to provide.
The appointment
Assessment
Examined seated and upright, under overhead light and then side light, at rest and smiling. The lid is pinched to judge skin thickness and the fat pads are palpated. Photographs are taken in standard views. This is where the decision is actually made.
Consent and planning
Product, plane, volume per side and the specific risks — vascular occlusion, visual compromise, Tyndall discolouration, prolonged swelling — are discussed before anything is drawn up. Hyaluronidase is kept on site at every session.
Placement
Almost always a blunt cannula through a single entry point per side, deep and on bone, with slow low-pressure delivery and small aliquots. You are shown the result upright, in a mirror, as it develops.
Review
Seen at two to four weeks. Under-eye filler settles more than most areas, and I would rather add a little at review than remove something at three months.
Risks and limits
The under-eye carries the highest stakes of any routine injectable site. The supratrochlear, supraorbital, dorsal nasal and angular arteries all run nearby and all connect back to the ophthalmic circulation. Inadvertent intra-arterial injection can, rarely, cause skin loss or visual compromise. This is why placement is deep, why a cannula is preferred, why pressure is kept low, and why hyaluronidase is on the trolley rather than in a cupboard.
- Bruising — common here. The skin is thin and the vessels are superficial. Three to seven days, occasionally longer.
- Prolonged swelling — the characteristic complication of this area. It can appear weeks later and can persist. It is treatable with hyaluronidase.
- Tyndall effect — a bluish cast when product sits too superficially. Correctable, but better avoided by placing deep.
- Lumps or irregularity — assessed at review and dissolved if they do not settle.
- Vascular occlusion — rare, urgent, and the reason for every precaution above.
Results vary between individuals. Nothing here is permanent, and nothing here is guaranteed.
After treatment
Sleep with your head raised for the first two or three nights and keep salt down for a week — both reduce the fluid that this area is prone to holding. Avoid heavy exercise, heat and alcohol for 48 hours. Do not massage or press the area unless I have asked you to. Makeup can go on after 12 hours.
Tell me straight away, on the number you have, if you develop pain that is increasing rather than settling, blanching or mottling of the skin, or any change in vision. Those are urgent and I would far rather see you for nothing.
Questions
Asked often
Am I actually a candidate for under-eye filler?
Only an examination answers that honestly. Roughly speaking, if the darkness is a genuine groove that softens when you lift the skin gently, filler may help. If it is pigment in the skin, a bulging fat pad, or puffiness that changes through the day, filler is the wrong tool and I will say so.
Will it get rid of my dark circles?
It will improve a shadow cast by a hollow. It will not lighten pigment in the skin, and it will not remove a bag. Many under-eyes are a combination, which is why the improvement is usually partial and worth agreeing on beforehand.
How long does under-eye filler last?
Commonly nine to eighteen months, and often longer than filler placed in mobile parts of the face because there is little movement here. Duration varies between individuals and cannot be guaranteed.
Is it painful?
Topical anaesthetic is used and the gel contains lidocaine. Most people describe pressure rather than pain. A cannula entry point stings briefly.
Why do some people look puffy afterwards?
Usually because too much was placed, it was placed too superficially, or it was placed into a lid that retains fluid. All three are avoidable at the assessment, and all three are correctable with hyaluronidase.
Can it be reversed?
Yes. Hyaluronic acid is dissolved with hyaluronidase, usually within a day. That is the reason nothing permanent is used in this area.
Can I have it before a wedding or an event?
Yes, with time in hand. Allow at least four to six weeks so bruising resolves and swelling settles, and so there is room for a review. Booking a few days beforehand is how people end up disappointed.
Also relevant
Related treatments
Consultation
Every face is read before it is treated
A consultation establishes whether this treatment is the right one for you. Sometimes the answer is that it is not.