The Truth About Under Eye Filler

A seemingly quick fix treatment that has caught on like wildfire, your social media feed may have you thinking that under eye filler is a universal solution for common aesthetic eye concerns. While the treatment can be very effective for the right candidate, it – like just about every other cosmetic procedure – is not for everyone.

Until recently, under eye filler was an ‘off label’ (read: not approved by the United States Food and Drug Administration) use of hyaluronic acid-based dermal fillers. Earlier this year, the FDA approved Juvéderm® Volbella XC for the improvement of infraorbital hollows in adults over the age of 21. As part of this new indication, Allergan Aesthetics will be providing training programs, including how to assess facial anatomy holistically and the identification and management of potential complications, to anyone who wishes to inject. This is because injecting the tear troughs and hollows beneath the orbital rim is not without risk.

Good under eye filler can be transformative, but it can be hard to get it right. Not everyone wielding a needle is well-versed in the procedure, and not everyone who thinks they want the procedure is actually a candidate. Here, we investigate the under eye filler craze and why it's not a singular solution for all under eye concerns.

How Under Eye Filler Works

For some, under the eyes lives a slight depression in the skin that absorbs light rather than reflecting it. When darkness casts a shadow on this inner part of the eye, known as the tear trough, a crease between the upper cheek and the lower eyelid becomes evident. Most patients who desire under eye filler complain of a hollow, dark, tired-looking eye that does not seem to go away, no matter what skincare they use or do or how much concealer they layer on.

Blame your genes and the natural aging process for the cause of shadowing under the eyes. “The tissue structures supporting the eyelids weaken from aging or genetics,” says Michele Green, MD, a board certified dermatologist in New York City. “This weakening causes a hollowness and sagging of the skin in the under eye area, but hyaluronic acid fillers replenish volume to the area.” Although remediation with fillers is a relatively quick process, the procedure relies on dermal fillers placed into the deep hollows to replenish lost volume. Putting HA filler into deep under eye creases plumps them up so that the skin is smoother and can reflect light properly.

That, in turn, addresses more than just the tear trough. Injections can also help alleviate dark circles, which sometimes develop from volume loss in the lower eyelid fat pads, creating hollows, explains Snehal Amin, MD, an NYC-based board certified dermatologist. “By correcting underlying volume loss, shadows under the eye reduce,” he shares. “Volbella is FDA-approved for this indication, but it is imperative to seek out an experienced, qualified provider.”

Well-injected filler under the thin skin of the eyes are a great way to brighten up the eyes and reduce hollowness and that tired appearance from some of the tissues underneath the eye, says Usha Rajagopal, MD, a board certified plastic and reconstructive surgeon in San Francisco. She adds that smoothing out the grooves under the eye helps to improve the overall contour of the lower eyelid and, secondarily, reduce discoloration.

Since not all discoloration is an effect of shadowing and hollowing, it is crucial to identify the cause of discoloration before jumping into the under eye filler pool. For example, Dr. Amin says discoloration under the eyes can also be caused by rubbing the skin in cases of eczema or allergies. And, for this type of darkness, filler isn't the answer. “Instead, chemical peels or lasers best address this discoloration,” he says.

With no downtime, the effects of under eye injections using hyaluronic acid-based filler are immediate (save for some minimal and typical bruising and swelling). Within minutes of injecting the under eyes, patients can see a smoothness to the area, less darkness, and no more shadowing. The results generally last about a year.

Choose Your Injector Wisely

This is where it starts to get a little dicey. The array of providers offering under eye filler treatment ranges from board certified dermatologists and plastic surgeons to your strip mall med-spa injector. And because those who don't hold a medical degree or have years of experience don't know the pitfalls of injections around the eye or facial anatomy, you may be putting yourself in a dangerous position by not going to a qualified provider. “The success of under eye fillers is not solely dependent upon the product used, but also the skills of the injector, their experience, and their comfort level using the filler product,” Dr. Green says. “There is an increased risk for developing unwanted side effects when performing injections with an inexperienced or unqualified injector.”

All filler should be injected by a highly trained provider, but the under eye presents its own unique set of challenges. “This is not a med-spa procedure,” Dr. Amin cautions. “This is a medical procedure because of the complexity of the anatomy and the dangers of complications.” Additionally, the injector must be able to suss out who is a candidate and manage expectations accordingly. For example, filler is an acceptable treatment option when a patient has a bothersome hollowness without large under eye bags, says Jonathan Cabin, MD, a double board certified facial plastic and reconstructive surgeon in Arlington, VA. However, the addition of filler to bulging under eye bags (caused by protruding or displaced fat pads) will not do much of anything to correct the hollowness. “Patients must have realistic expectations of what can and cannot be corrected with filler and understand that filler will not improve wrinkles or primary dark circles,” Dr. Cabin explains.

In most cases, filler cannot correct excess skin or pigmentation-related color changes to the skin. Also, people with fluctuating lower lid and mid-cheek swelling (known as malar edema) are usually not fit for filler treatment since injections can exacerbate this condition.

The Issues with Under Eye Filler

Under eye filler is tricky because, as Dr. Rajagopal explains, volume deficits under the eye exist in many layers. “It can be deep and right next to the bone, just above the bone, or in the muscle layer or the skin layer,” she shares. “All these areas may need to be addressed differently in different patients.” Generally, the deeper the injection, the less visible the product. Furthermore, doctors must use a very thin filler in patients who require more superficial placement. If not, lumps, bumps, and even discoloration (i.e. the infamous blue tint) can ensue.

The most important takeaway with under eye fillers is that less is more. “A tiny amount of filler goes a long way,” Dr. Rajagopal says. “And the result should be an improvement of the area and not full correction because full correction leads to overcorrection, overfilling, a lumpy look, and often swelling underneath the eye.” It is important to remember that it is entirely normal to have mild depressions and some lines under the eyes. Attempting to eradicate them with too much smoothness can lead to an unnatural look.

Overcorrection is, unfortunately, a common mistake. It creates less distinction between the cheek and the tear trough, which causes the eye to get smaller from above, says Doris Day, MD, a board certified dermatologist in NYC. Too much filler makes the eyes appear small and squinty and, conversely, the cheeks look disproportionately big. “When you keep filling and adding layers, the eyes can look off-balance,” she explains. “Instead, the eyes may require opening and the skin may need some tightening, but the key is not to erase those points of distinction.” When you do, “the face looks distorted, and it's a look that everyone is walking around with,” she adds.

But the aesthetic concerns related to overfilling are just the half of it. There are also more serious issues to be aware of, including:

• Swelling: Mild swelling for 24 to 48 hours after treatment is to be expected, but long-term swelling that never goes away can occur. Patients with poor lymphatic drainage tend to hold onto more water and fluid in the eye area, so the addition of HA filler (which attracts water to plump) causes lasting fluid retention. Since certain fillers are more hydrophilic (meaning it holds onto water) than others, this presents the potential for the filler to puff a bit. Dr. Green adds that patients who present with bulging from water retention or sagging skin due to loss of elasticity should avoid under eye filler.
• Filler Migration: Filler that moves under the eyes isn't atypical. As Dr. Day explains, migration partially occurs because of constant movement in the area and ligaments that push the filler around a bit. When filler migrates, it can shift downwards or to the side and even take on a bumpy or lumpy appearance depending on the filler used and how much of it there is. “Sometimes, we don't see the effects for months or even years later,” she notes.
• Visible Product: Known as the Tyndall effect, a bluish tint to the skin can occur from placing the filler too close to the surface of the skin. Some fillers are more prone to this than others. “I prefer using Belotero® for the tear troughs because there is no Tyndall effect,” Dr. Amin says. Although this discoloration can technically happen in any area of filler used, Dr. Cabin says it is most commonly seen under the eyes because the skin is fragile. However, he adds that your provider can prevent the Tyndall effect by injecting filler in the deeper areas (over bone) and only injecting small amounts per injection while keeping the cannula moving.
• Vascular Occlusion: One of the more severe complications that can arise, vascular occlusion refers to accidentally injecting into an artery. When not immediately corrected (via HA-dissolving hyaluronidase injections), an occlusion can result in skin necrosis or skin death. While vascular occlusion and necrosis are rare, they do happen. Injection techniques that involve a pulling-back effect are critical, as is the correct type of injection tool (more on that below).
• Blindness: Blindness from filler injections is the most serious byproduct of an occlusion or blood clot that arises and blocks the typical blood flow pattern throughout and around the eyes. It's crucial to understand facial anatomy when injecting this area because there are far more blood vessels around the eye than other areas in the face. Although blindness from under eye fillers is the rarest complication, it is nothing to take lightly. A 2015 study found 98 cases of blindness related to the use of filler.

Your injector should use only hyaluronic acid-based filler under the eyes. “Non-hyaluronic acid fillers, like Sculptra® and Radiesse®, are too thick for this area,” Dr. Cabin says. "Also, Sculptra® and Radiesse® work over time by stimulating the body's collagen creation mechanisms, and movement around the eye can create irregularities as these fillers settle in.” While lumpiness as a result of HA filler is dissolvable with hyaluronidase, biostimulatory injectables are not reversible.

The Right Way to Inject Under the Eyes

When injecting under the eyes, your injector has the choice between two different tools to prevent less-than-ideal results and complications: a blunt-tipped cannula (a soft plastic catheter that cannot interrupt a vessel) or a needle. Both have their place, and it's up to your provider to choose the best one.

“The use of a blunt-tipped cannula to access the treatment area from below and just to the side of the lower eyelid is the gold standard for under eye treatment,” Dr. Cabin says. It nearly eliminates the risk of bruising, significantly reduces post-injection swelling, and also dramatically lessens the chance of a rare complication by preventing entry into the veins or arteries around the eye. “With all filler injections, injecting small aliquots while actively withdrawing the cannula helps reduce the risk of lumping or clumping and vascular or lymphatic disruption,” he adds.

All you have to do is think of how many times a day you blink to know the under eyes are an area of movement. They're anatomically complex, thin, and delicate, with an intricate network of several blood vessels and lymphatic drainage pathways. This makes filler placement more taxing than other parts of the face. “Therefore, under eye filler needs to be placed deep, just over the bone (periosteal), to be in an area that corrects the hollowness without causing any injury or disruption to the delicate structures of the under eye,” Dr. Cabin explains. “Placing the filler in a deep plane, just under the bone, also minimizes the risk of filler migration over time and will lower the risk of the Tyndall effect.”

Perhaps the best way to ensure good results (in addition to seeing a board certified dermatologist or plastic surgeon) is to make sure your injector has a deep understanding of facial anatomy, especially the periorbital area. “Many doctors inject filler as they withdraw the needle out of the skin; in other words, they push the plunger on the syringe as they pull the syringe backward,” Dr. Amin says. This technique prevents cannulation of blood vessels and limits the risk of intravascular filler injections.

Taking a Holistic Approach

The features of the face live in harmony, not isolation. To ensure that the under eyes look natural and not artificially augmented, Dr. Rajagopal says to look at the face as a whole. “When you look at a beautiful face, it's the entire face,” she shares. “Generally, not just one area makes someone beautiful, but rather a complement of how one area flatters the other.” Selectively filling the under eye and failing to treat the surrounding areas, like the cheeks, isn't usually the best approach. “Often, the eyelid-cheek conjunction is in continuity,” she shares. “So, to give the best results, it's important to inject part of the cheek along with the lower lid.”

A higher cheekbone or zygoma will pull the skin taught under the eyes. “Your doctor can inject filler into the cheek area to improve the under eye area,” Dr. Amin says. Plus, injecting directly into the cheeks instead of under the eyelids is safer. “Filler placement in the cheeks lasts a lot longer than the fillers used in the periorbital area,” he adds. Beyond the cheeks, the temples also need to be considered.

Sometimes, addressing the neighboring features is all it takes to create the effect of more refreshed eyes. “That’s why I address everywhere around the eyes before correcting them because it may just be an adjustment to the cheeks or brows that a patient needs instead,” Dr. Day says.

Does the Recent FDA Approval Change Anything?

As we mentioned, under eye filler was an off-label use (meaning it did not hold an FDA-approved indication) until the recent approval of Juvéderm® Volbella XC. “Volbella is a hyaluronic acid dermal filler with an innovative combination of low and high molecular weight technology, which improves the cross-linking efficiency of the hyaluronic acid chains,” Dr. Green explains. “In addition, this new Vycross technology delivers an ultra-smooth gel that is malleable, which results in a natural look and feel to improve the appearance of under eye bags.”

However, just because there’s now an FDA-approved filler for use under the eyes doesn’t equate to every dermatologist and plastic surgeon jumping on the Juvéderm® Volbella XC bandwagon. Some physicians, including Dr. Day, do not use like to use it under the eyes. “In general, I think it’s a problematic product,” she explains. “It can be somewhat unpredictable, and Juvéderm® tends to swell under the eyes.” While she concedes that the data from Juvéderm® Volbella XC “doesn’t show issues with it,” she prefers Restylane® and Belotero® for correcting under eye hollows.

So, does a new FDA indication mean that everything we know about under eye filler and its safety go entirely out the window? No. Like all aesthetic treatments, patients must weigh risk and reward. Dr. Cabin says whether a treatment or specific product is categorized as on-label or off-label has very little to do with safety and efficacy. “Receiving FDA approval is a very complicated and expensive process that can take years, so some filler manufacturers have to decide which on-label indications to pursue given these constraints,” he explains. “When a filler (or other aesthetic treatments) is not on-label, it doesn't mean they are less effective or more dangerous.”