Under-Eye Filler: Who Is It Suitable For, Who Is It Not, When Does the Swelling Go Down and How Long Does It Last?

What is under-eye filler and how does it work?

The groove that runs under the eye from the side of the nose towards the cheek is called the tear trough. When volume is lost in and around this groove through age, inherited facial structure or weight loss, a hollow forms under the eye and casts a shadow. In under-eye filler treatment, hyaluronic acid gel is placed into this hollow in small amounts; the aim is to soften the transition between the lower eyelid and the cheek and to reduce the shadow.

Hyaluronic acid is a molecule that occurs naturally in the body and attracts water. This water-attracting property may be regarded as an advantage in other areas of the face; under the eye, however, it calls for caution because it can increase the tendency to swell. For the substance itself and its use in other areas, see our article “Hyaluronic Acid Filler”.

Under-eye filler is not a general treatment for dark circles. It targets only the shadow created by the hollow; it does not change darkness that comes from the colour of the skin.

Which dark circles does under-eye filler correct, and which does it not?

A dark appearance under the eyes does not have a single cause, and in most people several causes are present together. What determines whether filler will help is which of these causes is the main one. The causes are explained in detail in our article “Dark Circles Under the Eyes”.

This distinction cannot always be made by looking in the mirror; during the examination the physician assesses the under-eye area in different lighting, while you look upwards and while you smile. The outcome of the examination may also be 'filler is not suitable for you'; this can be a sounder decision than going ahead with the procedure.

Who is under-eye filler suitable for?

Those who benefit most from under-eye filler are adults in whom the hollow and the shadow are the main issue, whose skin is relatively thick and elastic, and who have no prominent fat bags or tendency to puffiness. Realistic expectations are part of this description too: the aim is to soften the shadow, not to change the under-eye area completely.

Who is under-eye filler not suitable for?

• People with prominent under-eye fat bags: filler can fill the groove below the bag; the bag itself stays where it is, and the area may look fuller.
• People whose under-eye area is puffy in the morning, or whose eye area easily retains fluid because of allergies or sinus problems: the risk of prolonged swelling may be higher.
• People who already have puffiness or bagging over the upper part of the cheekbone
• People whose under-eye skin is very thin: the gel may show through the skin and create a bluish tone or irregularity.
• People in whom the main cause of the darkness is pigment or visible blood vessels
• People with marked excess and loose skin
• People who have earlier filler still in place in the area, or who have had a filler of unknown content: the existing situation needs to be assessed first.
• Pregnancy and breastfeeding: safety data are insufficient; the procedure is generally postponed.
• Active infection, a stye, an eczema flare or a cold sore around the eye
• A history of allergic reaction to filler components or to local anaesthetic
• A bleeding disorder or use of blood-thinning medicines: do not stop your medicine on your own; talk to your physician.
• Being under 18: under-eye filler for aesthetic purposes is not recommended in this age group.

This list is not complete. Tell your physician about any eye conditions, any eyelid surgery you have had, the medicines and supplements you take, and your previous fillers, even if they were done years ago.

Why is the under-eye a difficult area?

• The skin is among the thinnest on the face; a small excess or superficial placement is noticeable straight away.
• Fluid and lymph drainage in the area is delicate; a gel that holds water can upset this balance.
• The hollow is a narrow space; the difference between the right amount and too much is very small.
• The blood vessels around the eye are connected to the vascular system that supplies the eye.
• The appearance usually has more than one cause; filler targets only one of them.

For this reason, the approach of 'a small amount, and a second session if needed' is especially important under the eye. We do not go into the problems specific to this area, their causes and their treatment here; they are all explained in our article “Under-Eye Filler Complications”.

Is under-eye filler a licensed use?

Filler products are licensed on the basis of studies carried out for specific areas of the face; a product being approved for the lips or cheeks does not mean it is also approved for the under-eye area. The general information page on fillers of the US Food and Drug Administration (FDA) still lists injection around the eyes among unapproved uses. On the other hand, the FDA's approval records show that in recent years a small number of hyaluronic acid products have been given separate approval for the under-eye hollow.

The conclusion to draw is this: use in this area varies by product, and for many products on the market it falls outside the scope of the licence. Physicians may also use a product outside the scope of its licence; however, you have the right to know this and to discuss it during the consent consultation. The information above relates to the USA; in Turkey, ask the physician who will perform the treatment which product is licensed for which area, and ask for the product information in writing.

Who should perform under-eye filler, and where?

Under-eye filler should be performed in a healthcare facility by a physician who knows the anatomy of the eye area well, is experienced in this area and is able to manage complications. Ask in advance whether the enzyme hyaluronidase is available on site, what is done if a problem with vision occurs, and how you can reach the physician outside working hours. Non-medical settings such as beauty salons, homes or hotel rooms are not suitable for this procedure.

Preparing for the procedure

• Describe whether you have morning puffiness, your allergies and how your under-eye area changes during the day; if you have photographs taken at different times, show them.
• Mention your previous under-eye fillers, and when and with which product they were done if you know.
• Ask your physician about medicines and supplements that may increase the risk of bruising; do not stop your prescription medicines yourself.
• Do not schedule the procedure just before an important event; bruising around the eyes is conspicuous and may take time to fade.
• Come to the procedure without make-up; if you wear contact lenses, ask your physician.
• Read the consent form without hurrying; ask about anything you do not understand.

The day of the procedure, step by step: needle or cannula?

1. The physician assesses your under-eye area while you are sitting, in different lighting and with facial expressions, and agrees the aim and the approximate amount with you. Photographs are usually taken for the record.
2. The informed consent form is read; the risks, the licensing status of the product for this area and the options are discussed.
3. Make-up is removed and the area is wiped with an antiseptic solution. A numbing cream may be applied; in many products the gel itself also contains a small amount of local anaesthetic.
4. The gel is placed in small amounts with a fine needle or a blunt-tipped cannula, mostly deep, just above the bone.
5. Throughout the treatment the physician watches the colour of the skin. If you feel sudden, severe pain or any change in your vision, say so immediately.
6. At the end of the procedure the area is checked; aftercare advice and details of how to reach the physician are given.

There is no single right answer to the question of needle or cannula. Because a cannula advances from a single entry point, it is associated with less bruising; a needle, on the other hand, is preferred by some physicians for more precise placement. Both instruments have been used in published studies. The physician decides which one to use, and no instrument eliminates the risk of vascular occlusion. The procedure is short; even with numbing, prickling and pressure are felt.

When do swelling and bruising settle after under-eye filler?

In a meta-analysis bringing together 31 studies on under-eye filler and about 2,500 people, swelling and bruising were each reported in about one in five people; palpable irregularity and bluish discolouration were less common. Because the studies used different methods and follow-up periods varied, these rates are not exact; nevertheless they show that bruising and swelling are ordinary with this procedure.

The course of bruising and what counts as usual are explained in detail in our article “Bruising and Swelling”. Swelling that does not go away for weeks and increases in the mornings, or a bluish colour that does not turn yellow and fade, is not part of the usual course; show it to your physician.

Aftercare

• In the first days do not rub your eyes, press on the under-eye area or massage it.
• Apply cold only if your physician has recommended it, and in the way recommended.
• For eye make-up and eye-area products, wait for the period your physician recommends.
• In the first days stay away from intense exercise, saunas, Turkish baths and very hot environments.
• Your physician may recommend sleeping with your head slightly raised for the first few nights.
• Keep the product name and the date of the procedure; you will need them if you consult another physician years later.

Expected side effects and emergency signs

Bruising, swelling, tenderness and slight palpable irregularity in the first days are expected side effects. Less commonly, bluish discolouration (the Tyndall effect), a visible or palpable bulge, swelling over the upper cheek lasting weeks or months, swelling or nodules appearing months later and, very rarely, vascular occlusion may occur. In a systematic review collating published late-onset problems, the most frequently reported were swelling and nodules, and the problems appeared on average more than a year after the procedure.

What you should and should not do if these symptoms occur is explained step by step in our article “After Fillers: When Is It an Emergency?”.

How long does under-eye filler last?

There is no definite answer to this question. In a systematic review of studies on under-eye filler, the duration of effect was reported as between 8 and 12 months. However, more recent data suggest that the effect and the product can stay longer than expected in this area: in a study that looked back at the records of 155 people, the improvement in the under-eye hollow was still present at 18 months. This study was conducted at a single centre, is based on a review of photographs and case notes, and one of its authors declared a consultancy relationship with filler manufacturers; its results cannot be generalised to everyone.

The possibility that filler stays longer has two consequences. First, repeat treatments done by the calendar on the assumption that 'it has worn off' can lead to new product being added on top of product that is still in place, and to the area looking progressively puffier. Second, a filler placed years ago may be the cause of swelling today. We describe what imaging studies show on this subject in our article “Rumour: Filler moves around the face and migrates elsewhere — What does the science say?”.

Realistic expectations: what can under-eye filler not do?

• It does not erase dark circles; it can only reduce the shadow due to the hollow.
• It does not correct fat bags, excess skin or fine wrinkles around the eyes.
• Too much filler can lead not to a more rested look but to a puffier, more tired one.
• No promise can be made about the result; small differences may remain between the two sides.
• If you are not happy with the result or a problem arises, hyaluronic acid can be dissolved; however, dissolving is also a medical procedure, and prolonged swelling may not always resolve straight away.

How dissolving is done, and its limits, are explained in our article “Dissolving Filler (Hyaluronidase)”.

What are the alternatives to under-eye filler?

The option is chosen according to the cause of the appearance. The table below is a general framework; which one suits you is decided by examination.

In some people the under-eye hollow is a consequence of volume loss in the upper part of the cheek; in this case the physician may assess the midface before touching the under-eye area. This area is covered in our article “Chin and Cheek Filler”.

This content is for information purposes; it does not replace an examination. The method that suits you can only be determined by a physician's assessment.