Why does the under-eye area call for a high level of skill?
The under-eye area, that is, the tear trough, is considered one of the more difficult areas for filler treatments, requiring particular care. There are several reasons for this:
- The skin is very thin. A small irregularity, too much product or superficial placement easily becomes visible.
- Lymph and fluid drainage in the area is delicate. Filler can affect how fluid is drawn in or drains away, leading to prolonged swelling.
- The blood vessels around the eye are connected to the vascular system that supplies the eye. For this reason, although vascular occlusion is rare, it can affect the eye.
- The appearance under the eyes does not depend on a single cause. Hollowing, fat bags, loose skin, increased pigmentation and fluid build-up can occur together; filler can only correct some of these.
For this reason, under-eye filler should be performed by an experienced physician who knows the anatomy of the area well and has the conditions in place to deal with possible complications. For the causes of darkness and circles under the eyes, see our article “Dark Circles Under the Eyes”.
How much swelling and bruising is normal after under-eye filler?
In the first days, bruising at the injection points, mild swelling and tenderness to the touch are common. Because the skin around the eyes is thin, bruising may look more noticeable, and the colour fades over time, turning yellow-green. Swelling increases in the first days and then goes down. You generally need to wait a few weeks to judge the result. For details about this process, see our article “Bruising and Swelling”.
What is the Tyndall effect? Why does a bluish tint appear under the eyes?
The Tyndall effect is a bluish or grey-blue appearance of the area caused by light scattering in the gel when hyaluronic acid filler is placed just under the thin skin below the eyes, that is, too superficially. The under-eye area is where this problem is seen most often. It can sometimes also occur when filler moves out of place or collects.
Some features distinguish the Tyndall effect from bruising: the colour does not turn yellow and fade, it can stay the same for weeks or even months, and a slight bump can often be felt underneath. This is not an emergency, but it can take a long time to go away on its own. Your physician may suggest dissolving the hyaluronic acid in the area with the enzyme hyaluronidase.
A purplish-bluish colour that starts suddenly, is painful and spreads like a net is not the Tyndall effect; it may be a sign of vascular occlusion. In this case, see the emergency warnings below.
Why does swelling that does not go away occur after under-eye filler?
One of the most difficult problems to manage after under-eye filler is swelling over the upper part of the cheekbone or in the lower eyelid that lasts for weeks or months. In medical terms this is called malar oedema. The swelling is usually more noticeable in the morning and may decrease during the day; it can get worse with salty food, alcohol, lack of sleep or hormonal changes.
The cause of this is not fully understood. The water-binding property of hyaluronic acid, the delicate fluid and lymph drainage of the area, the amount and type of product injected and a pre-existing tendency to swelling are among the factors that may play a role. The risk may be higher in people who already had morning puffiness under the eyes.
If the swelling is due to hyaluronic acid, the physician may consider dissolving the filler. However, malar oedema can sometimes persist for a while even after the filler has been dissolved, and treatment may require patience. Scientific knowledge on this subject is limited.
Visible filler, lumps and overcorrection
Filler under the eyes appearing as a band, bump or bead, being palpable or becoming more noticeable when you smile is one of the more common problems. These are usually linked to too much product, superficial placement or the filler moving out of place over time.
Overcorrection means the area looks swollen or baggy compared with its surroundings. Although it may seem paradoxical, filler used to correct under-eye hollowing can, when there is too much of it, make the under-eye area look more tired or puffy. It has also been reported that filler injected under the eyes can stay in the area much longer than expected. If you have had filler before, mention this at every new assessment.
According to literature reviews, the most frequently reported late problems after under-eye filler are swelling and nodules; these problems can appear months or even years later. A higher risk of nodules has been reported with fillers other than hyaluronic acid. For general filler problems, see our article “Filler Complications”.
The under-eye area is one of the most delicate areas of the face when it comes to fillers. Not everyone is a suitable candidate for this procedure; sometimes the right recommendation is not filler but a conversation about a different method.
Dr. Hamza GemiciMedical Director, DoktorClub · Aesthetic Medicine Physician
Can under-eye filler affect your vision? When is it an emergency?
Filler entering a blood vessel or pressing on a vessel is a rare but serious complication. Because the vessels around the eye are connected to the vascular system that supplies the eye, filler can, very rarely, disrupt blood flow to the eye and cause sudden loss of vision. Whitening of the skin, a purplish colour and tissue loss can also occur. In cases of vision loss, time is very limited; treatment options are limited and may not always be successful.
We describe what you should do step by step in our article “After Fillers: When Is It an Emergency?”. In short: any change in vision is an emergency, and do not lose time while trying to reach the physician.
Call 112 without delay or go to the nearest emergency department
- Blurred vision, darkening of the field of vision or loss of vision, even if only in one eye
- Double vision, a drooping eyelid or difficulty moving the eye
- Sudden, severe pain in or around the eye
- Speech problems, facial drooping, weakness in an arm or leg
- Shortness of breath; rapidly increasing swelling of the face, lips or tongue
Contact the physician who performed the treatment immediately (if you cannot reach them, go to the nearest emergency department)
- Whitening, or a purplish colour spreading like a net, under the eye, on the cheek or on the side of the nose
- Sudden, severe or steadily increasing pain
- The area being cold, colour that darkens over the following hours, blisters or crusting
- Fever, rapidly spreading redness, warmth or discharge
Who may not be a suitable candidate for under-eye filler?
Under-eye filler gives better results in people in whom hollowing and shadowing are the main issue and whose skin quality is relatively good. In the following situations, filler may not improve the appearance and may even make it worse:
- Prominent under-eye fat bags: filler can fill the hollow below the bag but does not remove the bag; the result may be a puffier look.
- Puffiness or bagging over the upper cheek, or pre-existing swelling under the eyes: the risk of prolonged swelling may increase.
- Marked excess and looseness of the skin: filler does not tighten loose skin.
- Darkness under the eyes mainly caused by increased pigmentation or visible blood vessels: filler does not correct discolouration.
- Filler injected in the area previously and still present: the current situation needs to be assessed first.
- Unrealistic expectations: filler does not turn the under-eye area into that of a young person; the aim is to soften the shadow.
For people with prominent fat bags and loose skin, options such as eyelid surgery (lower blepharoplasty) may be more suitable. This decision should be made after an examination by a physician who deals with eyelid surgery, such as an oculoplastic surgeon, a plastic surgeon or an ear, nose and throat (ENT) specialist.
Normal, see your physician, or an emergency?
| May be considered normal (keep an eye on it) | Consult your physician | Emergency |
|---|---|---|
| Bruising at the injection points with well-defined edges that turns yellow and fades over time | A bluish colour that stays the same for weeks (may be the Tyndall effect) | Any change in vision, double vision, eye pain: 112 |
| Swelling that increases in the first days and then goes down | Swelling that lasts for weeks and is worse in the morning | Whitening or a purplish colour spreading like a net: physician or emergency department immediately |
| Mild irregularity that decreases as the swelling goes down | A visible or palpable band, bump, or an overfilled look | Sudden, severe and steadily increasing pain: physician or emergency department immediately |
| Mild tenderness | Swelling or a nodule that appears months later | Rapidly increasing swelling of the face or tongue, shortness of breath: 112 |
What are the treatment options? What can your physician do?
Your physician will first examine you and ask which product was used, when and how much. If needed, imaging such as ultrasound may be used. Depending on the type of problem, the following options may be considered:
- Waiting and monitoring: most early bruising, swelling and mild irregularities resolve on their own.
- Dissolving the filler: with hyaluronic acid fillers, the physician can use the enzyme hyaluronidase for the Tyndall effect, overcorrection, visible or displaced filler and vascular occlusion.
- Medication: treatments the physician considers appropriate when an infection or an inflammatory reaction is suspected.
- Surgical assessment: if, after the filler has been dissolved, fat bags or excess skin are the main issue, eyelid surgery may be discussed.
- Referral: to ophthalmology in any situation involving vision; if needed, to oculoplastic surgery or other relevant specialties.
Hyaluronidase is also a medicine and can rarely cause an allergy; if you are allergic to bee or wasp stings, say so. There may be temporary swelling after dissolving, and sometimes more than one treatment is needed. Under-eye problems caused by fillers that do not dissolve in the body or that stay for a very long time are harder to treat.
What can you do at home, and what should you avoid?
- Follow the aftercare instructions your physician gives you; in the first days, do not press on the area around the eyes or rub your eyes.
- Record any changes, especially morning and evening swelling, with the date and a photo.
- Keep the product type and treatment date with you.
- Try not to be alone in the first hours, and pay attention to any change in your vision.
Do not do the following:
- Unless your physician recommends it, do not massage the under-eye area or squeeze a bump.
- Do not apply heat or ice without consulting your physician.
- Do not use steroid creams, eye drops or other prescription medicines on your own.
- If your vision changes, do not wait for it to pass; do not take a painkiller and hope the symptoms go away.
- Do not have new filler injected under the eyes somewhere else to fix the problem.
How can under-eye filler complications be prevented?
To reduce the risk:
- First have the cause of your under-eye appearance clarified through an examination; filler is not the solution to every under-eye problem.
- Have the treatment done by a physician who knows the anatomy around the eyes well and is experienced in this area, in a licensed healthcare facility.
- Ask whether the product to be used is hyaluronic acid; discuss whether dissolvable products are preferred under the eyes.
- Find out whether hyaluronidase enzyme and emergency facilities are available where the treatment is done.
- Mention morning puffiness, allergies, eye conditions, any previous under-eye fillers and eyelid operations.
- Discuss starting with a small amount and, if needed, proceeding gradually.
For general safety advice, see our article “Reducing the Risk of Complications”.
Questions to ask your physician
- What is the main cause of the appearance under my eyes: hollowing, fat bags or pigmentation?
- Is under-eye filler suitable in my case, or could it make the appearance worse?
- My under-eye area gets puffy in the morning; does this increase my risk of prolonged swelling?
- Is the product you will use hyaluronic acid? Can I have the product information in writing?
- Are hyaluronidase enzyme and emergency facilities available here?
- Could my previous under-eye filler still be present?
- What should I do if my vision changes, and how do I reach you?
- Might eyelid surgery be more suitable for me than filler?
Frequently asked questions
Does the bluish tint after under-eye filler go away?
A bluish tint caused by bruising usually turns yellow and fades within days. A bluish colour that stays the same for weeks may be the Tyndall effect and can take a long time to go away on its own. With hyaluronic acid fillers, your physician may suggest dissolving the product with the enzyme hyaluronidase.
How long does swelling last after under-eye filler?
Swelling from the procedure usually increases in the first days and then goes down. In some people, however, swelling over the upper cheek may develop that lasts for weeks or months and is worse in the morning. In this case, see the physician who performed the treatment; treatment may require patience.
Can under-eye filler cause loss of vision?
Although very rare, loss of vision has been reported when filler enters a blood vessel. For this reason, if you have any change in vision, double vision or eye pain during or after the procedure, call 112 without delay. It is important to have the procedure done where the conditions exist to respond to this risk.
Can people with under-eye bags have filler?
In people with prominent fat bags, filler does not remove the bag and can make the area look puffier. For these people, options such as eyelid surgery may be more suitable. The decision should be made after an examination.
Can under-eye filler be dissolved?
Hyaluronic acid fillers can be dissolved by a physician with the enzyme hyaluronidase. There may be temporary swelling after dissolving, and sometimes more than one treatment is needed. Fillers other than hyaluronic acid cannot be dissolved this way.
Can under-eye filler cause problems years later?
Rarely, swelling, nodules or discolouration have been reported months or years after under-eye filler. It is also known that filler can stay in this area longer than expected. If you develop a new complaint, be sure to tell your physician that you have had filler before.
Should I massage the area after under-eye filler?
Not unless your physician specifically recommends it. The skin under the eyes is thin, and random massage can cause the filler to move or the swelling to increase. If you notice an irregularity, consult your physician first.
Sources
- Complications associated with infraorbital filler injection (Reddy S, Nguyen TA, Gharavi N). J Cosmet Laser Ther 22(6–8):226–229 — Journal of Cosmetic and Laser Therapy, 2020
- Complications of Periocular Dermal Fillers (Wang Y, Massry G, Holds JB). Facial Plast Surg Clin North Am 29(2):349–357 — Facial Plastic Surgery Clinics of North America, 2021
- Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review (Trinh LN, McGuigan KC, Gupta A). Facial Plast Surg 38(3):250–259 — Facial Plastic Surgery, 2022
- Infraorbital Hollow Rejuvenation: Considerations, Complications, and the Contributions of Midface Volumization (Woodward J et al.). Aesthet Surg J Open Forum 5:ojad016 — Aesthetic Surgery Journal Open Forum, 2023
- Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature (Beleznay K et al.). Aesthet Surg J 39(6):662–674 — Aesthetic Surgery Journal, 2019
- Tear trough deformity: review of anatomy and treatment options (Stutman RL, Codner MA). Aesthet Surg J 32(4):426–440 — Aesthetic Surgery Journal, 2012
Medical Aesthetics Expert Board
This article has been reviewed by the DoktorClub Medical Aesthetics Expert Board.
