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Designer Under Eye Bags: Tear Trough Filler

Updated: Jan 27, 2021



The under eye, or tear trough, is one of the more delicate and complex areas that dermal filler is commonly used to treat. Every single tear trough, even between your own two tear troughs, are different. Features under the eyes that injectors assess are the orbicularis retaining ligament line, inferior orbital fat pad, sub orbicularis oculi fat pads (SOOF), and medial cheek fat.



Most people are bothered by the ligament line that surrounds the eye (orbicularis retaining ligament, or ORL). Filler can be used to fill that line, but surrounding structures must be balanced the create a smooth, seamless tear trough.


What is Under Eye/Tear Trough Filler?

Fillers that are used today under the eyes are made of Hyaluronic Acid, a molecule occurring naturally in your body. Dermal fillers are made of lab made hyaluronic acid (or HA), and are used to provide hydration or volume to the area they are injected in.

Dermal filler can be used to hide the prominence of ligament lines and replace lost volume in the mid face.


How Does Under Eye/Tear Trough Filler Work?

HA filler is injected, or placed in the tear trough by use of a needle or cannula. HA filler is a gel-like substance that draws water to it. We call filler that draws water to it 'hydrophilic.' There are different types of HA fillers brands. The most common HA fillers are Juvéderm, and Restylane family fillers. Think of Juvederm and Restylane as a last name. Juvederm fillers include Juvederm Voluma, Juvederm Vollure, Juvederm Volbella, Juvederm Ultra XC, and Juvederm Ultra Plus XC. Restylane fillers include Restylane Refyne, Restylane Defyne, Restylane Lyft, Restylane Silk, Restylane-L, and Restylane Kysse.

The fillers have different consistencies. Consistency of filler is measured by viscosity, elasticity, and cohesivity. The more firm the filler is, the greater the viscosity. The higher the G' (G prime), the less elasticity, or greater the stiffness it has. They also have different amount of hyaluronic acid and cross linking. The greater HA content, the more hydrophilic, and the greater the cross linking, the longer it can last.

Once the filler is placed, the tear trough will need to heal. The filler will integrate with the tissue more and more over time. Our body breaks down hyaluronic acid the same way it breaks down our natural hyaluronic acid.


What Are The Risks of Under Eye/Tear Trough Filler?

Injection Site Reactions

The most common risks are injection site reactions such as bruising and swelling. The eyes are the most common area to bruise and swelling is expected. Bruising happens when a blood vessel is punctured, which happens with a needle. A cannula can decrease this risk. A cannula is a blunt, flexible tube that travels through the tissue. The blunt end decreases the risk of puncturing vessels, though the risk is still possible. Swelling is also decreased with a cannula, though swelling under the eye is almost guaranteed for the first 2-4 weeks.

The three major adverse events with dermal filler are infection, rejection, and occlusion.

Infection

When we get a needle poke or scratch of any kind, this creates an opening to our body that has the potential for infection. The provider should clean the injection site with an appropriate antiseptic before injecting. Do not wear makeup for 24 hours treatment and keep the area clean to decrease the risk of infection.

Rejection

This is an incredibly rare risk where our bodies can identify the filler as a foreign body and attack it with our immune system. This looks like inflammation and nodule formation an average of eight weeks after treatment. It is not something minor, and truly is a reaction. The severity may vary. This is every so slightly more likely with the presence of an autoimmune disease, where the autoimmune system is already hyperactive. This can also happen after or during an intense illness.

Occlusion

This is the scariest risk with filler anywhere in the face. This is also a very rare risk. There are arteries, or large blood vessels in the face. In the tear trough there is the infraorbital artery. If filler is injected into an artery and the artery becomes blocked from flow, the tissue that relies on the artery for blood and oxygen can die. This may result in a scab or a scar if not treated immediately. This looks like severe, throbbing pain after the injection, along with visible blanching or a stark white appearance of the tissue. It usually occurs immediately upon injection.

A properly trained practitioner is constantly assessing for this risk while injecting. This risk can happen to any provider, no matter how long they have been injecting, but is detrimental in the hands of an untrained practitioner. Once identified, the filler reversal agent will be injected, and the occlusion will be reversed. Reversing an occlusion can be difficult. The sooner the occlusion is reversed, the skin will have less damage.

Symptoms of an occlusion include severe pain, blanching, mottling of the skin, and blistering. The longer the tissue is unable to get blood and oxygen, the tissue will begin to die. A cannula decreases the risk of occlusion by being less likely to puncture blood vessels. It is still possible to occlude an artery with a cannula.


How Much Does Under Eye/Tear Trough Filler Cost?

The price of the filler depends on a lot of factors. These factors include the volume of fillers injected by the practice, the demand of the injector, the license, the location, and the type of practice. Tear trough fillers cost anywhere from $550-$1000+. Anything under $500 as a standard price is very suspicious. Pharmaceutical companies may run promotions with a practice, where they get access to different discounts. If this is the case and the product is verified by the pharmaceutical company, you will be enrolled in a rewards program by the pharmaceutical company.

Can I Get A Half Syringe Under My Eyes?

You can absolutely get any amount less than a full syringe injected in any given area, but syringes are sold by the pharmaceutical company as 1mL, or full syringes (except for Volbella which offers a half syringe). If you are offered to purchase a half syringe, you are getting an opened, unsterile syringe of filler. What is most common is to purchase a full syringe and use the rest in other areas of the face.


What Should I Do Before My Under Eye Filler Appointment (Pre Care)?

Avoiding blood thinners to prevent the risk of bruising is a good idea. Common blood thinners are alcohol, aspirin (and NSAIDs), fish oil, gingko biloba, ginseng, and garlic. If you are on a prescription blood thinner, it is possible to have injections as long as your primary care gives the okay and you are not in critical health.

Do take supplements like Bromelain and Arnica to help decrease your risk of bruising and severity of swelling. You can take them for three days to a week prior to the appointment and continue to take them while healing.

If you have high anxiety or are really nervous, you may have a history of fainting with injectables, like getting needle pokes or giving blood. This is called vasovagal syncope. To avoid fainting, make sure you have eaten before the appointment, avoid coffee, and be hydrated. Communicate your fainting history to your provider. It helps to talk during the treatment, or be distracted. To avoid fainting, make sure you do not hold your breath. Relax your upper body. If you feel yourself about to faint, squeeze your abdominal muscles, and tell your provider so they can lay you down.

If you love to workout, plan your workout before your appointment. Working out is discouraged for a few days after filler.


What Are Under Eye Filler Appointments Like?

First your provider will assess your concerns and expectations. They will assess your face and check your medical history. You should disclose any medical conditions, allergies, medications, and current pregnancy or breastfeeding information. The only people who should not get filler are those who are pregnant, breastfeeding, severely or acutely ill.

They should take baseline pictures in consistent lighting of your treatment area to store in your chart. They should educate you on the risks of the procedure. They should assess the characteristics of your facial features.

You will likely have numbing cream on for at least 30 minutes if you arrive on time and check in promptly. I have heard of some clinics that do not numb.

Your mid face will be cleaned and prepped, and they will inject the product with a series of injections with a needle, or two injection sites with a cannula. It will take about 10-25 minutes. You may bleed from the pokes. You will still feel the needle pokes even if fully numb.


What Should I Do After My Under Eye Filler Treatment?

Do not wear makeup for 24 hours. Do not work out for the first few days because it can make your filler swell. Avoid blood thinners for the day after your treatment. Do take healing supplements like arnica and bromelain to help facilitate healing. Do gently massage your under eyes if you see bumps a few days after treatment. Not all providers want their patients to massage their filler. Do ice under the eyes to help the swelling and pain. Do sleep sitting upright if you would like to decrease your swelling. Do schedule a follow up after two weeks if they are not satisfactory.


What Does Lip Filler Feel Like Under The Eyes?

Nobody ever told me this, but the first time you get under eye filler, it will feel like there is something under your eyes for the first two weeks to month. After the first month, that firm feeling goes away as the filler softens. Once fully healed, under eyes look smooth, lifted, and brighter from the light being able to catch the skin under the eyes better.


What To Expect From Under Eye/Tear Trough Filler

If you express your goals and expectations to your provider, your provider should be able to educate you on if those goals and expectations are realistic or not, and what they recommend.

In the first few days after tear trough filler, it is normal for the filler to be quite swollen. Sometimes filler can gather and create bumps. Sometimes filler bumps do not fully resolve on their own and need to be touched up either by massage or by placing a small drop of Hyaluronidase, the reversal agent for filler. This does not take away from the tear trough, only the bumps.

One syringe looks different for every person. You may not get the result or have the experience that a friend of yours had. Bodies are very different, and lips are very different.

Important Considerations

Something that I tell patients very often is DO NOT strive for perfectly smooth under eyes unless you are considering surgery. Non-surgically, filler hides and blends the structures under the eyes. Your eyes fluctuate greatly. If you look up with your eyes, the fat pads under your eyes protrude more. If you look down with your eyes, the fat pads hide and look more smooth. Filler will not create perfection at every angle with the presence of a protruding fat pad, or inferior orbital fat, the fat we call the eye bag.

If your fat pad protrudes past the area of tissue surrounding it, you cannot have perfectly smooth under eyes. You cannot match a puffy fat pad with filler, because you will end up with big, round, bulging under eyes to match the fat pad. If your fat pad protrudes, surgery is the best option with a facial plastic or oculoplastic surgeon. The surgery is called a lower blepharoplasty, in which they alter the fat pad so it becomes perfectly smooth.

If your mid-cheek below your eyes is flat, especially if you are a woman, and you fill only your under eyes, you will be left wondering why your eyes are filled but you still look tired. The cheek needs to be filled to create a seamless slope with the under eyes. The under eyes need to have a concavity to them for them to look natural. They also need to be supported by the cheek.

Once again, your eyes fluctuate. At the beginning of the day, your eyes may be smooth (if you are naturally more sunken in) or puffy (if you have a protruding fat pad) due to the face holding more fluid at the beginning of the day. At the end of the day, you may notice the structures under the eye become more apparent because the fluid has dispersed away from the face throughout the day due to gravity. With filler, you will still encounter this phenomenon.

DO NOT treat something that is only visible in certain lighting or certain times of the day. If it changes throughout the day, treating it will change the area for the entirety of the day. If something that bothers you is not visible or identifiable in the clinic at the time of treatment, it should not be treated. Chasing these fluctuating imperfections can often lead to body dysmorphic tendencies. It is not realistic to have perfect facial features 100% of the time, or at all.


Which Type of Filler Should I Choose For My Under Eyes?

It is best to defer to the injector to choose your lip product. When I inject patients, I get a feel for the look and outcome the patient is expecting. Here is a small bit of information to help you get an idea of what filler type you may want.

We do not want filler under the eye to be puffy, so we choose less hydrophilic fillers. Some people will do best with soft filler superficially while some do best with more firm filler placed deep for structure. Some need both. Firm, structural fillers include Voluma, Lyft, and Defyne. Softer fillers for under the eyes include Volbella, Refyne, Defyne, and Vollure. Juvederm Ultra XC and Ultra Plus XC (commonly referred to as Juvederm) are very hydrophilic and are not likely to be used under the eyes.


Am I A Good Candidate for Under Eye/Tear Trough Filler?

You are not a candidate if you pregnant or breastfeeding, expect a perfect result, or do not accept the risks that come with the injection. Filler is a medical device that is bound to the rules of science. It does not work like makeup. It is also very possible to not see significant results. If you are not okay with this, you are not a good candidate.

A good candidate is someone who is looking to add support or soften visible structures under the eyes. They understand and consent the risks of the injection. They understand they cannot achieve perfection, and that less is more under the eyes. They do not expect absolute perfection without a touch up. They are able to be local to the clinic two weeks later in case they need a touch up.


If you live in Southern California, specifically Los Angeles, Orange County, or San Diego, schedule to see Jasmin in Costa Mesa, California for Under Eye or Tear Trough Dermal Filler Augmentation. Consultations are free.


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