Are you fed up with how you always look tired in the mirror? Is the hollowness underneath your eyes so severe that no amount of makeup can conceal it?
You are not alone. The eyes are usually the first facial feature that you will notice when looking into the mirror. In recent years, an increasing number of both men and women are seeking filler treatment to resolve their tired-looking eyes.
In order to treat undereye hollowness effectively, we need to first understand what causes it. Undereye hollowness worsens the appearance of dark eye circles and makes one look tired and old. This happens because of either a true or pseudo tear trough deformity.
In true tear trough deformity, the skin beneath the eyes is attached directly to the underlying muscle and bone causing a concave appearance.1 This is more evident in some individuals due to genetics, and start early on in the teenage years.
On the other hand, pseudo tear trough deformity is caused by aging due to mid cheek fat volume loss with aging. This leads to a lack of structural support of the undereye therefore revealing hollowness underneath the eyes.
A test that your practitioner should perform prior to filler treatment is to push the fat in the lower cheeks up to see if the undereye hollowness improves. If it does improve, the tear trough deformity has a component of being caused by volume loss in the mid cheek.
Often, most patients have a combination of both true and pseudo tear trough deformities. Both are anatomical problems that can only be solved by filling the hollowness, and more hours of sleep or hydration will not resolve this issue.
Your practitioner’s choice of filler and where to place the filler will depend on his or her assessment of what is causing your undereye hollowness. In pseudo tear trough deformity, the mid cheek volume loss should be replaced by using a thicker filler for more projection and lift. This should be injected deep in the mid cheek fat pad.
In the treatment of true tear trough deformity, a finer and less hydrophilic (water absorbing) filler should be used to fill between the skin and muscle in the undereye. Not only is the type of filler important, the amount of filler and injection technique are keys to avoid complications from overfilling such as lumps and the Tyndall effect (a bluish hue of the skin when light is scattered by filler particles injected too superficially or in large boluses).2
Undereye filler technique
Filler to correct the tear trough can be performed either using direct needle or cannula technique. My preference is to use a cannula even though it its technically more challenging because it helps to reduce the risk of complications and is more comfortable for my patients. Further, using the cannula technique is a one-step approach to fill both the mid cheeks (in pseudo tear trough deformity) and the undereye (in true tear trough deformity) using the same single-entry point.
The cannula which has a round blunt tip, is inserted after a small needle is used to create an entry point at the side of the cheek. The cannula threads through the tissues without piercing through any veins leading to less bruising. It also provides the injector with a much better feel of the tissue planes to inject filler at the correct depth. It takes experience to feel and recognise the correct tissue depth using a cannula.
It is important for you to understand that the tear trough should generally be underfilled. This is because the skin underneath your eyes is extremely thin and a tiny amount of filler placed in this area will cause a significant difference. Instantaneous results with undereye filler will generally look even better in 1 to 2 weeks’ time as the filler particles draw water leading to volume expansion. Therefore, it is important to slightly underfill in the first treatment session followed by a follow up in 2 to 3 weeks to decide if a filler touch up is required, for the most natural outcome. It is natural to have slight residue hollowness underneath the eyes after filler treatment. This provides some margin for fluctuations of the filler when your body is more hydrated in the morning leading to filler volume expansion or less at night.
Contrary to popular belief, undereye filler is not as painful as it looks. The skin underneath the eyes is thin and adheres to the underlying muscle and bone. Therefore, you may feel a slight discomfort rather than a sharp pain when the cannula glides between the skin and underlying structures.
During mid cheek filler procedure to correct pseudo tear trough deformity, you may feel an initial soreness as the cannula bypasses the muscle containing nerves in the more superficial plane to reach the deep fat pad. Injecting fillers into the deep fat pad itself is an almost painless manoeuvre. Factors that will help to reduce discomfort include topical anaesthetic to the skin before the procedure and lidocaine that is present in the fillers.
This depends on the type of filler that is chosen by the doctor and how quickly the individual metabolises the filler material. On average, the finer hyaluronic acid fillers used for true tear trough deformity last between 6 to 9 months whilst the thicker hyaluronic acid fillers used for mid cheek deep fat pad volume replacement last between 12 to 18 months. In my practice, I also use collagen stimulators such as calcium hydroxyapatite (Radiesse) and polycaprolactone (Ellanse) to fill the mid cheek to provide longer lasting results.
As you can see, undereye filler is an advanced procedure requiring excellent understanding of facial anatomy and experience in injecting. When performed by a skilled practitioner, it is associated with minimal risks. Bruising and swelling may rarely occur in the delicate undereye area which usually resolves in a few days to a week.
Complications such as filler lumps and the Tyndall effect caused by too superficial and/ or too much filler injected can be avoided with experience.
In summary, non-surgical rejuvenation of the undereye for brighter looking eyes can be safely accomplished giving a natural result using the right fillers and technique under an experienced injector. As always, it is important that your practitioner performs a proper physical examination and provides a detailed explanation of the treatment steps prior to embarking on any aesthetic treatment.
Written by Dr. David Deng,
Disclaimer: The material contained in this is for informational purposes only and do not constitute medical advice. The content is not intended to be a substitute for doctor's advice, diagnosis, or treatment.