The Curious World of Under-Eye Treatments
Under-eye filler has acquired a peculiar reputation for being both a popular choice in injectors’ offices and, as we're informed, one of the most challenging procedures. In recent months, several practitioners have turned to social media, warning against the use of certain fillers in the delicate tear trough area and emphasizing how strategic placement, technique, and patient selection can help prevent complications, both in the short and long term. (It's worth noting that tear trough filler is an off-label treatment, as no injectable gel is currently approved for this area.)
"The under-eye region is complex and among the trickier areas to treat on the face for achieving refined results," remarks Dr. Amelia K. Hausauer, a board-certified dermatologist in Campbell, California. Various elements contribute to the complexity of the tear troughs, including the quality and substantiality of the tissues beneath the eyes. Not only is the skin here the thinnest in the body, but fat is also scarce; combined, these factors make the area highly unforgiving. "There's less tissue to cover the filler, so lumps, swelling, and a blue discoloration from gel placed too high in the skin, known as the Tyndall effect, are more prevalent," Dr. Hausauer elaborates. Additionally, whatever fat exists in the region tends to sag and bulge, forming bags, which are difficult to disguise with filler, especially if your skin lacks elasticity.
Just beneath the skin of the lower eyelids lies a lymphatic system, responsible for clearing fluids and enhancing immune function. If clogged and incapacitated by improperly placed filler, pockets of puffiness can develop, fluctuating over time (at least until the filler is dissolved). Hyaluronic acid (HA) gels also attract and retain water, with some being more efficient than others, and can break down slowly in the tear trough region. Thus, if an unsuitable product is used, the under-eyes can appear swollen and soggy for years after injection.
Given the intricate anatomy of the tear troughs and the potential for issues, "only 30% of patients who come requesting under-eye filler ultimately receive that treatment due to candidacy," notes Dr. Flora Levin, a board-certified oculoplastic surgeon in Westport, Connecticut. She also removes a significant amount of tear trough filler that should never have been injected in the first place.
As injectors become more discerning about which dark circles truly qualify for filler, some are offering blood-derived platelet-rich plasma (PRP) injections as an alternative for selected patients. While the evidence supporting PRP's effectiveness specifically under the eyes is somewhat limited, the growth-factor-rich product has been shown to stimulate collagen production for thicker, smoother skin – making it a promising solution for tired under-eyes.
Ahead, experts explain who can genuinely benefit from tear trough filler; when PRP might be a superior option; and which under-eye problems require an altogether different treatment.
Who is – and isn't – a Candidate for Tear-Trough Filler?
"Patients with hollowness, excellent skin complexion, and minimal to no under-eye bags are the prime candidates," Dr. Levin tells us. For those whose dark circles are a direct consequence of volume loss – meaning there's an actual depression where the lower lid meets the cheek – a small quantity of HA gel can be injected deeply, beneath the skin and muscle, she says, to level the topography of the area and eliminate shadows in the most seamless manner possible. "Injectors must have an excellent understanding of anatomy to reach the appropriate injection level known to avoid complications," adds Dr. Hausauer.
Dr. Shereene Idriss, a board-certified New York City dermatologist, discovers that under-eye issues often arise due to volume loss occurring more laterally on the face – typically, in the temples and/or cheeks, which sink and flatten with age. So it's crucial for injectors to think comprehensively before acting locally – "to adopt a 360-degree approach and view the face as a whole when addressing the under-eyes," she adds, rather than focusing solely on inflating the tear trough. Dr. Hausauer concurs that addressing the cheek and under-eye area simultaneously "yields the most harmonious result, with a lower risk of overfilling the tear trough and other undesirable side effects," she says.
As we've discovered, the majority of people are not well-suited for tear-trough filler, despite the treatment's apparent prevalence. If you're typically prone to fluid retention under the eyes – related to chronic allergies or sluggish lymphatics – you might want to avoid filler, as it "can intensify existing swelling due to its hydrophilic [or water-attracting] properties," says Dr. Levin. Flaccid skin, which doesn't hold filler effectively, is another disqualifying factor. Doctors also hesitate before placing filler around under-eye bags (protruding fat pads), as the gel can easily make them look worse. "If the [fat] protrusion above the cheekbone exceeds the degree of hollowness, the patient is a better candidate for surgery," according to Dr. Levin. (A lower blepharoplasty can remove or reposition excessive under-eye fat to eliminate bags while tightening sagging skin.) However, in the right patient, strategically placed filler "can help diminish the distinction between a protruding fat pad and the cheek," says Dr. Idriss, by reducing its prominence and facilitating better blending. Our doctors agree that only minor bags can be concealed with filler and that mastering this technique for a truly natural appearance requires advanced skill and aesthetic judgment.
The Advantages and Disadvantages of PRP for Dark Circles
First and foremost: "PRP is a blood product collected using an FDA-cleared device," explains Dr. Hausauer. Whether it's applied to a freshly microneedled face or injected into the skin or scalp, these are considered off-label PRP uses. PRP in the under-eye area "shows considerable potential for safety and efficacy in small studies but still requires large-scale clinical trials to be better comprehended," she emphasizes.
Since PRP lacks the viscosity of a gel filler, "it's not as effective at restoring volume as filler is – but it has the potential to address different concerns," Dr. Hausauer adds. The existing studies exploring PRP for the under-eyes have found that it can assist in improving hyperpigmentation and significantly enhance skin firmness and elasticity, making it beneficial for the delicate area.
"PRP can perform miracles on dark circles and crepey skin under the eyes – when it works," says Dr. Idriss, highlighting that only approximately 30% of patients experience success with this treatment. (She recommends undergoing three sessions, spaced about a month apart, and then pausing to observe how your body responds.) "I always inform patients that PRP is not a magical cure but that it's worth attempting, especially for candidates who don't fare well with filler," Dr. Idriss states. Doctors frequently combine PRP with other procedures, such as lasers, radiofrequency, and microneedling, to enhance collagen growth and to "better address the complexity of the under-eye area," Dr. Hausauer says. She occasionally layers PRP injections over deeply placed filler for a comprehensive rejuvenation of the under-eye area.
Naturally, there are physicians who are less enthusiastic about PRP's potential for enhancing the eyes. "I find it frustrating because the results are inconsistent," says Dr. Nazanin Saedi, a board-certified dermatologist in Philadelphia. She laments the scarcity of data behind the treatment and reminds us that the precise mechanism of action of PRP is unknown. "I don't perform it frequently because I can't guarantee consistent, reproducible results," says Dr. Saedi, who reserves it mainly for patients seeking a "natural" alternative to fillers.
On the positive side, since PRP is more fluid than gel and not as thick as filler, it's much less likely to cause lumps and contour irregularities or to clog an artery, resulting in a vascular occlusion. Both filler and PRP injections can lead to temporary swelling and bruising under the eyes (though our physicians note that, in the case of filler, using cannulas instead of needles can help reduce bruising). Dr. Levin points out that results from PRP take weeks and multiple treatments, whereas filler, when done correctly, provides an immediate improvement.
As with any cosmetic treatment, managing expectations is crucial. "Because this is a new field with many unanswered questions, I'm very upfront with patients about not only the potential of PRP – I have witnessed it improve thin, pigmented skin – but also the limitations and the need for further investigation," summarizes Dr. Hausauer.
When Injectables Alone Aren't Sufficient
From wrinkledness to laxity, darkness to puffiness – it's almost unimaginable for such a small area of skin to bear so many burdens. But it's a common situation – and typically, numerous problems contribute to a tired appearance. That's why, "for many individuals, rejuvenating the eye area involves multiple types of treatments to achieve the best outcome," says Dr. Hausauer.
Discoloration alone can originate from several sources – excess melanin, blood vessels showing through translucent skin, shadows cast by hollows and bags – all of which can occur simultaneously. In such cases, the hollowness might respond to filler, says Dr. Saedi, but the vessels will require meticulous vascular laser treatment – trust only a laser specialist to target veins around the eyes – and stubborn pigment might need a series of picosecond laser sessions.
Adding to the darkness, there may be other anatomical factors at play. "Some patients have a roll of muscle under the eye that is mistaken for a tear trough – a thickening of the circular muscle surrounding the entire eye – which can be effectively targeted with off-label neuromodulators, such as Botox, Xeomin, Dysport, or Jeuveau," Dr. Hausauer tells us. "I also encounter patients with wrinkled or crepey skin [who] are more appropriately treated with lasers or other methods that build collagen and tighten the area – something filler alone cannot achieve as a standalone treatment."
So while filler is a staple for under-eye circles and PRP has its place, neither is a universal cure. When aiming to revitalize the eyes, your best option is to consult with a board-certified dermatologist or plastic surgeon, who can customize treatments based on your specific concerns.
