How to choose the best filler under eyes and tear trough

Is one type of filler the best for under eyes and tear troughs?

The delicate area under the eyes is a popular area for facial fillers because this treatment can eliminate or reduce dark circles and eye bags without surgery.

But there are many types of under eye filler and which one works the best and is the safest?

Note: This blog post is my opinion based on my extensive experience and specialized training in oculoplastic and cosmetic surgery but I discuss off-label applications for FDA-approved fillers.  Every person is different and you need to discuss the best options for you with your doctor.  Ultimately, if you carefully choose an expert in under-eye filler treatments, she or he will select a filler or combination of fillers that works well for them based on their experience and skill.

Permanent fillers that I don’t like to use under the eyes

kotlus trough and under eye filler

Before I describe the best under-eye fillers I want to share the list of fillers I don’t use under the eyes. There are always exceptions but in general I don’t use these fillers for the under-eyes.

I treat many patients who have had these fillers with untoward results.

I don’t like to use permanent or semi-permanent injectable fillers under the eyes.  These include Belafill (made of plastic beads floating in pig collagen), Radiesse (calcium spheres floating in hydrogel), Silicone (or Silikon 1000), and Sculptra.   These fillers are not reversible and lumps and bumps can be difficult to correct if the filler isn’t placed in exactly the right place.  In my opinion, it’s not worth the aggravation and potential for permanent problems in an area that can be unforgiving.  There have been many occasions in my NYC practice when I’ve had to do surgery to remove permanent fillers from someone’s under-eyes.

The safest fillers for the under-eyes and tear trough (HA gel)

kotlus restylane

Currently the best fillers for the under-eyes for the vast majority of people are made of cross-linked hyaluronic acid (HA) gel.  They are soft, pliable, and most importantly, reversible. If there is a problem with a lump or a bulge or a discoloration (tyndall effect) or a bubble from the filler, I can take it away with an enzyme injection that dissolves the filler.

There are a lot of different varieties of HA gel fillers and the number of choices are growing.  These include the Restylane family, the Juvederm family and Belotero.

Which are best?  They all act differently when they are under your skin and have different stiffness, flexibility, dispersion, and swelling behaviors.  The right mix of characteristics makes for the right filler for the job.

The list of under-eye HA fillers

I still choose Restylane-L as the best under eye filler because of it’s great behavior profile.  I explain why later.  But first, below is a list of FDA-approved HA fillers (which are all off-label for under eyes) and how they work for the under-eyes and tear trough:

  • Restylane

    This is not the newest filler but for under-eyes it’s still the best.  It has the right balance of stiffness, cohesivity, duration of effect (about a year under the eyes), and relatively low swelling.  It can also be fine tailored for deep or shallow injections by modifying the filler through hydration.

  • Belotero Balance

    This filler is popular for under-eyes because it’s very forgiving for the injector.  It is not very stiff and it tends not to lump up or cause discoloration but the downside is that it doesn’t provide great lift if there is a deep tear trough.  It’s an acceptable choice but in my opinion not as versatile as Restylane.

  • Juvederm Volbella and Juvederm Vollure

    These are newer fillers within the Juvderm family.  They Volbella is softer and Vollure (also known as Volift outside the U.S.) is stiffer.  They cause less swelling than the older variety of Juvederm products and are good options for shallow (Volbella) and deeper (Vollure) injections under the eyes. My slight hesitation in giving these my highest rating is that a low incidence of inflammatory nodules (bumps) have been reported to occur after 4 months with Volbella.  It’s a low risk but I haven’t seen this type of problem with Restylane or Belotero.

  • Restylane Refyne and Restylane Defyne

    These fillers have a different type of crosslinking than regular Restylane making them more “flexible” which can be of benefit in areas with a lot of facial movement (especially around the mouth).  There is benefit of using Refyne in the “crow’s feet” area but so far there is no shown benefit over regular Restylane for the under-eyes.

  • Restylane Silk

    This is the thinnest, softest version of Restylane but it also has the highest swelling capacity.  Not the best choice when it comes to the thin under-eye skin which doesn’t take well to significant swelling.

  • Juvderm Ultra and Juvederm Ultra Plus

    I’ve used Juvederm Ultra for under-eye filling in the past and I’ve mostly switched away from these for this area because they swell more, are more likely to spread out causing the treatment to be less accurate and the product to end up in a different place than where it was meant to be injected.

  • Juvederm Voluma

    This thicker version of Juvederm is best for cheeks but not great for under-eyes.  It tends to look lumpy and can also create long-term swelling.  It’s also resistant to dissolving with hyaluronidase so it can take several office visits to remove it from the under eyes.

kotlus restylane tear trough

Before and after Restylane (placed with a cannula) for under-eye bags and dark circles

What about fat injections under the eyes?

Fat injection, also known as fat transfer or fat grafting is a permanent filler that uses your own fat cells to add volume, similar to injectable synthetic fillers.

I frequently perform under-eye fat grafting but usually in conjunction with cosmetic eyelid surgery to blend and provide volume support to the areas around the eyes (temples, under the brows, under-eye hollows, and cheeks).

Many surgeons are reluctant to do under-eye fat injections and may even criticize this procedure.  I find it to be safe and effective and it’s success depends very highly on the technique being used.  I process the fat in a sterile, closed system, I place conservative amounts of fat in the deepest level with very small fat parcels in each location.

Fat grafting is less predictable than filler because some of the cells being injected will not survive, but even at a 50% survival rate the benefits can be very worthwhile.

Dr. brett kotlus cosmetic oculoplastic blepharoplasty lower ny

I performed under-eye and cheek fat injections with a lower eyelid lift surgery to smooth this woman’s under-eyes

You may have had the wrong under eye filler if you see:

Swelling that lasts longer than a few weeks

Lumps that don’t dissipate

Blueish discoloration

Uneven appearance

Unwanted results arising from the wrong under eye filler can often be corrected but it’s important for you to seek a cosmetic eyelid plastic surgeon who specializes in this delicate area.  Oculoplastic surgeons are best trained to manage these issues and in NYC I frequently correct under-eye filler problems.  Your first step is arranging a consultation with an expert.