Under-Eye Filler Candidacy: Anatomy, Risks, and Alternatives

There is no single filler that suits every under-eye concern: hyaluronic acid (HA) fillers are the type usually discussed for under-eye hollows, and specific HA products have FDA approval for that area, but whether any filler is right for you depends on what is actually causing the look you want to change. This guide explains the anatomy involved, who may or may not be a candidate, the risks to discuss, and the alternatives.

Is there one best dermal filler for under the eyes?

No product is right for everyone. The FDA reviews and approves dermal fillers for specific areas, and it notes that it may not have reviewed every filler for every location. Examples of FDA-approved hyaluronic acid fillers for under-eye hollowing in people over age 21 include Juvéderm Volbella XC and Restylane Eyelight. Filler placed in these hollows is often called tear trough filler. Approval is specific to the product, the area and the purpose, so ask which product your clinician plans to use and whether that use is on-label or off-label.

The material matters too. Clinicians may use hyaluronidase off-label to reduce HA filler, and the FDA notes that procedures to remove or reduce filler carry their own risks. The FDA cautions that fillers not made of materials such as HA, and especially long-lasting fillers, may be difficult or impossible to remove. For a delicate area like the under-eye, that difference is worth discussing before treatment.

What causes the under-eye look you want to change?

"Dark circles" and "bags" can come from several different sources, and filler addresses only some of them. Cleveland Clinic explains that with age the skin under the eyes loosens and thins, so blood vessels beneath it can show through more. Hollow areas called tear troughs can also develop, and they cast shadows that can make the eyes look puffier. Other contributors include genetics, eczema or allergies, rubbing the eyes, and extra pigment from sun exposure.

Puffiness can be a different problem altogether. The American Society of Plastic Surgeons (ASPS) lists fatty deposits that appear as puffiness, bags under the eyes, and excess skin and fine wrinkles of the lower eyelid among the concerns that eyelid surgery can treat. The under-eye filler approvals above cover hollowing, not eye bags, fine lines or loose lower-lid skin. Filler adds volume. It does not remove fat or skin, and it does not lighten pigment, so an accurate assessment of the cause comes first.

Who may be a candidate, and who may not?

People whose main concern is a hollow or sunken area under the eye are the group studied for the approved under-eye use. Filler may be less suitable when the main issue is a prominent bag, loose lower-lid skin, or darkness caused by pigment.

The Juvéderm Volbella XC labeling lists situations that rule out treatment or call for caution. It should not be used in people with severe allergies or a history of anaphylaxis, an allergy to lidocaine, or a past allergic reaction to HA fillers. Treatment should be postponed where there are skin sores, pimples, rashes, hives, cysts or infection. Tell your clinician if you:

• Take aspirin, ibuprofen, blood thinners or other medicines that can increase bruising or bleeding.
• Take medicines that lower your immune defenses, such as steroids or treatments for autoimmune disease.
• Are pregnant or breastfeeding. Safety in these groups has not been studied.
• Have a history of thick or raised scars, or of pigmentation disorders.
• Plan a laser treatment, chemical peel or other procedure after the filler.

Review every medicine and supplement you take with the treating team. The FDA also notes that filler safety is unknown in people under 22.

What are the risks of under-eye filler?

In the Volbella XC under-eye study, a majority of participants reported at least one side effect in their diaries. The most common were tenderness, bruising, swelling, lumps or bumps, redness, pain, firmness, discoloration and itching. Most went away within 30 days, though a few people had mild swelling that began months after treatment. Reports collected after approval also include nodules, inflammation, infection, allergic reaction, discoloration and filler moving away from where it was placed.

The most serious risk with any dermal filler is accidental injection into a blood vessel. The FDA states that this is uncommon but can cause tissue death, vision problems including blindness, and stroke, and these effects may not be reversible. The area around the eyes is one reason experience and anatomy knowledge matter so much in choosing who treats you.

The FDA recommends a licensed health care provider with experience in dermatology or plastic surgery who is trained to perform filler injections, and suggests asking about their training and experience injecting the face. The FDA adds that a filler treatment should be considered a medical procedure, not a cosmetic one, and advises injectors to know the signs of injection into a blood vessel and have a plan for how it will be treated.

When do you need urgent care after under-eye filler?

Seek emergency care right away for any change in vision, signs of a stroke (sudden trouble speaking, face drooping, weakness or numbness in the face, arms or legs, trouble walking, severe headache, dizziness or confusion), skin near the injection that turns white, gray or blue, or unusual pain during or soon after the injection. Get emergency help for trouble breathing or swelling of the face or throat that could signal a severe allergic reaction.

For less urgent problems, contact the treating clinic promptly. The Volbella XC labeling advises calling your doctor about significant pain away from the injection site, redness or swelling that lasts more than a few days, any side effect that appears weeks or months later, or any other symptom that worries you.

What are the alternatives to under-eye filler?

The right alternative depends on the cause. Cleveland Clinic lists several medical options for dark circles, including topical creams and lightening agents, chemical peels, laser treatments, injectable fillers, and eyelid surgery (blepharoplasty), which removes excess fat and skin. Pigment-related darkness may respond better to skin treatments than to volume. Bags from fat or loose skin are more often discussed as surgical concerns.

Everyday measures can also help. Cleveland Clinic suggests sun protection around the eyes, adequate sleep, and elevating the head to reduce fluid collecting overnight. Concealer is a simple, reversible option while you decide.

Questions to ask at your consultation

• What is causing my under-eye concern: hollowness, pigment, puffiness, loose skin, or a mix?
• Which product would you use, and is it approved by the FDA for the under-eye area or used off-label?
• Can this filler be dissolved if I have a problem or dislike the result?
• How do you reduce the risk of injecting into a blood vessel, and what is your plan if it happens?
• Would a skin treatment or a surgical consultation suit my anatomy better?
• Which symptoms should prompt a same-day call, and which need emergency care?

Prepare with the aesthetic treatment consultation checklist, read about facial aesthetics at Anew Laser MD, or use the contact page to ask whether under-eye filler is offered at your location. Individual results vary, and the treating clinician's instructions come first.

Independent sources

• FDA: Restylane Eyelight instructions for use, indication for infraorbital hollowing (PMA P040024/S135)
• FDA: Juvederm Volbella XC for undereye hollows, patient information labeling
• FDA: Dermal fillers (soft tissue fillers)
• Cleveland Clinic: Dark circles under the eyes
• American Society of Plastic Surgeons: Eyelid surgery
• FDA: Hylenex recombinant (hyaluronidase human injection) prescribing information, revised 01/2024 (approved uses do not include filler removal)