Under-eye filler: Dermatologists explain the cost, benefits and the risks

If you notice your under-eye area looking a bit hollow, dark or just tired, you might have what are commonly called "tear troughs."

It's not unusual for patients to complain of having shadows or "bags under their eyes," Dr. Ivona Percec, associate director of cosmetic surgery at Penn Medicine, tells TODAY.com. There are a few different underlying issues that can contribute to that, she says, such as hyperpigmentation, sagging skin as well as the basic anatomy of the eye area and genetic factors.

But tear trough filler isn't necessarily the best treatment for all of those issues, experts say, and it's a procedure that comes with unique risks for some rare but serious side effects if not performed properly.

"It's a very delicate process, and it's one that you really need to do your research on," Dr. Evan Rieder, a board-certified dermatologist and psychologist in New York City, tells TODAY.com. "Not all people who practice in aesthetics are gifted at treating the tear trough," he explains. "And not all people are honest with you about what can and cannot be done."

Before getting filler in this sometimes challenging area, here's what experts want you to know.

What is tear trough filler?

When injecting tear trough filler, a dermatologist or plastic surgeon will place hyaluronic acid filler into the under-eye area to give it a fuller, more awake look. But they need to be careful about exactly which type of filler they're using — one that's too hydrophilic, meaning it attracts water, can swell too much, Rieder says.

There's only one filler on the market that's approved by the Food and Drug Administration for use in the under-eye area, Percec says, which is Juvederm Volbella. "It doesn't absorb a lot of water and it's very smooth, so it's an ideal product for that region," she explains.

However, she adds, many injectors also use other fillers off-label for tear trough injections. It really comes down to the provider's personal preference, Percec says.

Who is a good candidate for under-eye filler?

Whether or not tear trough filler will be effective, "is really a lot about appropriate patient selection," Rieder says. "There's a lot of people who would think that they could get tear trough filler but they'd be very disappointed in the outcome."

An ideal candidate for under-eye filler is someone who has some shadowing under their eye that is due to volume loss or the migration of fat in the area, he explains. Sometimes, when a patient has a depression under the eye, "it'll look like it's pigment," he says. "But when you stretch the skin of the eye, the pigment sort of goes away."

However, tear trough filler is not going to be as successful in those with baggy or crinkly skin or in people who have bulges of skin and fat known as festoons, Rieder adds. "If (their skin is) too loose, they really would be a better surgical candidate because you could do more harm than good by injecting a filler," Percec agrees.

For patients with crinkly texture under their eyes, laser treatments are often a better option, Rieder says. Or, if the issue is solely due to pigmentation, then skin care, chemical peels or other laser treatments will likely be more useful depending on the patient's complexion and how deep the pigment is.

Above all, the experts stress, tear trough filler is such a nuanced procedure that it really pays to get a thorough consultation — in person, not via telehealth — with a knowledgeable expert. Rieder also suggests asking for before-and-after photos before deciding on a provider.

Tear trough filler safety and possible complications

The area around your eyes is extremely complex, so there are some unique risks associated with injections in this part of the face.

Compared to other parts of the face, like the lips or cheeks, the under-eye area has a lot of blood vessels, which raises the risk for significant bruising, Percec explains. As with all fillers, your results will be immediate, but "you want to let all the swelling and bruising settle down," she says. "And it usually takes a good two weeks."

To reduce swelling, Percec recommends patients take antihistamines before the procedure if they get seasonal allergies. Afterward, she recommends they use ice and arnica and gives patients anti-inflammatory creams to take home.

And to prevent some of that swelling, "Often we will underfill the tear trough with the assumption that it will swell and take on water," Rieder adds.

Additionally, if the filler is injected too superficially, patients can end up with skin that has a tint, like "a blueish sausage or blueish nodule underneath the skin," Rieder says. That's due to something called the Tyndall effect, which describes the different ways light scatters depending on the substance it runs into.

At the more extreme end, the filler can be accidentally injected into a blood vessel, potentially cutting off circulation to a part of the skin. "Or, in a super catastrophic turn events, that can go into an artery and then get pushed into the retina in the back of the eye and you can cause blindness," Reider says.

In these cases, providers need to immediately dissolve the filler using an enzyme they should have in their office. But, in some cases, the blindness is permanent, case reports show.

How much does tear trough filler cost?

The cost of under-eye fillers depends on the provider you're seeing and how much filler they need to use.

"We charge by syringe and it's typically around $1,000 per syringe," Percec says. "Typically, a patient will need one to two syringes for that region." Similarly, Rieder estimates most people can expect to pay between $1,500 and $2,000 for tear trough filler.

That might be more expensive than filler in other parts of the face, but keep in mind that tear trough filler frequently lasts longer than filler injected elsewhere. "There's not a lot of animation (under the eyes," Percec explains. "So the same filler used in the under-eye area lasts much longer than if you were to inject it around the mouth where you have a lot of motion."

Generally, tear trough filler will last between nine and 12 months, Rieder says, adding that he's seen it last up to 15 months in some patients. "Most of my patients for under-eye filler don't come back any more frequently than once a year," Percec agrees.

In the right patient, tear trough filler can make a huge difference in the under-eye area, the experts say. But, because the procedure can also lead to rare but serious complications, it's something you should only get done with an experienced injector who will talk you through the decision.

"These are necessary, but somewhat unpleasant conversations that we have to have every time before we do a filler injection," Rieder says, "but especially around the eye where we're in a very delicate area."

This article was originally published on TODAY.com