Injectables / Rejuvenation Dermatology Calgary South
Tear trough filler is the hardest injectable treatment on the face and the one most often regretted. In the right patient it can soften a hollow that makes the eyes look tired. In the wrong patient it produces puffiness, a bluish tint or a heavier lower lid that lasts far longer than anyone expects. Dr. Paul Kuzel, MD FRCPC, turns people down for this treatment regularly, and that is the point of the consultation.
What it is
The tear trough is the groove that runs from the inner corner of the eye downward and outward along the orbital rim. It exists because the skin of the lower lid is the thinnest on the body, the tissue there is tethered to bone by ligaments, and there is very little fat between the two. As the midface deflates and the orbital rim recedes, that tether becomes a visible line and the shadow it casts reads as tiredness.
Under eye filler places a small amount of hyaluronic acid gel deep in that groove to soften the step. What it cannot do is fix a dark circle that is not caused by a shadow, and this is where most disappointment comes from. Four different problems produce what patients describe with the same words.
A real depression along the orbital rim casting a shadow. This is the only one of the four that filler directly addresses.
Constitutional or post inflammatory pigmentation in the lower lid skin. It is darkness in the skin itself, not a shadow. Filler does nothing for it.
Blue and purple tones from veins showing through very thin skin. Filler placed underneath can help slightly by adding cover, and can also make it worse if placed too superficially.
Orbital fat bulging forward over the rim, creating a bag with a shadow beneath it. Adding filler in front of the bulge fills the valley and enlarges the whole area. This is a surgical problem.
Who it suits
With most injectables, technique determines the result. Here, selection does. A well chosen patient treated adequately does better than a poorly chosen patient treated brilliantly.
This is the part that is often left out. In an unsuitable candidate, under eye filler does not simply fail to help. It creates a new problem on top of the old one.
The lower lid has poor lymphatic drainage, and hyaluronic acid binds water. In tissue that is already prone to fluid retention, gel placed in or above the wrong plane can produce persistent puffiness over the cheekbone. This is called malar oedema. It can appear weeks or months after treatment, it is worse in the morning, and it can last as long as the product does, which may be years. It is one of the most common reasons patients come in asking to have under eye filler dissolved.
The second problem is the Tyndall effect. When hyaluronic acid gel sits too superficially under very thin skin, the skin scatters shorter wavelengths of light and the area takes on a bluish grey cast, sometimes as a visible line following the trough. A patient who came in about dark circles now has a lighter coloured but bluer, more obviously treated under eye. Both of these are treatable with hyaluronidase, and both are better avoided.
Filler changes contour. It does not change texture, fine lines, laxity or pigmentation, and no amount of it will. If the complaint is crepey skin, fine wrinkling or a dark tone rather than a groove, the useful treatments are the ones aimed at the skin itself: consistent sun protection, appropriate topical therapy, and where suitable, energy based or biostimulatory treatments. Skinvive is a hyaluronic acid microdroplet treatment intended to improve the smoothness of cheek skin rather than to add volume. PRP and exosomes are sometimes discussed for the under eye area, and it is worth being clear that the published evidence for them here is limited and mixed. None of these is a guaranteed substitute for filler, and none of them fills a hollow.
Very often the safest and most effective plan does not involve injecting the tear trough at all. Supporting the midface can improve the appearance of the under eye by restoring the platform the lower lid sits on, without putting product into the thinnest skin on the face. See cheek filler.
What happens
Dr. Kuzel examines the lower lid in different lighting, checks skin quality by pinch, tests for fluid, looks for fat prolapse and festoons, and asks about morning puffiness, thyroid disease, kidney disease, allergies and previous treatment or surgery. If you are not a good candidate, you will be told so at this appointment, along with what would actually help.
Sometimes that means treating the cheek and reassessing the under eye afterwards. Sometimes it means treating nothing and addressing skin quality instead. Where filler is appropriate, the plan is deliberately conservative and expects a second visit.
A firm, low water binding, low spread gel is used here, quite deliberately. The soft, highly hydrophilic gels that work well in lips are the wrong choice under the eye because they attract fluid. Both the Juvederm and Restylane families include gels formulated for this area.
Small volumes, placed deep, on or just above the periosteum below the orbital rim, keeping under the muscle rather than in the superficial layers where Tyndall and lumps occur. A blunt cannula through a single lateral entry point is often preferred because it reduces the chance of piercing a vessel and reduces bruising. Very small amounts are used per side.
The area is reviewed sitting up, in normal light and with a mirror. Undercorrection is intentional. Filling a tear trough to what looks complete on the day almost always looks like too much at four weeks.
This appointment matters more here than anywhere else on the face. Any residual hollow can be topped up, and any early sign of puffiness or discoloration can be addressed with hyaluronidase before it becomes established.
Afterwards
Malar oedema. Persistent puffiness over the cheekbone caused by hydrophilic gel in an area with limited lymphatic drainage. It can start weeks or months after treatment and can persist for as long as the filler is present. Treated with hyaluronidase.
Tyndall effect. A bluish grey discoloration from gel placed too superficially under thin skin. It does not fade on its own while the product is there. Treated with hyaluronidase.
Lumps, ridges and asymmetry. More visible here than anywhere else because there is so little tissue covering the product.
Vascular occlusion. The infraorbital and angular arteries run near this area, and they connect with the ophthalmic circulation. Filler entering an artery can cause skin necrosis and, rarely, partial or complete vision loss, which is usually permanent. It is rare. It is also why volumes are small, delivery is slow and low pressure, a cannula is often chosen, and hyaluronidase is kept on site. Sudden vision change, severe pain or spreading discoloration after filler is an emergency: call the clinic and seek care immediately.
Infection and delayed nodules. Uncommon, and treatable, but they need to be seen rather than waited out.
Hyaluronic acid is the only filler category that can be directly reversed, and that is the single most important reason nothing else belongs under the eye. Hyaluronidase is an enzyme injected into the treated area to break the gel down. It usually takes effect within days and can be repeated if needed. It is not perfectly selective, so it temporarily affects some of the hyaluronic acid your own tissue contains, and the area can look hollower than it did before for a couple of weeks while that recovers. Allergic reaction is possible but uncommon. Anyone who offers you a permanent or semi permanent filler under the eye is offering you a problem that cannot be undone.
Questions
Next step
Dr. Paul Kuzel, MD FRCPC, is a board certified dermatologist and the founder and Medical Director of Rejuvenation Dermatology Calgary South. For the under eye, the consultation decides whether the treatment should happen at all. He sees patients in English and Czech.
Dr. Paul Kuzel, MD FRCPCBook a consultation Call (403) 286-6888
Related pages: cheek filler, hyaluronidase, Skinvive, PRP, exosomes.
