Everything You Need To Know Before Getting Undereye Filler

Illustrated by Vero Romero.
While it might seem like undereye filler exploded into the beauty conversation the moment Katy Perry copped to it, the reality is that it's been an insider Hollywood secret for well over a decade. Tear trough filler, the actual name dermatologists use for the procedure, does what creams or makeup never could: smooths the circles under the eyes by filling in the hollow that becomes deeper as we age.
While it's easy to understand why the filler spot has increased in popularity, it’s also one of the riskier places to inject on the face due to its proximity to the eyes. If it's something you're considering, it's not to be taken lightly and should only be performed by a board-certified medical doctor who specializes in their field — also called core doctors — like dermatology and plastic surgery.
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For everything you need to know, from the consultation and aftercare to the risks and pricing, we turned to three of the top injectors in Los Angeles. Click ahead for everything you need to know about tear trough filler, including a video to see exactly how it's done.
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Filling in the circles under your eyes sounds like a dream in theory, but the consultation is where you learn what comes along with the fairytale. Your provider should go over the side effects, risks, maintenance required, before-and-after images of their work, and price. Every city is different, but our experts in L.A. charge between $750 and $950 a syringe; most people only need one syringe to start, unless you have major volume loss.

This is also the time when your MD can determine if you're even a candidate to begin with. "People will come in thinking they need undereye filler when they don’t," board-certified dermatologist Karyn Grossman, MD, says. "Dark circles can be from discoloration or an indent." In other words, if the darkness under your eyes is a result of hyperpigmentation or a reflection of blood or muscle, filler won't do much.

"Tear trough filler is best for people who have minor fat pad bulges and can soften, but not erase, more significant fat pad bulges with some layering of filler," Dr. Grossman says. Some indents caused by fat pad bulges are genetic and can be seen in young people, while others find hollows develop or deepen through the aging process when collagen and elastin begin to break down and skin begins to sag.
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After covering your bases from a safety perspective, you want to make sure you choose someone whose aesthetic matches your desired end result. While there are many practitioners who offer it, the delicate procedure requires an experienced doctor with a trained eye. "Many people overfill the undereye," Dr. Grossman says. "But do you need to look younger than a 12-year-old?"

Board-certified dermatologist Ava Shamban, MD, agrees, adding that the area around the eyes is one of the hardest to achieve a natural result. Because the filler is injected above the bone, but below the muscle, the provider has to steer clear of veins in a very veiny area. A mistake here can result in unsightly or catastrophic results (more on that later).

Do your research, read every review you can, and prioritize quality and safety first. "This is not the time to use Groupon," Dr. Shamban says.
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First timers should only ask for hyaluronic acid dermal fillers, like Restylane, Juvederm, or Belotero. Yes, there are other options that last longer, including various forms of your own fat, but H.A. filler is the only reversible substance, which makes it ideal for newbies. And those three types in particular respond best to hyaluronidase, the substance injected to dissolve the filler if there is an emergency or the patient dislikes the result.

Which H.A. filler your provider chooses is important to the end result. Shamban prefers fillers from the Restylane family for this procedure, because you don't risk what she calls the "tyndall effect," or the blue-gray shadow that can occur when Juvederm is placed too close to the surface of skin.

Dr. Grossman agrees that Restylane is a more foolproof pick, but notes that Belotero is better for those with thin skin because it doesn't absorb as much water, so swelling is more minimal when you eat a big, salty meal. (Yep, filler can puff up a little when it absorbs water because it's hydrophilic.)
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We'll just come right out and say it: Yes, it will hurt. But your provider can apply topical numbing cream for 10 to 20 minutes beforehand to make the procedure more comfortable for you. Ahead of your appointment, you'll also want to avoid anticoagulants (blood thinners) like ibuprofen or aspirin, which can increase your risk of bruising. Lay off fish oil supplements and alcohol for as long as you can, too. (Some doctors say a day is fine, while others say two weeks is better.)

Of course, pain is relative, but most rank it a four to five out of 10: bearable, but memorable and 100% made worse by nerves. (Subsequent visits tend to rank closer to a two.) Your eyes will be sore as the numbing cream wears off, so get home and relax. But expect to feel fine by the following day. If not, follow up with your doctor.
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On the day of your procedure, your doctor will remove your makeup and cleanse your skin with both hibiclens (a medical-grade skin cleanser) and rubbing alcohol to prevent infection. Then, they will either inject your undereye area directly or use a cannula, which is a tiny tube that's inserted above the cheekbone and used to distribute product elsewhere, like under the eyes. Dr. Grossman and Dr. Shamban normally opt for a needle because it's said to be more precise, but board-certified dermatologist Annie Chiu, MD, sometimes uses a cannula because the risk of bruising is lower.

A skilled injector will go slowly, adding a bit of product at a time until they reach the desired result. “It’s important to do it in stages so we don’t over traumatize and have too much swelling,” Dr. Chiu points out. Most doctors will keep patients sitting up so they can assess the work as they go and try to limit the injection spots. "I usually do one to three entry points so you have less bruising," Dr. Shamban says.

Many doctors also mold the product with their fingers quickly after it's injected to shape it into place before it fully sets. The whole procedure should take about 15 minutes (post numbing) and your provider will immediately ice the area to reduce swelling and bruising afterward. It's important not to mess with your undereye area for the rest of the day because you want to avoid germs as much as possible. Makeup, for example, is a no-no.
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Some results will be visible immediately, albeit swelling means that you won't get a full picture until a few days later. The swelling should be on par with what your eyes look like after a sad movie or at the height of allergy season — nothing more and nothing a stranger would notice. If the swelling doesn't disappear after a few days, consult with your doctor.

“Undereye filler lasts between nine months and a year for the average person,” Chiu explains. Some fullness might stick around for longer depending on your anatomy and how quickly filler dissolves in your body — some even notice results for up to three years. Either way, all our experts recommend getting a touch-up before you lose all your results so you minimize the amount injected each time, plus any potential side effects.
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At this point, you're probably well aware that bruising is common. Some say it can be reduced with oral arnica and bromelain, but prepare to ice the area in 10 minute sessions throughout the first 24 hours. You'll also want to avoid working out for least a day, because raising your heart rate could exacerbate bruising.

If a nasty bruise does appear, Dr. Grossman has patients come back to the office for a quick ultrasound or laser treatment to help it disappear faster. Something called a "bleb" can also happen, which looks a bit like a welt in the injection spot. This means the filler was applied too close to the surface of the skin and needs to be dissolved.

Swelling and bruising are common, but more serious results can occur down the road. "Your filler could be fine then, six months later, your eyes are red, swollen, and tender," Dr. Grossman says. She says that's either a result of biofilm, which is a kind of infection that forms around the filler, or a sensitivity reaction that is developing to the filler. "That's treated with hyaluronate, antibiotics, and oral steroids," she says.
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Although incredibly rare, there are also vascular risks, like occlusions. "Any place that filler is injected can go into a blood vessel then go downstream and block blood flow to an area," Dr. Grossman says. "If it's just a skin occlusion, you see a blanching where the skin turns white and then it turns this dusty gray purple color and there are protocols that you do to deal with it."

But, in rarer cases, it can be much, much worse than that. "When a particle goes into a blood vessel and instead of going downstream to cause a skin occlusion it somehow has enough force to go upstream and into a larger blood vessel, and then back downstream from that, ocular occlusion [can occur]." That is, blindness or partial blindness in one or both eyes. The chance of this happening is a fraction of a percent, but that doesn't mean it's impossible, so it's important to consider.

Dr. Shamban points out that your risks slightly improve if you use a cannula, "But even a cannula can get into a vein," she says. Dr. Grossman agrees and adds that cannula occlusions have been reported. Which is why it's important to go to a doctor who can treat you in the event of an emergency, not a medi spa where the solution is to call 911.
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Press play to watch Dr. Chiu give a patient tear trough filler for the first time.
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Have a question we missed? Leave it in the comments below and we'll check in with our experts for the answer.
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