Cosmetic Fillers to Rejuvenate Lower Eyelid Area - Dark Circles and Under Eye Hollow

Eyes are the first area on the face that starts betraying age. Visibly that aging frequently looks like an under eye hollow, dark circles, and deflated look. Correcting under eye puffiness is not reviewed here. Click here if you want to jump to the under eye fillers summary table.

​Under eye area is different from other parts of the face because the skin is thinner and more delicate, and because anatomically this area has a more complex structure than other areas of the face. Injecting fillers under eyes requires advanced techniques, and we will re-emphasize the importance of selecting a knowledgeable and experienced injector. Also, not many fillers work for this area.

Anatomically, the under eye hollow consists of the tear trough deformity (from the nose or the inner corner of the eye, down) and palpebro-malar grove aka ocular-malar groove (the hollow circular line from the outer age of the eye down till the middle where it meets the tear trough).

CONTENT
​What Causes the Aged Look of the Lower Eyelid Area? 
The Best Treatment Areas and Sequence to Achieve Naturally Looking Results
The Most Suitable Cosmetic Fillers to Treat Under Eye Area (and what not to use)
Summary Table of the Fillers Best Suited for Under Eye Injections

What Causes the Aged Look of the Lower Eyelid Area?

There are several factors working together that create an aged look under eyes. Visibly that aged look is expressed in dull looking thin skin with lines and wrinkles and the under eye hollow semi-circle frequently combined with a dark circle. Those factors are - 

• First, the under the eye hollows are partially caused by the deflation of the deep fat pockets in the cheeks underneath the eye area; they are located deep below the skin. Those two deep fat pockets are Buccal fat and the Deep medical cheek fat on the picture. These two deep fat compartment are a structure that also holds the eye area tissue in a youthful position. When that support diminishes, the tissue located directly above them, that is immediate under the eye, flattens and sinks down. The deflation of the deep fat pockets commences around the age 30 - 35. Therefore, this factor is not applicable to someone younger than 30 years of age.

Correction of those two deep fat pockets should be performed with a volumetric, firmer and longer lasting filler like HA based Teosyal RHA 4, Juviderm Voluma, or Restylane Lift or possibly with the Calcium based Radiesse or Poly-L-Lactic acid based Sculptra.

The other three components creating an aged look around the eyes are located directly underneath the eye. 

• The second reason for the aged eye look is the deflation of the deep fat pockets directly under the eyes. ​On the picture where the deep fat pockets are marked (above), those are the two SOOF, Lateral and Medial, pockets. When we look at the facial layers on Facial Anatomy Layers drawing (below), that is layer 5. Those two deep fat pockets of the deep fat layer are the Lateral and Medial SOOF fat pockets of that fat deep fat layer (see the picture above). 
• The third reason of the aged under the eye appearance is aging of the skin itself (layer 1). More precisely, as we age, starting in our 20s, the quality of the dermis starts deteriorating. There is less collagen, elastin and hyaluronic acid. 
• Finally, the fourth reason for the aged eye look may be thinning of the superficial fat layer (layer 2 on the picture), and here you can also see where precisely those superficial fat pockets are located. Visibly, thinning of the superficial fat pockets has almost the same effect on the aged look as the thinning dermis does. This layer typically gets thin in very slim/fit people, including those who have lost a lot of weight. 

The Best Treatment Areas and Sequence to Achieve Naturally Looking Results

One of the reasons why we often see that a face is 'done' and can tell that a person has had filler injections is because the injections were done incorrectly. ​For example, an injection was done where the aging is visible and not where it actually occurred. Such results do not look natural.

With the eye area rejuvenation, for someone in there 30's and above, it is highly desirable to - 

• first restore cheek/mid face volume. That on its own, without an injection around the eyes, will also partially improve under the eye hollow and sagging. ​Typically, volumetric fillers are used that hold the shape and stay in place. The injection is performed deep under the muscle. For someone earlier than 30 years of age (sometimes up to 35), this step is not needed as the problem is more superficial; 
• The left-over under the eye hollow and dark circle (in medical terms, tear-trough deformity and palpebro-malar groove) are treated with Hyaluronic Acid based fillers as described below, addressing the three other reasons for the aged look of the lower eyelid. To address aging of the layer 1 – dermis of the under the eye skin - and layer 2, superficial fat pockets, fillers are injected in the dermis.

Besides the HA based filler injections, there are other options for restoring volume and/or rejuvenation of the skin layer under the eye e.g. more traditional fat transfer, ALMI injections or PRP injections. 
Read more about options for the volume restoration in the publication Restoring Volume.  

The Most Suitable Cosmetic Fillers to Treat the Under the Eye Area

The thickness and composition of the Hyaluronic Acid (HA) fillers used in the dermis (skin) is different from the thickness and composition of the fillers used under the muscle.  

There have been accounts of nodule formation from Sculptra (poly-L-lactic acid) injections under the eyes.
Radiesse (Calcium Hydroxylapatite) is too thick for under the eye injections.
For this reason, Hyaluronic Acid based fillers are best suited for treating under the eye area. 
 
Note that in the USA, FDA has not approved any filler for injecting under the eyes; cosmetic fillers are used to treat the eye area off-label (doctors are allowed to do that; off-label means that such a use is not stated on the manufacturer's label/insert/advertising for the product). Having said that, HA fillers have been successfully used under the eyes in Europe and off-label in the USA for many years. 
 
For the restoration of the under the eye volume (to compensate for the deep fat loss), based on the properties of the HA fillers and from the experience of the injectors with the fillers approved in the USA, the clear preference is for and recommendations are  -

1. Restylane or Restylane –L (Galderma) (not the newer Restylane varieties such as Defyne, Refyne, Lyft or Silk) – deeper under the muscle injection to compensate the loss of volume in the two deep fat pockets under the eyes. If injected superficially in the dermis, Restylane may cause what is called Tyndall effect (the bluish discoloration in the injection area); or
2. Belotero Balance (Merz) – either deeper or more shallow injection; or
3. Vollure (Allergan) (outside USA sold as Volift) for the deeper under the muscle injections to compensate for the loss of volume in the two deep fat compartments under the eye
4. A somewhat recently (2018) FDA approved filler in the USA is Revanesse Versa. It is a somewhat thicker filler, 25 mg of HA/ml. Some injectors consider it versatile and inject it under the eyes. We did n to include it on the summary table because there is not sufficient volume of information to recommend without reservations it for the under the eye injections. 

For the more superficial injections into the under eye dermis, to compensate its thinning and quality deterioration -  

1. Volbella (Allergan); or 
2. Belotero Balance (Merz). 

Summary and comparison of the dissolvable Hyaluronic Acid based fillers best suited for use under the eyes is shown in the table below.  ​​

Summary Table of the Fillers Best Suited for Under Eye Injections

Comparison Point/Filler	Belotero Balance	Volbella	Restylane	Restylane-L	Vollure
Manufacturer	Merz	Allergan	Galderma	Galderma	Allergan
On label duration*	Up to 6 months	Up to 12 months	6 - 12 months	12 - 18 months	Up to 18 months
Syringe Size	1 ml	0.5 ml	1 ml	1 ml	1 ml
Typical Price per Syringe	$500 - $800	$350 - $500	$500 - $800	$500 - $800	$550 - $900
Under the muscle for the volume restoration?	Yes, but does not last long	** not worth it	Yes	Yes	Yes
Superficially into dermis?	Yes	Yes	No, may cause Tyndall effect	No, too thick and may cause Tyndall effect	No, too thick
How it achieves its effect?	CPDM***	Vycross technology; cohesively of the gel	Particle size in the HA gel	Particle size in the HA gel	Vycross technology; cohesively of the gel

* After repeat treatments, fillers are likely to last longer than after the very first injection and longer than is stated on-label.
​** The filler could be used for the injection under the muscle to restore the lost volume, however, it may not hold the shape well because it is a thinner filler, and it is also not worth it because it won't last as long as the fillers specifically formulated for the volume restoration 
**** CPDM - Cohesive Polydensified Matrix is a technology patented by Merz. CPDM produces a very homogenous soft-flowing gel that should allow more even integration into a facial tissue, which leads to favorable esthetic results (Kuhne U., 2016). 
​
For those traveling to Europe or Canada, you may want to consider a filler formulated specifically for under the eye area - PureSense Redensity [II] by Teoxane (Teosyal range of HA fillers. three of Teoxane fillers are approved by FDA and marked in the USA under the names RHA 2, RHA 3, and RHA4. However, none of them is an analogue of PureSense Redensity 2).

The summary and comparison of all the fillers available in the USA can be viewed in the publication on All Cosmetic Fillers.