In my field of expertise, one of the most difficult areas to improve is the lower eyelid tear trough (a combination of puffiness and hollowness), though I have found a combination of treatments that works.

In younger patients I use dermal fillers. My favorite for this area is Restylane®. If there is some atrophy of the cheek bone, I inject the cheek with Radiesse® for a lift to the cheek, which minimizes hollows.

With patients in their 40s and 50s, in addition to fillers in this area, I may add Botox® or Dysport® to decrease the crow’s feet around their eyes. To soften fine lines, I suggest either Fraxel® or TCA peels of their lower eyelid skin. For puffiness, I may recommend having the fatty pockets conservatively removed via an outpatient surgery called trans-conjunctival (inside the eyelid) lower eyelid blepharoplasty.

In older patients, to help with sagging skin and deeper wrinkles, I usually recommend a subcilliary (incision below the lashes) lower eyelid blepharoplasty with or without fat removal. These patients also benefit from Radiesse® injections in the cheek area, since bone volume is lost from the face as aging occurs.

The use of dermal fillers around the eyes is currently an off-label use of the products. However, in the hands of competent oculoplastic specialist, it is a very effective tool in improving lower eyelid tear trough deformities. The eyelids are very unforgiving and any mistake in this area is very difficult or even impossible to correct. This is why I prefer Restylane®, a hyaluronic acid filler. Hyaluronic acid is a natural substance in our bodies that provides fullness and elasticity. If anything were to go wrong with this type of filler, it can be erased with hyaluronidase.

I have seen patients who received filler injections for tear trough deformities with undesired results. I was able to repair some of these complications, but others were impossible to repair, especially in cases of the wrong filler choice and superficial injection technique. Only time will be able to remedy these complications (like heavy discoloration), as the product, if it is non-permanent and is absorbable, gradually wears off.

Despite the caveats, fillers are great tools for improving the appearance of aging eyes. However, dermal filler selection and injection technique are paramount to the success of the procedure. If you are considering filler injections of the lower eyelids, choose a surgeon who is properly trained in the anatomy and blood flow of the eyes.
The pictures above show the results of Restylane® injections to treat the lower eyelid area. The ‘after’ picture was taken immediately following treatment, which is why the area is slightly red. This is only temporary. Photo courtesy of Rostami OPC.