Using facial fillers in general, without expertise in facial anatomy, can result in an irregular appearance.

One of the most common causes for dark circles under the eyes is fullness due to fat changes that occur in and around the eyes as we age. The advent of facial fillers such as Juvderm^®, Restylane^®, Belotero^®, Radiesse^®, Artefill^®, Fat, Silicone, and Sculptra^® has proven very useful in reversing age-related changes in the face from volume loss.

Many doctors also use these fillers to camouflage the appearance of dark circles under the eyes (also due to a lack of fat, which causes a sunken appearance to the under-eye area). I myself have used fillers in this region to address this specific cause of dark circles under the eyes.

Is Your Practitioner Qualified?

I have seen many problems arise from people having fillers put under their eyes to camouflage the fat changes that come with aging. As we age, the fat around our eyes can shift forward into the lower eyelid region as a result of the relaxation of retaining ligaments and sheets in this area:

Relaxation of ligaments and sheets in the lower eyelid region can cause fat around our eyes to shift.

You can see this in the sets of photos here:

Before and after using fillers to treat fat shifts in the lower eyelid area.

This effect of “bags under the eyes” can be further accentuated by loss of volume in the cheek region.

Certain practitioners today are injecting fillers under the eyes to camouflage the appearance of fat pushing forward in this region. While expert injectors with great experience can be successful in improving the appearance of bulging fat in this area, the more effective procedure to address this problem is surgery around the eyes to remove and, in some cases, reposition the fat bulging forward around the eyes. This requires thorough expert knowledge of the eye region, which many practitioners lack.

In the U.S., the number of individuals performing facial fillers has exploded in the last few years, and the background of these individuals can vary. Traditional cosmetic specialists such as oculoplastic surgeons, facial plastic surgeons, oral maxillofacial plastic surgeons, general plastic surgeons, and cosmetic dermatologists are all using these fillers.

Unfortunately, doctors with less-extensive facial background are also using facial fillers, including dentists, general surgeons, family medicine doctors, internal medical doctors, pediatricians, emergency room physicians, allergists, and gynecologists.

Finally, non-physician extenders such as physician assistants, nurse practitioners, general nurses, and medical estheticians can also be involved with injecting fillers in the face. These individuals can have limited medical background, depending on the state in which they are operating.

Since the age-related changes around the eyes dramatically affects the way others perceive us, it’s understandable that so many people are seeking out ways to improve their appearance in this area. What’s scary is that these people often end up in the hands of the diverse—and not always qualified—group of facial filler injectors described above.

Issues That Arise From Lack of Qualification

Since many of these injectors don’t perform any facial surgery, they use what knowledge they have to help these patients. But this often works to the disadvantage of the patients. People without knowledge of facial anatomy can create irregular results when using facial fillers in general, and in the eyelid region specifically. You can see one such result below:

Using facial fillers in general, without expertise in facial anatomy, can result in an irregular appearance.

I have no doubt that many of these practitioners mean nothing but the best when performing facial filler injections. But they don’t have the expertise necessary to truly help their patients.

It’s been said that when all you’ve mastered is a hammer, everything looks like a nail. Expert facial rejuvenation requires a broad base of knowledge, as well as skill with a large variety of facial rejuvenation tools and techniques.
The large number of new injectors, from varying backgrounds and with various skills, means that not all have what it takes to be expert injectors. And since injecting the lower lids should only be performed by those with advanced knowledge and experience in this area, the large majority of injectors out there are likely to cause irregularities in the lower lid area due to their insufficient knowledge and skill, which actually makes patients’ appearances worse than they were before they came in.

The second issue that arises involves the material used in these injections. Certain fillers, called hyaluronic acids (Juvederm^®, Restylane^®, Belotero^®), are able to be dissolved by injecting a product called a hyaluronidase into them. This enzyme and can be used to dissolve any of the hyaluronic acid products that are injected into the face and is only available commercially to doctors. This dissolution can be necessary when the filler affects the blood supply in a part of the face. It can also be useful to correct problems when these fillers lead to bad results.

I myself have used these hyaluronidases to dissolve fillers that were badly placed in patients. See the irregular-looking filler in the lower eyelid region of the woman below, and how this region looked after dissolving the filler with hyaluronidase:

An enzyme, called hyaluronidase, can be used to dissolve certain fillers and correct irregular results.

In the last year, I’ve been dissolving more and more badly placed filler for patients who come to see me from around the world for my eyelid rejuvenation techniques. I am just happy I have a product that works against the major class of fillers put in this region (hyaluronic acids). Since it can dissolve this material, I am therefore able to help these patients.

Unfortunately, the other classes of fillers used (Radiesse^®, Silicone, Sculptra^®, Artefill^®) do not have anything available to dissolve them—and, as a result, errors made with these fillers are very difficult to reverse. In these cases, I can sometimes use invasive surgical techniques to remove these products, but often, there is nothing that can be done to help these patients. As a result, it is my strong recommendation that these types of permanent and partially permanent filler products not be placed in the eyelid region.

In the End

Although facial fillers have been a great tool in helping practitioners reverse age-related changes in their patients’ faces, it’s important for patients to know the background and experience of the people injecting their faces. Some plastic surgeons actually have their more qualified physician extenders do their filler work for them, so having the plastic surgeon inject those fillers could be a mistake. And while some physician extenders have great background and experience, one should be careful because many do not.

In the end, although using fillers to help the eyelid region is an option when dealing with an expert, knowledgeable, and skilled injector, most cases would be best-served by having an expert in eyelid rejuvenation assess the situation and, if indicated, consider a more definitive surgical option to correct the problem (with surgery) rather than trying to hide the problem from others (with fillers).