Dark circles. Undereye bags. Raccoon eyes. No matter what you call the darkened area of thin skin right below the eyes — maybe due to genetics or a telltale sign of a lack of solid sleep — that everyone (literally everyone) has been plagued with at least one point in their lives. Just know that there's a cosmetic treatment to clear them up — and for a long time. 

Tear trough filler injections encapsulate the best and worst of plastic surgery: they're easy to get wrong, but when done right, patients walk away looking like they just came back from the most relaxing vacation on Earth.

What is tear trough filler?

A tear trough procedure, more commonly referred to as "undereye filler," targets the tear trough, which is the lower, sometimes blue-ish area under the eye, just before the cheek. According to plastic surgeons, the procedure's popularity has soared over the last few years — especially among the younger crowd — without any indication of slowing down.

"Wrinkles and hollowing around the eyes begin at around age 35, and it's a common area that both women and men are concerned with," says Daniel Maman, a board-certified plastic surgeon at 740 Park Plastic Surgery in New York City. 

Adds Min S. Ahn, a facial plastic surgeon based in Boston: "It is especially popular with millennials who complain of looking tired, but because of their age are not ready for surgery — filling the tear trough area makes them look less tired, completely rejuvenating the lower eyelid area."

Who is an ideal candidate?

Contrary to popular belief, the procedure is far more nuanced than most patients realize — and certainly comes with limitations. One of the most common misconceptions is that tear trough filler can completely revitalize the undereye, yet undereye filler "does not address the 'puffiness' or bulging around the eye," says Maman, "because that is fat and requires surgery."

Anyone who has woken up with puffy eyes, only to look totally normal by noon, knows very well that the eye is notoriously delicate and finicky. And for this reason precisely, says Chicago-based board-certified plastic surgeon Julius Few, that "absolutely" makes it the trickiest area to treat with filler. "Part of the reason why treating tear troughs is so tricky, especially if somebody is not an expert injector is number one: the anatomy, and then diagnosing that someone needs filler in the tear trough," explains Few, of the blood vessel-rich area.

Placing dermal fillers under the eye, while incredibly popular and safe in the hands of an experienced injector, is an off-label procedure, which means that it has not been approved by the Food and Drug Administration (FDA) for use in this specific area. In other words: Don't mess around with injectors who aren't board-certified dermatologists or plastic surgeons. Instead, do your research and pony up the money to see the true expert in your area because, for this location, in particular, injector experience is the key to a happy outcome.

Here's where the nuance really begins. For patients with consistent daily puffiness — usually indicative of a condition called chronic malaraderma, which is essentially morning eye puffiness that subsides by the afternoon, caused by abnormal fluid drainage — the procedure is even trickier. "If you put a water-loving hyaluronic acid filler there, you’ve now made their puffy eyes worse," explains Few.

Patients with light skin sometimes have an additional step in the tear trough procedure because their veins are more prominently visible through their fair skin. "You have to do a laser first before treating them with filler in order to make those veins shrink first," explains Few. "Otherwise, the filler would actually lift the vein closer to the surface of the skin and make their dark circle worse."

But that's not to say tear trough filler can't be done in patients under these circumstances, it just means that the condition has to be properly evaluated and identified. "It's this algorithm of understanding the anatomy, understanding pre-existing subtleties of the area, and knowing when a filler is the right choice versus a laser versus surgery," says Few.

Before-and-after photos of a patient with tear trough filler.

What can I expect when getting tear trough filler?

Because the area is sensitive, the injection technique has become relatively standardized. The skin is first cleaned (in order to prevent infection), and then small ice cubes are held up to the skin for about five to 10 minutes to anesthetize the area, says Ahn.

Once numb, a small needle is used to create an entry point for the doctor to inject the filler. Most doctors inject undereye filler with a blunt-tip cannula (a tube that can be inserted into the body), rather than a needle directly, for increased precision and because "the blunt tip of the cannula is less likely to bruise patients than when using a sharp-pointed needle," Ahn says.

For the undereye area, Few relies on two specific brands of hyaluronic acid filler: Restylane, which he estimates he's used on more than 6,000 patients, and Belotero Balance, which he considers to be "very predictable, perfect for this area."

The injections themselves take less than 30 minutes to administer and patients require little to no downtime, or as Few says, "they're cruising." Around 30 percent to 40 percent of patients, estimates Few, will wake up the next day with mild swelling in the area that "usually goes away in the first couple hours they're awake," he assures, recommending the holistic remedy, Arnica Montana, a lightly applied cool compress and "just being up and active" will make it go away.

How long will it last?

The blessing and the potential curse of tear trough filler is the fact that the undereye is relatively stagnant, especially when compared to the lips or cheek, meaning that this area offers the longest lifespan to fillers. "If an injector knows how to place filler in the tear trough at the right level, I've had it last in this area for six or seven years," says Few. "Less is more, and the goal should be to improve the area by 85 percent."

His 85 percent rule, surprising at first, makes perfect sense. HA fillers are always at risk for attracting water, even months or years after the injection, "so you need to have that little bit of wiggle room" in case the undereye unexpectedly attracts water. "For example, on a hot day, the filler will swell a little bit," warns Few, listing a cold, congestion, and a sinus infection as other puffy-inducing culprits. "With 15 percent of wiggle room, it means that day in and day out, somebody can look good, no matter what else is going on."

How much does it cost?

Ahn warns, before you book an appointment, do your research. "It is very important to find a provider who is experienced in treating this area, as the skin is thin and, if not done properly, can give the patient a 'puffy' look," Ahn says.

Three key questions to ask a prospective injector, recommends Few, are:

No one should be coupon shopping when it comes to aesthetics, but least of all for the undereye area. The average cost per tear trough treatment is about $950, depending on your location and injector.

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