Are my tear troughs too hollow to be filled? I can not afford fat grafting but was told fillers are too dangerous. (Photos)

Question

Was booked for Restylane for my tear troughs, but went to another dermatologist to get a second opinion. She said fillers are dangerous and risk blindness, that it is too difficult (she is a highly respected surgical dermatologist). Said my thin undereye skin mixed with fat cheeks, the amount of filler needed would make me look like I have edema and make my eyes look worse and even darker, and that there's nothing I can do to correct it. Can't afford fat graft, is there anything else I can do?

Randy Wong, MD · Answer

Your photos depict the common effect of thinning SubOrbicularis Ocular Fat (SOOF) at the region of the orbital margin that defines the semicircular ring under the lower lids.  Injectable fillers are placed to raise the SOOF so that it can eclipse the lower lid fat pad and this will help to efface the tear trough.  However, injectable volume in the eyelid fat pad will make the "bags" worse and accentuate the tear trough.  Blindness is a rare complication that may be associated with injection into the Arcuate vessels at the lateral nose region, or into the infraorbital vessels.  Your lower lid configuration could be improved with injectable fillers, but I would recommend lower lid blepharoplasty with midfacial suspension to release the tear trough attachments and provide smoother structural reconstruction.  As many of my colleagues have suggested, it is important to find a qualified surgeon/injector who is well aware of the anatomy and location for the injectable fillers to provide the best results possible with the least amount of risk.

Harold J. Kaplan, MD · Answer

Hello,As with any filler treatment on the face, safety and effectiveness is based upon the one performing the treatment.  Filler under the eyes, (aka:  tear trough treatment) is very safe and is our most common filler treatment for men and women in our practice.  Although injectors generally have their own techniques and products that they prefer, we believe that there is one tried and true technique in this delicate area (under the muscle) and we prefer Restylane as being safe and most predictable.  We do not find that using a cannula offers any benefit and sometimes will inhibit the artristy of a filler treatment.  The majority of injection treatments (filler and/or Botox, Dysport) are "off-label" procedures.  However, that does not mean they are not done routinely with a good track record.  Although you recognize that there is a cost difference between fat grafts and dermal fillers, you may also want to consider the amount of filler needed for full correction and compare that cost (and duration) with a fat transfer.  For example, you may need up to 3cc of Restylane for a duration of 9 to 12 months.  Although a tear trough treatment will not affect changes on the fat pads, they will be nicely camouflaged and more light/less shadows will be an added benefit.  Please see the below link for before/after photos of patients with similar conditions as yours.

W. John Bullis, MD · Answer

Thank you for your questions and photos.  From what I can see in the photos, I think you could benefit from tear trough filler (or fat).  Injecting anything into this area definitely carries some risks, including blindness, but they are quite rare.  I do these injections routinely in my practice and I use a blunt cannula especially for this region, as it is prone to bruising.  The cannula minimizes the risk of damaging blood vessels (causing bruising) or accidentally injecting into a blood vessel (possibly causing blindness, depending on which blood vessel and how much stuff was injected).  Replacing volume in the TT region, will definitely help the hollow eyes, but may not do much for the color.  I would recommend yet another consultation with a physician who has experience with tear trough injections.  These injections are "off label" uses of these fillers, so not all doctors have experience with them - you'll have to ask specifically.  In my practice, I have a nurse-injector who does many of our injections, but tear troughs are done only by me.  Lastly, perhaps there is something about your skin or anatomy that I am not able to appreciate via photos only.  It is possible that if I were to see you in person, I might agree with others who have told you it's too risky or dangerous, but from what I can tell, your tear troughs don't look to be any more prone to complications than anyone else's.  I hope my answer was helpful - good luck!

Mehryar (Ray) Taban, MD, FACS · Answer

Fillers are not dangerous. Expertise is important to have best results. See following video and website link.

Daniel Barrett, MD · Answer

Dear sarah1180,filler can be injected in the tear trough area. That is a high risk area so be sure you go to someone well trained such as a plastic surgeon. I will tell you, some of the results I have in my office with filling this area are extremely satisfying.Daniel Barrett, MD, MHA, MS 
Certified, American Board of Plastic Surgery  
Member, Am. Society of Plastic Surgery

Are my tear troughs too hollow to be filled? I can not afford fat grafting but was told fillers are too dangerous. (Photos)

Answers (9)