Under-eye filler versus lower blepharoplasty

What it treats

• Tear trough deformity (TTD) is a groove at the lower lid-cheek junction where the visible orbital rim is not covered by soft tissue (PMID 34012281).
• Causes are grouped as bone deficiency, fat prolapse or atrophy, and skin laxity; a published atrophy-bulging-laxity (ABL) system matches each cause to a treatment approach (PMID 32716132).
• TTD is described in the filler literature as the single most challenging facial area to treat with HA (PMID 34012281).
• Filler effectiveness varies by age: a 600-patient multicenter study found the strongest results between ages 30 and 40, benefit extending to 50, and recommended against filler as first choice after that (PMID 35478038).
• Filler and surgery are not always separate populations: many patients fall on a continuum where either approach is appropriate and the choice depends on individual risk tolerance (PMID 35386936).

How it is done

Filler technique

• HA gel is placed pre-periosteally, deep to the orbicularis oculi muscle, anterior to the infraorbital rim, by serial puncture or retrograde threading with a fine needle (PMID 34192769).
• A systematic review of 42 articles found no statistically significant difference in outcomes or adverse events between needle and cannula technique (PMID 35259144); a meta-analysis of prospective trials found needles carry more bruising (ecchymosis) and cannulas carry more edema (PMID 37424173).
• Pairing a firmer (higher G-prime) filler at the midface with a softer, less hydrophilic filler in the tear trough itself is reported to reduce the volume needed and prolong the result (PMID 39590588).

Surgical technique

• Fat repositioning blepharoplasty moves or grafts orbital fat over the rim instead of removing it; the transconjunctival approach suits patients with minimal skin excess, and the supraperiosteal plane allows a quicker procedure with no difference in final cosmetic outcome compared with other planes (PMID 39590588).
• Internal fixation of the repositioned fat lowers the risk of fat relapse and skin scarring but carries its own risk of suboptimal fat position (PMID 39590588).
• Midfacial volumization alongside, or in place of, direct tear-trough treatment is reported to improve overall infraorbital results in both filler and surgical planning (PMID 36998744).

Results and evidence

• Meta-analysis of 31 reports, 2,556 HA filler patients: pooled overall satisfaction 91.0% (95% CI 84.9-95.7%) (PMID 37684413).
• Real-world periorbital filler study, 136 subjects, 958 injections: over 70% achieved a Global Aesthetic Improvement Scale (GAIS) improvement at the tear trough, 84.3% satisfaction, effect observed out to 12 months (PMID 40442496).
• Retrospective study of 155 patients treated 2007-2023: infraorbital hollowing improvement on the Merz scale was sustained at 18 months, with no significant difference in outcome between the 6-, 12- and 18-month follow-ups, challenging the usual 6-12 month duration estimate (PMID 41446717).
• 3D-imaging pilot study, 11 patients: injected HA volume retention was 70-81% at 30 days and fell to 50-70% at 90 days (PMID 39670215).
• Composite non-cross-linked HA, 55 patients with tear trough-eyelid bag deformity: improvement in trough depression and infraorbital triangular depression, only transient complications (bruising, swelling, erythema) (PMID 38545776).
• Randomized comparison of HA alone, HA plus collagen, and collagen alone, 60 patients: HA alone produced significantly more Tyndall effect (3 of 20 patients) than the combined or collagen-alone groups (PMID 38299745).
• Narrative review of 20 studies comparing the two approaches directly: fat repositioning gives long-lasting results at higher surgical risk; HA filler gives immediate, minimally invasive results that require periodic maintenance (PMID 39590588).
• Surgical comparator, pooled literature review, 49 studies, 10,698 lower blepharoplasty patients: reoperation 0.77%, scleral show 0.37%, lid malposition 0.25%, ectropion 0.24%, mean follow-up 14.8 months (PMID 30084870).
• Surgical fat grafting/repositioning comparator, meta-analysis, 33 studies, 4,671 patients: total complications 11.2%, contour irregularity or undercorrection 6.2%, hematoma/swelling/bruising 6.2%, reoperation 2.4% (PMID 39158343).

Risks and complications

Filler, nonvascular

• Pooled rates from the 2,556-patient HA meta-analysis: swelling/edema 19.2%, bruising/ecchymosis 18.4%, redness/erythema 7.1%, contour irregularity or lump 5.3%, blue discoloration/Tyndall effect 0.9% (PMID 37684413).
• Malar edema, a delayed complication distinct to the periocular area, was reported in 11% of patients in one review; 90% of adverse events overall were mild and self-resolved within a month (PMID 33546985).
• The physical basis of the "Tyndall effect" is disputed: HA gels are not the uniform, sub-wavelength spherical particles the true Tyndall effect requires, and skin's light-filtering properties make true subdermal blue-light scattering an unlikely mechanism; a vein-coloration-like optical effect is proposed instead (PMID 25192332).

Filler, vascular occlusion and blindness

• Systematic review of published cases: 190 total blindness cases attributed to soft-tissue fillers of all types; 53 (28%) were attributed to HA and 90 (47%) to autologous fat (PMID 31321177).
• Meta-analysis of 93 vascular-complication cases across 30 articles (2004-2016): blindness was the outcome in 57 cases (61%); only 24 of 93 (28%) had partial or total recovery, 61 (72%) had no improvement (PMID 31360292).
• Systematic review of 34 articles (2000-2021) on periocular HA ocular complications: vision loss was the most common complication (17 of 34 studies, 50%); 45.45% of reported cases showed no improvement despite treatment (PMID 35091771).
• Case series of 6 patients with vision loss after facial HA injection: all had retinal or ophthalmic artery embolization, with recovery dependent on timing and type of subsequent treatment (PMID 30006992).
• 12-patient retinal-artery-occlusion series (HA and autologous fat): all ophthalmic-artery-occlusion patients had no improvement in visual acuity, and 2 cases each of central retinal and ophthalmic artery occlusion had concomitant brain infarction (PMID 22835509).
• 2026 single-center series of 33 patients with ophthalmic-cerebral embolic stroke after cosmetic facial injection (72.7% HA, 24.2% autologous fat): severe visual impairment improved in only 6 of 29 patients (20.7%) by discharge, and earlier treatment was not associated with visual improvement in this cohort (PMID 42588251).
• Scoping review of 55 studies on HA facial filler complications: tissue necrosis in 29.1% and tissue embolism in 20% of reported severe complications, with some cases progressing to blindness or stroke (PMID 42525051).

Surgery

• Pooled surgical complication data (same series as above): scleral show 0.37%, ectropion 0.24%, reoperation 0.77% across 10,698 patients (PMID 30084870); fat grafting/repositioning complications 11.2%, reoperation 2.4% across 4,671 patients (PMID 39158343).
• Vascular and nonvascular filler complication categories, including granuloma, migration and skin necrosis, are reviewed with prevention strategies keyed to anatomy and injection technique (PMID 33102629, PMID 33500603).

Recovery

• Real-world filler study: common treatment responses were mild or moderate and resolved within a month; no severe adverse events were reported among 136 subjects (PMID 40442496).
• Needle injection causes more bruising, cannula injection causes more edema; both are transient (PMID 37424173).
• Ocular complications after periocular HA injection are described as having nearly always an immediate onset, which shapes the recovery and monitoring window (PMID 35091771).
• Supraperiosteal-plane fat repositioning surgery causes postoperative edema and temporary irregular contouring before settling to a final result equivalent to other surgical planes (PMID 39590588).
• When filler is misplaced, recovery can mean a second procedure: 22 patients with filler-associated tear trough deformity needed corrective transconjunctival or transcutaneous surgery with ligament release and fat transposition; 90.9% were satisfied with the corrective outcome (PMID 38727846).

Combined procedures

• Pairing a firmer filler at the midface cheek with a softer filler at the tear trough itself is used to blend the two zones and reduce the total filler volume needed (PMID 39590588).
• Combining collagen with HA reduced the rate of Tyndall discoloration compared with HA alone, while addressing collagen's shorter retention time (PMID 38299745).
• Midfacial volumization is used alongside infraorbital filler or surgery to address overlapping deformities such as malar mounds and festoons (PMID 36998744).
• Surgical correction (ligament release plus fat transposition) is used specifically to remove and treat filler that has produced a static or dynamic deformity (PMID 38727846).

Current questions

• Cost-effectiveness: the only identified economic comparison of injectable volumizers against surgical facial rejuvenation is a 2010 analysis of large-volume filler against rhytidectomy, which found no published cost-effectiveness study existed at that time and warned that repeat filler treatments can eventually exceed the cost of a single surgical procedure; no tear-trough-specific cost-effectiveness study was found in this search (PMID 20665407).
• Duration is contested: a 2025 retrospective study found sustained improvement to 18 months with no measured decline between 6, 12 and 18 months (PMID 41446717), while a 2022 multicenter study of 600 patients found benefit dropping off after age 50 and recommended the usual 12-month follow-up window (PMID 35478038).
• Whether retrobulbar hyaluronidase reliably reverses filler-induced blindness is unresolved: two systematic reviews together found visual improvement in only 5 of 26 documented treated cases, and both concluded the evidence does not support the treatment as reliably effective (PMID 31880685, PMID 35787383).
• Whether the Tyndall effect is the correct physical explanation for blue-gray tear trough discoloration is disputed on optical grounds, with a vein-coloration mechanism proposed as more plausible (PMID 25192332).
• Rising reports of filler-associated tear trough deformity needing MRI workup and corrective surgery suggest a need for standardized volume and depth limits in this region (PMID 38727846).
• A 2024 narrative review frames the choice as patient-goal-dependent rather than settled by outcome data: fat repositioning surgery for patients wanting a long-term correction and willing to accept surgical risk, HA filler for patients preferring a non-invasive, maintainable, reversible treatment (PMID 39590588).

Terms

• Tear trough deformity: a groove at the lower eyelid-cheek junction where the orbital rim shows through unsupported skin (PMID 34012281).
• Infraorbital hollow: the broader area of under-eye volume loss that includes, but extends beyond, the tear trough (PMID 32716132).
• Tyndall effect: a light-scattering phenomenon proposed, and disputed on physical grounds, as the cause of blue-gray discoloration over HA filler (PMID 25192332).
• Hyaluronidase: an enzyme that dissolves hyaluronic acid, used to treat filler overcorrection, migration, or vascular occlusion (PMID 34188752).
• Vascular occlusion: blockage of a blood vessel by injected filler, which can cause skin necrosis or blindness (PMID 33102629).
• Retrobulbar hyaluronidase: hyaluronidase injected behind the eye in an attempt to reverse filler-induced vision loss, of uncertain effectiveness (PMID 31880685).
• G-prime (G'): a measure of a filler's firmness or elasticity that guides where and how much is used (PMID 39590588).
• MIHAS: the Merz Infraorbital Hollow Assessment Scale, used to grade under-eye hollowing severity (PMID 41446717).
• GAIS: the Global Aesthetic Improvement Scale, a clinician- or patient-rated outcome measure (PMID 40442496).
• Fat repositioning: a surgical technique that moves lower-eyelid fat over the orbital rim to fill the tear trough instead of removing it (PMID 39590588).

Papers