The complaints I hear about the under-eye region come from all ages, ethnicities and genders. Many clients complain of looking tired. They’ve often tried many creams that have made little to no difference. But did you know there really is not a “one size fits all” solution when treating the under eyes, also known as the tear troughs?

I decided to write this blog after having a Cyber Monday sale where Belotero dermal filler was on sale in our Med Spa Scottsdale office. One area that we stated Belotero could be used was the tear trough region. We had an outstanding response to the sale, yet when people came in to be treated, I had quite a few clients that were not a good candidate for tear trough filler.

Let me preface this by saying no dermal filler is FDA approved for use in the tear troughs. But just as we use medications for reasons other than what the indication is for, we have been using fillers in the tear troughs for many years with good results. So this discussion is for an “off-label” non-FDA approved use. This is also why if you visit a manufacturer’s website you will find no information on the use of their products in the tear troughs. Manufacturers are not able to promote products for “off-label” use.

So why would someone not be a good candidate for tear trough filler you may ask? There are lots of variables to this question so I will give you lots of scenarios I have encountered.

Candidate #1- Their concern is the discoloration under their eyes, there is no volume deficit. Someone who truly has no volume deficit would benefit from Platelet Rich Plasma (PRP) and a brightening eye cream instead of a filler. More often it is a combination of discoloration and volume deficit. In this case they are still a candidate for filler but also will need PRP. They can start with PRP first or vice versa but they do tend to need both. PRP will improve the volume deficit but I’ve found most people will still need the filler.

Candidate #2- They have bags under their eyes. These clients would benefit either from surgery (blephroplasy) or Agnes RF to remove the bags. I usually tell them if they would consider it then they should just start there and not have filler placed. In some of these cases however, if they are not going to consider those options, I can place a little filler to camouflage the bags. I often start very gradual, and there are many cases where I do not want to treat because it can worsen the appearance. These cases should have a consult first before booking the procedure. Clients that have fluid under the eyes or notice that the bags worsen with salty foods really need to be careful. Dermal fillers pull in water, so potentially filler could make it worse.

Candidate #3- They have a volume deficit or perhaps even a line that starts in their under eye but runs all the way down their cheek. Most clients over 30 that have never had cheek filler but complain about their under eyes first need to address the cheek region. This can be done at one appointment or at separate sessions. Without the cheek support if you just treat the under eye you can sometimes see a line of filler because it is not supported. I learned the hard way many years ago with a client that I treated that I should just say no if multiple syringes are in the budget. I had a consult with a client who was in her 50s. Her concern was her tear troughs but she had a volume deficit. In the consult I told her that she had a volume deficit and that we needed to treat her cheeks with at least two syringes of filler and also her tear troughs would need one syringe. Because of her budget she wanted to only do one syringe in her cheeks and one in her tear troughs. I treated her and she later contacted us because she could see a line of filler. There clearly was not enough support in the cheek below the tear trough. She was upset and still did not want to pay for another syringe. I “fixed” her by adding the syringe that I had recommended on the initial consult and said this is definitely a learning experience for me. From this experience I learned that if my recommended dosing is not in the budget then we should either wait or just treat the cheeks first but never under treat the cheeks and go on to treat the tear troughs. That experience came out of my own pocket and definitely taught me to stand firm on my recommendations during a consult. Many people do not realize that cheek filler can have an impact on the under eyes- I’ve even had a few clients who decided they didn’t need tear trough filler after they had cheek filler done!

Candidate #4- They have a lot of loose, crepey skin. These clients may or may not benefit from some filler but depending on the severity they may need surgery or some sort of non-surgical skin tightening. I have seen some great results with Aquagold aka the Botox facial for tightening this area, as well as Ultherapy.

Well there are probably twenty more candidates we could discuss, but these are a few of the common ones I see in my office.

So back to my Cyber Monday sale. I had one particular client who had purchased the sale syringe of Belotero come in that I felt the need to really explain to her that I was not trying to upsell her. She was new to our practice but had followed us on Instagram. She had not had filler in her cheeks for years and was also a professional body builder. Body builders have such lean body masses and therefore less fat overall that their faces often show it. I am so glad that she trusted me and my expertise because I do not like to feel like I ever did a “bait and switch” on someone. She was able to make it work financially even though she did not come in expecting to need to pay for two additional syringes of filler. She was so pleased with her results afterward and let me post them on social media.

What I’m getting at is we cannot look at the face just by area. We must look at the whole face for optimal results. I had a client once come to me stating she was unhappy with the way her lip turned down. She had been to multiple providers who kept injecting her lips, yet it never fixed the issue. Well the reason why her lip was turning down was actually a volume deficit on that side. Her fat pad in her cheek had herniated and she also had a deficit right by her nostril (called the Pyriform fossa). We treated those areas and actually dissolved some filler in her lips to get the result she wanted. Had I not looked at the whole face, I could have missed this issue, just as those other injectors had.

So we have touched on quite a few scenarios, but definitely not all of them. If you are pregnant or breastfeeding you should not receive fillers. I recommend a consultation prior to booking your treatment or we can discuss it at an appointment for other treatments like Botox when you are in the office.

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