By Dr Gerard Ee
A common misconception that patients have is that dermal face fillers can fix all age-related problems, including eye bags. To save some readers a lot of money and regret, I would like to clarify right off the bat that fillers do not remove eye bags.
Fillers do not work as they add even more volume to an eye bag that is already caused by excess volume. An eye bag occurs when lower eyelid fat pushing forward through a weakened orbital septum. Adding volume next to, under or around a fat bulge does not make the bulge disappear. At best, it camouflages the transition gradient of the bulge. At worst, it makes the entire under-eye area look heavier, puffier and visibly lumpy when the patient smiles. The latter is unfortunately what I regularly see in my consultation room.
After more than 10 years treating the under-eye area, I noticed that this correctable mistake is most commonly made when a true eye bag is treated as if it were a tear trough. In this article, I will explain when it is appropriate to use fillers, when using fillers may backfire, and what to do if you are unhappy with your filler results.
When under-eye filler is the right treatment for you
When patients are dissatisfied with the results of fillers, the problem is usually not the product itself, but the diagnosis. Incorrect or improper diagnosis can lead to fillers being inappropriately used. A filler injection is generally the appropriate tool only when the under-eye problem is a deficit of volume.
- A true tear trough is ahollow groove running from the inner corner of the eye toward the cheek. The groove casts a shadow that reads as tiredness. A conservative amount of filler placed correctly in this groove can effectively soften the shadow.
- Mid-cheek deficiencyis a condition where the cheek below the eyelid has lost volume or projection. This results in the under-eye losing its support and looking sunken. Restoring the cheek, often without touching the eyelid itself, improves the appearance of the under-eye area.
In both situations listed above, the anatomy of the under-eye area is concave. Filler is thus effective because it can restore the volume of the concave area.
When filler is the wrong treatment for you
Filler is the wrong tool to use when the anatomy of the under-eye area is convex, such as when there is a bulge of protruding fat. The following happens when a true eye bag is treated with filler.
- The eye bag is exacerbated, not hidden.While it may seem logical to fill in the grooves under the eye bag so that the bulge blends in, in practice, this results in the total volume of the area increasing as the under-eye is now carrying the original fat pad plusthe added filler. In my experience, using filler does not hide the eye bag, it usually makes it worse.
- The under-eye area looks heavier.The lower eyelid is one of the least forgiving areas of the face to treat due to the particularly thin skin and soft tissue present in this area. Any changes in the volume of the under-eye area can dramatically alter its appearance. Injecting filler under a fat pad thus often results in a defined eye bag being converted into a broader zone of puffiness.
- It causes the appearance of a lump under the eye when smiling.This is due to the filler bunching when the cheek pushes up and compresses the under-eye area. Patients describe this lump as a shelf or ridge that appears in photos whenever they smile. While the results may look acceptable at rest, I do not recommend fillers for treating under eye bags as a treatment that fails the smile test is not a successful treatment.
- Filler in the under-eye area can persist and migrate.Hyaluronic acid filler under the eye attracts water and can persist for far longer than the commonly quoted 9 to 18 months, a slightly overfilled tear trough can thus become progressively puffier over months. Additionally, the filler may migrate. Due to this, the end result could be an under-eye that looks worse than it originally did a year after filler treatment.
- Correction may cost more than fixing the eye bag right the first time.The fix to a botched treatment usually involves dissolving the filler with hyaluronidase, waiting for the tissue to settle, re-examining the anatomy, and then performing fat reduction. Every step in the correction process has a cost that the patient has to pay on top of the original filler price.
The simple way to understand it
Under-Eye Anatomy and Whether Filler Helps
| Anatomical Problem | Cause of the Problem | Does Filler Help? |
|---|---|---|
| A Hollow Groove Also known as a tear trough |
Missing volume | Yes, if conservatively placed |
| Flattened Mid-Cheek | Missing support below the eyelid | Yes, if done in the cheek |
| A Soft Bulge Below the Lash Line This is a true eye bag |
Excess volume | No, it usually makes it worse |
| Bulge and Groove Together A true eye bag with a valley beside it |
Bulge caused by excess volume. Groove likely caused by missing volume. | Yes, for treating the groove.
However, the protruding fat pad is the priority and should be treated first. The groove can be reassessed and treated after the fat is removed. |
| Loose, Crepey Skin | Skin that cannot support added weight due to loss of elasticity | No, such cases often need surgery |
Most patients suffer from a mild eye bag with a groove beneath it. In my experience, the most appropriate way of dealing with this combination problem is addressing the protruding fat first with AGNES + Secret RF for mild Grade 1–2 eye bags, or eye bag removal surgery for advanced eye bags with loose skin, and then reassess whether any groove remains. Very often, once the fat bulge is gone, the trough largely disappears with it.
How I decide what treatment my patient needs
I have treated more than 500 eye bag cases at my practice, The Clifford Clinic and Surgery. Generally, I follow the checklist that I made below to gauge what treatment is suitable for the patient.
- Mild Grade 1–2 eye bags with firm skin→ AGNES + Secret RF non-surgical fat reduction.
- Deep tear trough or mid-cheek deficiency without significant fat protrusion→ Conservatively used filler.
- Grade 3–4 eye bags, or loose lower eyelid skin→ Eye bag removal surgery. Pinch blepharoplasty on top of eye bag removal surgery is often needed for older patients.
- Combination cases→ When a mild eye bag has a groove beneath it, I will treat the bulging fat first, then use filler later if needed.
I do not base my decision on the patient’s preference for a particular product or treatment, nor do I base it on what device or product I have in my clinic. To me, it is important that the patient’s anatomy and needs guide my decision.
Under-eye filler is not a one-size-fits-all treatment
Sometimes my patients ask me why I do not recommend under-eye filler for them when under-eye filler looks great and produced good results for their friends. Filler is an excellent treatment when it is matched to a problem it treats. If your friend had great results when using fillers, it is because your friend likely had a genuine tear trough or cheek deficiency.
Under-eye fillers are not suitable for every patient. The patients who come to me for help because they are unhappy with the results of their filler are almost never the victims of a bad product or treatment, but victims of a wrong diagnosis. Upon examination, I usually discover that these patients actually have true eye bags but where incorrectly given fillers.
If you are considering under-eye fillers, the single most valuable question you should ask your doctor is if you have a volume deficit or a fat protrusion. If the answer is vague, I recommend getting a second opinion before proceeding.
Baby fillers and prevention treatment
A recent trend I have been seeing online is younger patients in their twenties opting for getting small preventative tear trough fillers known as baby filler. If there is a genuine early trough present, conservative treatment can be reasonable. But I do not recommend injecting volume into a normal under-eye to prevent ageing as doing so is not logical. If there is no missing volume that needs replacing, a filler should not be given.
Additionally, if that patient carries a hereditary tendency for eye bags, they have now placed filler where a fat pad may later protrude, complicating both the diagnosis and the eventual treatment. Using sun protection and not rubbing your eyes is often a better preventative measure than jumping straight into getting fillers done.
What to do if you have already had filler and it made you look worse
Firstly, this is fixable problem. Below is the typical correction pathway.
- Assessment based on what was injected, where it was injected, and how long ago it was injected.
- Dissolving the filler with hyaluronidase if the filler is hyaluronic acid based. This is usually a quick procedure, but it sometimes needs more than one round treatment.
- Letting the tissue settle for a few weeks so the original anatomy of your face is visible again.
- Treating the actual problem, typically by doing a fat reduction via AGNES + Secret RF or surgery. Whether or not surgery is needed depends on grade of the eye bag and skin quality.
While I understand the temptation, please do not add more filler on top of what is already injected in an attempt to smooth things out as this will compound the problem.
Frequently asked questions
Can fillers remove eye bags? No, fillers add volume but eye bags are caused by excess fat volume. Filler cannot reduce protruding fat and often makes the area look heavier when used on true eye bags.
Why does my under-eye filler show a lump when I smile? Smiling pushes the cheek upward and compresses the under-eye tissue, this causes the filler to bunch under the pressure and create a visible ridge or lump. This is a classic sign that filler was incorrectly placed and a fat reduction is actually needed.
Is tear trough filler ever a good idea? Yes. When used for a genuine tear trough or mid-cheek deficiency without significant fat protrusion, conservative filler is an appropriate and effective treatment.
How long does under-eye filler last? Typically 9 to 18 months, but in the under-eye area it can persist considerably longer. Due to its water-attracting nature, it can occasionally cause late-onset puffiness.
Can badly placed under-eye filler be reversed? Yes. Hyaluronic acid fillers can usually be dissolved with hyaluronidase.
What should I do if I’m not sure whether I have bags or hollows? If you are unsure whether your issue is hollowing or fat bulging, you should get examined by a doctor before getting treated.
We welcome you to book an eye bag assessment at our clinic, The Clifford Clinic and Surgey, where both non-surgical eye bag removal and surgical options are available.
Dr Gerard Ee is the founder and medical director of The Clifford Clinic, Singapore. He has performed AGNES and Secret RF eye bag treatments for more than 10 years, across over 500 eye bag patients. This article reflects his clinical opinion and is for general information; it does not replace a medical consultation.
