The early 2000s ushered in a cosmetic era where low-downtime, no-downtime procedures could—at last!—stand in for cosmetic surgeries. Botox, for example, received FDA approval to soften  lines in 2002 and has sold 100 million vials since, and a few years later, Restalyne-L, a hyaluronic-acid filler used to add back volume lost in the face, was also approved for use in the United States. Over the course of the past two decades, the use of fillers has sky rocketed, and the latest pandemic-era data from the Aesthetic Plastic Surgery National Databank shows that the use of fillers is up 75 percent in 2020 as compared to 2019. One of the most talked about areas for filler use? The under eyes.

Under-eye filler is used to supplement volume that is typically lost in the area surrounding the orbital rim. While the hollows under the eyes can sink in with age, deeper set circles can also be hereditary, which means that the right 20-year-old could be just as good of a candidate as a person in their 70s for an under-eye filler procedure. “Under-eye filler is the most popular treatment I do in a day,” says Chaneve Jeanniton, MD, a Brooklyn-based oculofacial plastic surgeon and the founder of Epi.logic. “I would say, in a day, I do anywhere from six to 10 patients on the regular.”

Given that the procedure is growing in popularity and questions surrounding the first appointment might be mounting as well, keep scrolling for a first-hand look at the procedure—and what to expect from it.

What are the basics to know about under-eye filler?

Let’s get this part out of the way from the jump: The under eyes aren’t one of the FDA-approved areas to inject filler, so when doctors put product into the area, it’s called “off-label use”. This just means that when the product first came to the market in the U.S., the filler company paid to have it tested in various “on-label” areas—the cheeks and nasolabial folds (deep lines that can form from bottom of nose to sides of mouth) are common ones—that were proven for safety and efficacy. According to Dr. Jeanniton, “that’s probably a very important distinction legally, but when it comes to the everyday medical space, typically there’s just a conversation between a patient and the physician and there’s an understanding of what the desired goal is, and what the safety considerations are.”

And many, many MDs perform the procedure. “The on-label indications for most of these products are very strict,” says Dr. Jeanniton “If you think about the burden that a company has to prove in order to get FDA approval, it’s near impossible to really apply for on-label use in all areas of the face.” Still, you want to make sure that whoever you’re going to really understands the anatomy of the eye area ahead of injecting, as there is an increased risk of complications because the area is so delicate.

Who is the best candidate for under-eye filler?

There are a lot of different types of issues that we’re talking about when we talk about the under eye area: bags, dark circles, hyperpigmentation. “The slam dunk under-eye filler candidate is someone who just has hollowing—so no bag, no hyperpigmentation, no translucency of the skin causing that blue hue of seeing the vessels underneath,” says Dr. Jeanniton. “That’s not to say that people who have those other features are not great candidates. It’s just that’s really where the education comes in.”

In a nutshell, adding volume under the eye for anyone who has bags or areas of extra skin and puffiness can accentuate the problem more than address it. Though people with hyperpigmentory dark circles or dark circles due to thin skin can receive some benefits from getting under eye filler. “I can make it look 60 to 70 percent better,” says Dr. Jeanniton.

Often, that opportunity to improve (if not entirely address) the concern is enough for people to elect to move forward with under-eye filler. “A lot of people have multiple reasons for their under-eye issues, and even though I go through that conversation [about effectiveness] with them, on their followup they’re like, ‘I know you warned me, but I don’t even care about the hyperpigmentation anymore because I can cover that with a dollop of concealer and there was no amount of concealer that I could use to hide the hollow.'”

Even so, if you have multiple causes for your darkened under eyes, it could still be worth seeking out an expert’s advice on what filler can and can’t do for you personally.

Who should I go to for under-eye filler?

This is a tricky one. While some providers without an MD will often perform the treatment, the eye area does come with an increased risk, and you want to be sure that your provider is well acquainted with the anatomy of the eye area. We always recommend seeking out a board-certified doctor or plastic surgeon for these types of specialized procedures. Beyond that, Dr. Jeanniton recommends asking around within your network of people to find recommendations from people who have had good experiences with fillers.

Is there a particular type of filler I should ask for?

Again, complicated. Experts tend to reach for different fillers to fulfill different effects within the skin. The scientific study of this is called “rheology,” and it’s basically all about fluid dynamics in the skin. “Even within hyaluronic acid fillers, there’s a lot of difference in terms of stiffness,” says Dr. Jeanniton. “Under eye, you really don’t want a product that’s incredibly stiff. You want something that has a little bit of flexibility to it, and you want something that’s going to lay down relatively flat.”

This differs tremendously from other parts of the face. In the cheeks, for example, you might want something stiff to add structure, while in the lips you’d want something plump. Both of these options, under the eye, would be the wrong choice. “For the under-eye area, I really love Restylane-L—a lot of people call it Restylane classic,” says Dr. Jeanniton. “It’s going to lay down relatively flat, but give enough support to pick up that tear trough area. It’s not terribly hydrophilic [likely to dissolve in water], so what you see is what you get….I feel really safe knowing that the result that my patient walks out with is what they’re going to hold on to.”

As a footnote: That means you shouldn’t ever walk into your doc’s office and ask them to use one syringe over your entire face.

What is a filler appointment like?

Okay, so for starters, Dr. Jeanniton’s office is about two miles from my house, so I ran to the appointment and showed up really gross and sweaty. (She was very nice about this.) We’ve known each other for more than a year, but because of the pandemic, we’d never met in person, so after a quick catch up, we started talking about my skin goals. She did a quick consultation, where we discussed what my ideal outcomes were and what she’d suggest. Then, she numbed the area with a topical solution, and we got started.

What does under-eye filler feel like when it’s being injected?

There are two main ways to get under eye filler: with a needle and with a cannula, which is a longer, blunt-tipped hollow microtube that’s flexible and able to cover more surface area from a single entry point. Usually it comes down to the injector’s preference. Dr. Jeanniton prefers the latter. “I like the cannula because it allows me to really have a sense of what plane exactly I’m putting the filler in, and in the under eye area, more than anywhere else of the face, that is so incredibly important to me.” When using a cannula for under-eye filler, most doctors go in through the cheek and up to the under-eye area.

As I sat in Dr. Jeanniton’s chair, she gave me a step by step of what she was doing. She inserted the cannula into my cheek and I started to feel a bit of pressure where she was depositing the filler, almost like sinus pressure. As the filler gets put in place, it kind of feels like the Rice Krispies sensation of snap, crackle, pop within your skin, but it doesn’t hurt at all. And if I were to guess, it probably took about one minute per eye (but this would obviously vary depending on how much a given doctor needed to do and what their technique was).

“What I did for your under eye area is laid down a foundation really deep right on the bone. So I was taking the cannula and sweeping it on your orbital rim,” says Dr. Jeanniton. “When I saw that I got enough lift and I got the contour I really wanted, I snuck the cannula up right underneath your skin and I put the tiniest couple of droplets there, so that you get that lovely light bounce quality off of the under eyes again. I can’t do that and know I’m exactly where I want to be with a needle.”

Regardless of what your provider uses, it’s worth noting that the procedure itself isn’t painful, but it can cause some bruising and day-after swelling.

My friend said I’ll look “un-natural” if I get filler—is that true?

No, and if you’re getting a hyaluronic-acid filler, and you don’t like the results, you can dissolve them. But in general, we need to move away from stigmatizing cosmetic procedures like this. You wouldn’t judge someone because they need to take blood pressure medicine so think twice before imposing your views of filler onto others. “I think still I think still a lot of people kind of hide this from people in their lives, and that’s terrible for all of us overall,” she says. “I get it but at the same time, if we keep these things secret, we perpetuate the stigma, and we’re not helping our fellow female.”

Perhaps your “pal” should listen to this:

How much does under eye filler cost?

In Dr. Jeanniton’s practice, she says a treatment can cost anywhere between $1,000 and $2,000 depending on what needs to be done. But prices for procedures vary, and you will have to consult with your doctor to determine the actual cost of yours.

Give it to me straight, should I do it?

I’ve been in the beauty industry for a while, and have tried a lot of products that have made a lot of promises. My go-to advice of the moment is to spend on aesthetics and save on skin care. There are inexpensive hyaluronic-acid moisturizers to keep your skin dewy on the market, but investing in an appointment with someone who can use a hyaluronic filler to noticeably plump an area like the under-eyes can truly change the look of your face in a fairly quick and painless appointment.

For me, nothing has made a bigger impact on my skin than beginning to utilize fillers in both the under eye areas (and elsewhere); however, we’re all special little butterflies flitting around with different special needs. If you’re curious about the procedure, ask around and find a doctor who provides the service. Make an appointment and work with them to achieve the goals that you have for your face. But also remember to ask questions, feel confident in your provider…and in yourself too. With or without eye circles, with or without filler, having all the information from the get can make the decision more empowering. As Dr. Jeanniton puts it: “Your body is your business.”

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