The under-eye hollow is one of the most requested injectable treatments at Southwest Plastic Surgery. It is also one Dr. Frank Agullo is often asked to fix after someone else has done it.
We asked him to walk through how he treats the tear trough now, and why his answer has changed.
Do you inject the tear trough, and with what?
Dr. Agullo: “The tear trough is a very common area that we inject. My preference is the patient’s own fat, as it gives us a lasting result. It is done in the operating room, and I use cannulas to inject right above the inferior orbital rim. It softens the tear trough and gives us long-lasting results.”
Fat First: Your Own, or Lipoderma in the Office
Most patients hear “tear trough filler” and picture a syringe of hyaluronic acid gel. At this practice the first option is fat. It can be the patient’s own, harvested and placed in the operating room, or it can be Lipoderma, a donor fat graft that is injected in an exam room the same way a filler would be.
Dr. Agullo: “The advantage of using a patient’s fat is that we can also place these fat grafts in other places, like the cheek and zygoma, the nasolabial lines, lips, temples, superior orbital hollows, chin, and jawline. We can also use Lipoderma, which is a donor fat graft. This comes already prepared in a vial, so it can be injected in the office in one of the exam rooms, and it gives a lot of the same benefits as using your own graft. These benefits are that the results are soft, very long-lasting, and very natural.”
For a general explainer on how fat grafting works, how much of the graft stays, and what recovery looks like, read Fat Transfer 101.
Cannula, Not Needle
Cannula or needle?
Dr. Agullo: “I prefer to use a cannula in this area, as it decreases the chance of bruising from piercing a vessel, or even intravascular injection.”
Readers of the practice’s hand rejuvenation post will recognize the argument. A blunt cannula pushes vessels aside. A sharp needle can enter one. Under the eye, where the skin is thin and the vessels sit close to the surface, that difference matters more, not less.
The Three Options, Side by Side
| Your own fat | Lipoderma | Hyaluronic acid filler | |
|---|---|---|---|
| What it is | Fat harvested from your own body | Donor fat graft, prepared in a vial | Gel filler |
| Where it is done | Operating room | Exam room at the practice | Exam room |
| Placed with | Cannula, above the inferior orbital rim | Cannula | Cannula, softer product |
| How long it lasts | Long-lasting | Very long-lasting | Results about a year |
| What happens over time | Stays | Stays | Does not dissolve; disperses |
| Dr. Agullo’s current position | First choice | First choice for the office | Possible, but moving away from it |
What He Has Seen Hyaluronic Acid Do Under the Eyes
What about hyaluronic acid fillers?
Dr. Agullo: “We can use hyaluronic acid fillers in the tear trough area. In these areas, we want to use a softer filler to avoid lumps. Fillers over time have started to come out of favor, as we are now noticing that the filler really never dissolves. The results can last about a year, but the filler does not dissolve, it just disperses. I have seen cases where it blocks the lymphatic drainage, and patients start having bags under the eyes, which are worse in the mornings, or they have discoloration or lumpiness. Sometimes they can also get inflamed. So I have dissolved a lot of under-eye fillers in order to improve all these complications, and that is why I am more inclined to use fat rather than hyaluronic acid fillers.”
Read that once more. The visible result fades in about a year. The product does not. It spreads into the tissue, and under the eye the tissue it spreads into is the drainage system. That is where the morning puffiness, the grey tint and the small lumps come from, sometimes years after the injection.
This is also why the practice will not treat the under-eye as a quick add-on. The DIY injectables post covers what a blind injection can do anywhere on the face. Under the eye the margin is smaller.
Who Should Not Be Injected
Who is not a good candidate?
Dr. Agullo: “Patients with festoons, thin skin, and true fat herniation are not the greatest candidates for fillers under the eyes. Fat is one of the procedures we perform when treating the periorbital area, and just adding volume to the tear trough can hide the under-eye bags for a while. But as they keep progressing, it comes to a point where adding volume is not going to help, and we actually need to remove those herniated fat pads.”
Three groups, then. Very thin skin, where anything placed underneath shows. True fat herniation, the real bag, where the answer is eyelid surgery rather than more volume next to it. And festoons.
Festoons Are a Different Problem
Dr. Agullo: “Festoons are frustrating because they are very difficult to remove completely. They are a combination of edema or swelling in the area, skin retraction from the facial ligaments, and loose skin. We can usually improve them, and in some cases remove them, using Morpheus8 microneedling with radiofrequency, and it often takes more than one treatment to repair this area. Sometimes it just has to be done surgically with a midface lift.”
A festoon is the soft mound that sits on the cheekbone below the eye bag. Filler placed into it makes it heavier. Morpheus8 is the first tool, usually over more than one session, and a midface lift is the surgical answer when the skin and swelling will not respond.
What to Expect at Southwest Plastic Surgery
Every under-eye consultation starts with a diagnosis, not a product. Is the hollow a true tear trough, a fat pad pushing forward, thin skin, a festoon, or old filler that never left? Each has a different answer, and only the first one is a filler question.
If the answer is volume, the choice is fat in the operating room or Lipoderma in the office, both placed with a cannula. If old filler is the problem, it can be dissolved first. If the problem is a bag or a festoon, the practice will say so and point to the treatment that fits.
Dr. Agullo is certified by the American Board of Plastic Surgery and the American Board of Surgery, completed his plastic surgery fellowship at the Mayo Clinic, and serves as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center.
Schedule a Consultation
To have your under-eyes evaluated at Southwest Plastic Surgery, or to ask about dissolving filler that was placed elsewhere, call (915) 590-7900 or text 1-866-814-0038. #StayBeautiful
