How to Treat Under Eye Hollows and Bags


Last week I had a client say to me, “I think of all the money that I have spent over the years on make-up, creams and lotions trying to get rid of under eye hollows, and all I really needed was to get under eye filler. Imagine how much money I could have saved”. That’s the kind of response that gives me great satisfaction as an injector.

When it comes to injecting dermal fillers, as much as I love injecting lip filler, I think that the cheeks and under the eyes are my favourite place to treat. I love the effect that can be achieved by the careful placement of under eye filler and to the tears troughs: people often can’t believe the subtle transformation that occurs. It’s almost like someone has instantly had twelve hours of sleep, and the years can fall away.

We may not realise how tired-looking that bags under the eyes and hollowness in the tear troughs can make us look, and how ageing it can be. In the past this has been a difficult area to treat with fillers, but with newer and safer techniques involving blunt-tipped cannulas instead of sharp needles, the results are vastly improved.

Tear troughs are that area of hollowness and emptiness immediately under the middle of the eyes, near the nose. The reason that we end up with them as well as bags under the eyes, like lot of the ageing process in the face, is due to loss of volume of bone and fat. Many people may think that losing fat in the face is a good thing, and it can be, but not in all places on the face.

Within the face there are specific pockets of known as “facial fat pads”, and these are responsible for much of the structure of the face. There’s are few in the cheeks and underneath the eyes which I think are especially important, as when we lose fat here the whole face can start to sag, and hollows can appear under the eyes. This leads to a “flatness” of the cheeks and those bags under eyes that are so hard to get rid of, even with a good night’s sleep.

It’s more than just the cheek volume loss itself: the flatness of the cheeks causes what is almost like an optical illusion, and the interplay of light and shadow on the face is changed, worsening the appearance of the bags. This can be incredibly ageing and makes us look tired and worn-out.

Traditionally the tear troughs have been a difficult area to treat, as most injectors used sharp needles in this tricky spot. Not only does this require multiple injection points (increasing the risk of bruising and other complications with each injection), but accurate placement of the needle can be difficult.

The skin under the eyes is very thin, and the filler could end up too close to the surface of the skin causing a blue tinge known as the Tyndall Effect. The Tyndall Effect is a scattering of blue light, and it’s the same reason that veins under your skin show up blue, even though the blood is red.

The physics behind it doesn’t really matter here though; the main point is that no one wants blue showing up under their eyes! The thin skin also meant that it was much more likely that lumps could appear under the skin, another thing that we obviously don’t want, and to avoid it very thin filler types were used.

Long story short, tear troughs and sunken eyes have gotten a bit of a bad reputation as a place to treat with fillers. However now that we can use blunt tipped cannulas to inject under eye fillers, rather than needles, the tear troughs are a much safer and more satisfying place to treat.


With the technique of injecting dermal fillers using a blunt tipped cannula, we can achieve very accurate placement of filler in the cheeks, in the bags under the eyes and in the tear troughs.

And instead of having to make multiple injection points with needles, we only have to use one injection point per side, as the cannula allows us access to the whole cheek, under the eyes, even all the way to the temples. That’s great for multiple reasons: firstly, less injection points means less chance of complications such as infection or bruising.

Although dermal fillers are a cosmetic treatment, it’s important to remember that there are some small risks, and the less times we have to pierce the skin, the less chance of these complications.

Because the cannula has a blunt tip, as it slides under the surface of the skin it tends to push away rather than go through small blood vessels, meaning even less chance of bruising and swelling afterwards.

We begin with cleaning the skin with some antiseptic. This will be repeated a few times, as coming from a surgical background, I like to clean the skin a lot! Then a small amount of ice to numb the cheeks before I inject a tiny amount of local anaesthetic into the cheek. This is probably the part of the procedure that stings the most to be honest.

It’s the same type of local anaesthetic that gets used at the dentist, and it lasts for about as long: you may see the “whiteness” of the anaesthetic on the skin for the next forty-five minutes or so. After the skin is well and truly numb, a sharp needle is used to pierce the skin, and the blunt tipped cannula is passed under the skin.

You shouldn’t actually feel very much at all, just a bit of “pushing”. It feels a bit strange, but people actually tolerate it very well. The cannula is passed to the tear troughs, or the under eyes bags and the under eye filler starts to be injected. Remember too, that the filler itself contains local anaesthetic, so pain is minimal.

Imagine that we are using just one ml of filler in total, or half a ml each side. As I’ll go on to talk about, half to one ml per side is a standard amount to inject in this area. For the ease of the numbers, let’s talk about one ml in total.

I like to use about 0.3ml to 0.4ml on one side first, then stop to reassess. This is also the time when I hand the mirror to the client and let them compare one side with the other. It’s my favourite moment, as people get to see the difference between sides. The process is repeated on the opposite side, and then we stop and have look together in the mirror.

It also helps for me to step back and have a look at a bit more of a distance, and from the sides. Are both sides equal? Does one side need slightly more filler than the other? Do we need some more “here” on the left, and a bit more “there” on the right? That’s why we’ve held back and still have 0.1ml to 0.2ml up our sleeves for each side.

After all of the filler is injected, we just need to put a little bit of pressure over the injection site for a few seconds. If need be we can also treat the temples, cheeks and nasolabial folds from this one same injection point. Throughout the injections process I’ve been massaging the area with my hands, trying to spread the filler the evenly and reduce the chance of getting lumps.

Australian Law prohibits us from mentioning brand names in the advertising of prescription medications such as fillers and anti-wrinkle injections, but essentially fillers can be graded from thin to thick.

For an area like the lips, which are made for eating and kissing, we want a filler type which is nice and malleable and relatively thin. For somewhere like the temples, or the cheeks, where the aim is to replace volume, we want to place something nice and thick which will really help hold up that tissue that’s started to drop.

In the tear troughs and in the bags under the eyes we want a bit of a middle ground: not too thin that we don’t have enough support and structure, but not so thick that we see and feel lumps.

You may feel slightly tender under the eyes or in the cheeks following your treatment with fillers to the bags under the eyes or tear troughs, but it should be very manageable.

Some people find that a mild pain killer such a paracetamol helps for the first twenty-four hours or so but avoid pain killers containing aspirin and ibuprofen as they can make you more likely to bruise. If you do come up with any small bruises, I recommended arnica cream to the area.

You may wish to use an ice pack for the first evening if are experiencing some swelling or tenderness, but overall the swelling should be much less than injections via a needle, and much less than you may have experienced if you have had filler in your lips.

Most people feel fine to go back to work or their normal activities, but you may wish to take it a bit easy for the evening. It may also help to sleep sitting up on a few pillows, to keep the head well above the level of the heart, as this will minimise the amount of swelling. It’s the same reason that you ice your ankle and keep it up for a while if you have a sprain injury!

I like to stay in touch with my clients after their treatments, and for this reason I’ll usually give you a quick phone call in two or three day’s time just to make sure that everything is going along smoothly.

I also like to make an appointment to see you back the clinic after two or three weeks for a review. This is because over the first few weeks the filler actually expands a little as it attracts water. Think of the filler molecule as a tree with lots of branches and leaves, and each leaf attracts some water, causing it to “plump up” a little.

An experienced injector needs to be looking two weeks into the future as they inject the filler, to predict how your tear troughs and under eye bags will look when the filler has expanded!

The answer to that question varies from person to person, as everyone will have experienced different amounts of volume loss over the years. As a general rule though, I think that anywhere from half a ml to one ml of filler injected per side is a reasonable amount to start with.

Too little and you may not see much of a result and will be unsatisfied with things. Too much more in one go and you run the risk of starting to look “overfilled”. That’s certainly not to say that anyone with more than one ml of filler in each cheek is “overfilled”! Some people have a lot of volume loss and may even need much more filler than that to adequately restore their volume; it’s just that doing too much at one time may cause too much a change all at once.

It’s best to fill slowly, over a period of months until your volume has been restored and you are back to looking your natural best. As I tell many of my clients, “it’s easy to put more in later, but harder to take it out if you don’t like it”.

Again, this varies greatly from person to person, but you’ll probably find that your filler lasts somewhere from six to twelve months, depending on what type of filler is used. As a general rule, the thicker filler types used for volume replacement tend to last longer than the thinner, more malleable fillers used in lips.