How to Safely Treat Tear Troughs with Dermal Filler: Full Assessment, Injection Techniques & Aftercare for Medical Aesthetic Practitioners

The tear trough — that delicate groove between the lower eyelid and the upper cheek — is one of the most requested yet technically challenging areas for dermal filler treatment. Patients often describe looking tired, even when well-rested, due to hollowing beneath the eyes, dark shadows, or a sunken appearance.

When performed well, tear trough treatment can restore a refreshed, well-rested look. However, due to the complex anatomy of the periorbital region and the thinness of the overlying skin, this area carries higher risks of complications, including prolonged swelling, visible filler, Tyndall effect, vascular occlusion, and even blindness in rare cases.

In this educational guide for medical professionals, we’ll cover:

Patient assessment and selection

• Contraindications and unsuitable patients

• Relevant anatomy

• Injection depth, plane, and choice of needle or cannula

• Suitable products (UK-available characteristics without brand names)

• Post-treatment advice and red flags

  
  

Our aim is to provide a clear, evidence-based framework so you can approach this treatment area safely and confidently — and most importantly, keep both your patients and yourself happy.

Patient Assessment: Is Tear Trough Filler Right for This Patient?

 

Key Questions to Ask in Consultation

• Is the appearance due to true hollowing, pigmentation, or oedema?

• Is the skin quality sufficient to support filler without issues?

• Are there any signs of fat prolapse or eye bags?

• Is there pre-existing periorbital swelling (oedema or festoons)?

• Does the patient have realistic expectations?

• Are there any medical contraindications (e.g. infection, pregnancy, autoimmune conditions)?

  
  

Assessment Steps

Patient Positioning: Always assess the tear trough with the patient seated upright, not reclined. Shadows and hollows may disappear when lying down.

Degree of Hollowing: Mild to moderate concavities respond best to filler. Severe hollows may require staged treatment.

Skin Quality: Good elasticity and sufficient thickness = ideal. Thin, crepey, or lax skin increases risk of visible filler, Tyndall effect, and persistent swelling.

 

Fat Pad Prolapse (“Eye Bags”):

Mild prolapse can sometimes be masked with filler placed adjacent to the bulge.

Significant fat prolapse may require surgical referral (blepharoplasty) rather than filler.

Pigmentation vs Shadow:

Hyperpigmentation will not be corrected by filler.

Shadowing from hollowing can improve with filler.

Check by stretching the skin gently — pigment remains, shadow reduces.

Oedema or Fluid Retention:

Chronic puffiness, malar oedema, or festoons = relative contraindication.

Adding hydrophilic filler may worsen fluid accumulation.

Expectation Management:

Emphasise that filler will soften hollows but may not completely eliminate pigmentation or bags.

Discuss the possibility of staged treatment and the need for maintenance.

Contraindications: Who Should Not Have Tear Trough Filler?

 

Absolute Contraindications:

• Active skin infection (e.g. herpes, cellulitis, acne)

• Pregnancy or breastfeeding (no safety data for cosmetic fillers)

• Severe allergy to hyaluronic acid, lidocaine, or filler components

• History of severe anaphylaxis

• Previous permanent filler in the tear trough area

Relative Contraindications:

• Significant fat pad prolapse (“eye bags”)

• Pre-existing periorbital oedema, malar bags, or festoons

• Very thin, lax, or crepey skin with poor tone

• Unrealistic expectations, perfectionism, or body dysmorphic disorder

• Poor lymphatic drainage

• Anticoagulant use (higher bruising risk — manage with informed consent)

• Autoimmune or connective tissue disorders (case-by-case assessment)

Key message:

Not every under-eye concern is suitable for filler. Saying “no” when appropriate protects your patient and your reputation.

Relevant Anatomy: Know Before You Inject

Understanding the anatomy of the tear trough region is essential for safe, effective treatment.

Key Structures:

Skin: Thinnest on the body (~0.5 mm); minimal subcutaneous fat.

Orbicularis Oculi Muscle: Circular muscle surrounding the eye. Tear trough sits at the junction between the orbital and palpebral portions.

Orbitomalar Ligament (Tear Trough Ligament): Tethers the skin to the periosteum at the orbital rim, creating the characteristic groove.

Sub-Orbicularis Oculi Fat (SOOF): Deep fat pad under the muscle, just above the periosteum — preferred filler plane.

Infraorbital Foramen: Located ~1 cm below the orbital rim, aligned with the mid-pupillary line. Contains the infraorbital artery, vein, and nerve.

Vessels:

• Infraorbital artery and vein

• Angular artery (facial artery branch)

• Lacrimal artery medially

• Anastomoses with ophthalmic arterial system — blindness risk if intravascular injection occurs.

  
  

Lymphatics: Poor drainage in this area contributes to oedema risk.

Anatomical Safety Tips:

• Stay on the bone, at or just below the orbital rim.

• Avoid injecting above the rim into the orbital septum.

• Work medial to lateral, but be cautious of the angular artery medially.

• Avoid direct injection over the infraorbital foramen.

Injection Technique: Depth, Plane, Needle vs. Cannula

Ideal Depth of Placement:

Supraperiosteal (on bone) or

Sub-orbicularis, deep fat plane

This reduces visibility, supports tissue, and minimises oedema risk.

Volume Guidance:

• Typically 0.1–0.3 mL per side initially.

• Severe hollowing may need up to 0.5 mL but best done in staged treatments.

• Under fill and reassess in 2–4 weeks — avoid overcorrection!

  
  

Needle Technique:

27G-30G needle

• Serial puncture or retrograde linear threading on bone.

• Higher precision, but higher vascular injury and bruising risk.

• Aspirate where possible, inject slowly.

• Watch for blanching or pain.

  
  

Cannula Technique:

• 25G blunt cannula, 38–50 mm length

• Single entry point often on the mid-cheek.

• Safer regarding vessels, fewer bruises, more comfortable.

• May be harder to navigate through fibrous ligaments medially.

  
  

Choosing Needle vs. Cannula:

Needle                                    Cannula

Precision            High                                          Moderate

Vascular risk   Higher                                     Lower (but not zero)

Bruising               More likely                           Less likely

Comfort               Less comfortable         More comfortable

Suitable for       Fine adjustments         Broad area coverage

Some injectors combine approaches: cannula for bulk, needle for precision top-up.

Suitable Filler Products for Tear Troughs (UK)

The ideal filler for the tear trough should be:

• Hyaluronic acid-based (reversible with hyaluronidase)

• Low hydrophilicity (minimal water attraction = reduced oedema risk)

• Low to medium G' (soft, malleable, not stiff)

• Smooth gel consistency (monophasic preferred)

• High cohesivity (stays together without migration)

  
  

Particle size: small enough to integrate smoothly

Avoid: 

• Highly cross-linked, stiff fillers designed for structural lifting (e.g. cheek or jawline fillers)

• Permanent or semi-permanent fillers (e.g. silicone, PMMA, CaHA)

  
  

Many major UK-approved HA filler ranges offer a product specifically designed for tear trough or fine-line correction. Look for those designed for superficial or delicate areas, with low swelling potential.

Post-Treatment Advice: Aftercare for Optimal Results

What to Tell Patients:

Do for 24–48 hours:

• Apply cold compresses (not directly on skin)

• Keep head elevated (especially when sleeping)

• Take paracetamol if needed for discomfort

• Be gentle with the area — avoid rubbing or pressure

Avoid for 24–48 hours:

• Strenuous exercise

• Alcohol (reduces bruising risk)

• Makeup on the treated area (especially same day)

• Saunas, steam rooms, or sunbeds

Expected Side Effects:

• Mild swelling for a few days

• Possible bruising (may worsen before improving)

• Tenderness or mild ache

Red Flags: When to Seek Help

Instruct patients to contact you immediately if they experience:

• Severe or increasing pain

• Blanching, grey/white skin, or mottling

• Sudden or gradual changes in vision (blurred vision, loss of vision, “dark curtain”) — medical emergency

• Signs of infection (heat, redness, pus, fever)

• Persistent lumps or swelling not improving after 2 weeks

• Document aftercare advice and red flag education clearly in the patient notes.

Follow-Up and Maintenance

• Schedule follow-up at 2-4 weeks to assess symmetry, integration, and need for top-up.

• Avoid frequent top-ups — allow time for filler to settle.

• Maintenance usually required every 9–12 months depending on product and patient metabolism.

Final Thoughts: Safety First, Results Second

The tear trough is an advanced filler area — not to be rushed, and not suitable for every patient. The best outcomes come from:

• Careful patient selection

• Deep understanding of anatomy

• Conservative volume and technique

• Choosing the right filler for the area

• Providing clear aftercare advice and support

• As always, the happiest injectors are the safest injectors.

Do you want to master the tear trough filler technique and confidently use a cannula to ensure the best results?

The under-eye area is one of the most delicate and technically challenging areas to treat with dermal filler—and it requires precision, confidence, and a deep understanding of anatomy.

My 1:1 Tear Trough Filler training in Manchester has been designed specifically to help aesthetic clinicians feel fully prepared to assess, plan, and treat the tear trough area safely and effectively. 

Learn More