Tear Trough Filler – which product is my favorite?

Someone just recently asked me this question and I thought I’d share the answer here.


Dr Lee, what is your filler of choice for this tear trough area under the eyes?

I’ll answer this question as if you were asking me as another colleague injector. Most of the time my favorite tear trough filler is either Restylane-L used straight out of the box or a diluted version of it with about .1-.2 cc’s of either lidocaine or saline. I’m most interested in a new Juvederm offering which is not available to the public yet. Belotero was my previous favorite before Restylane-L, but it was on the too soft side and too short of a duration in my own preference. Before that I used Juvederm ultra for under the eyes, and funny thing, before that I used Restylane-L (what was just called Restylane at the time). Now I’m back full circle to Restylane-L – the old favorite. A blended version of Voluma has also worked very well for the area. But the key is a smooth continuous application placed possibly in two layers is my latest technique. Some tear troughs are so deep that two separate layers of fillers is needed separated by the patients own tissue – this is like making a filler “sandwich”. I hope this sheds some light into what I like. but just about any filler could work in this area, but adjustments need to be made due to swelling and clumping characteristics. In the end, I think it’s more the injector’s technique that matters than the actual product. But if I was teaching a beginner injector, I would probably say a product like Restylane SILK or Belotero – great choices to start with because they are very forgiving!! Forgiving is good in this area, especially if the depth chosen isn’t ideal. However “forgiving” products (belotero and restylane-silk) are usually made up of smaller Hyaluronic Acid (HA) molecules and thus don’t tend to last as long as something with larger HA molecules such as Restylane-L/Juvederm/Voluma.
One more aspect to consider is experience with the swelling characteristics of the HA filler chosen. Restylane-Silk, Juvederm Ultra XC, and Juvederm Ultra Plus XC tend to swell more than Belotero, Restylane-L, and Voluma. I have not personally tried Restylane-Lyft yet under the eyes, but I don’t see a reason for me to try unless a patient was strange and wanted me to do that. There are just so many good choices out there for me already. But stay tuned for the new Allergan product coming out in about 1 month. I think it might be a winner in this department as well.
Answers to questions like this tend to be very complicated when we try to break it down to why we choose what we choose. There are factors regarding skin thickness and color that need to be taken into account regarding if I blend a product or dilute a product too.. And there are choices regarding the tools that we want to use – either a straight needle or various different cannulas.
I’ve had many people ask, but I never got around answering this question. But my favorite filler changes from day to day… so today it’s Restylane-L for tear troughs.  It is versatile enough to adjust to most skin conditions especially with dilutional methods, and it fits nicely through a 27 gauge 1.5 inch cannula, and it lasts in this area around 7 months to 1.5 years, and it has built in lidocaine for patient comfort, and it has minimal swelling characteristics to deal with after implantation.  Fillers choice is highly personal, just like violin choice is for the violinist.