September 22, 2026 | Facial Procedures, Injectables
A patient sits down and asks for tear trough filler. Before I answer, I look at what is already there.
More often than people would guess, the answer is somebody else’s filler from years ago. It has not gone anywhere. It has spread out, and it is the reason the eyes look puffy first thing in the morning and better by noon.
That is the short version of why my approach to this area changed. The long version follows, in my own words. The full practice write-up, with the side-by-side table of the three options, is on the Southwest Plastic Surgery blog.
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.”
Why Fat, and Why Lipoderma When the OR Is Too Much
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.”
Fat is the tissue that was there before it left. Putting it back is like with like. When a patient wants the result without an operating room, Lipoderma gives me a fat graft I can place in the exam room. How fat grafting works in general, and how much of it stays, is in Fat Transfer 101. The specialty’s own numbers on the shift from fillers to fat are in my ASPS 2025 post.
Cannula Over Needle, Every Time
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.”
I made the same argument about hand filler in August. Thin skin, vessels close to the surface, a blunt tip that pushes them aside instead of a sharp one that can enter them. Under the eye the stakes are higher than on a hand.
The Filler That Never Leaves
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.”
Worse in the mornings. That is the tell. The dispersed gel sits in the drainage pathway, so the fluid that should clear overnight does not. Patients think they are aging. They are carrying old product.
I still can use hyaluronic acid under the eye. I just do not reach for it first anymore, and I explain why before a patient chooses. The DIY injectables post covers what goes wrong when this is done blind; this post is about what goes wrong even when it is done well.
Three Findings That Mean Filler Is the Wrong Answer
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.”
A true bag is fat pushing forward through a weak spot. Filling the groove next to it hides it for a while. Then the bag grows and the fix is eyelid surgery, not another syringe.
Festoons
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.”
Filler in a festoon adds weight to swelling. Morpheus8 first, more than once. A midface lift when the skin will not cooperate.
Who Is a Candidate
A true hollow between the lower lid and the cheek, reasonable skin thickness, no bag pushing forward, no festoon. Volume with a cannula, fat or Lipoderma. Everyone else gets a different conversation, and I would rather have it at the consult than dissolve something a year later.
Why Choose Dr. Agullo
I am certified by the American Board of Plastic Surgery and the American Board of Surgery, completed my plastic surgery fellowship at the Mayo Clinic, and teach as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly has listed me as a Top Doctor for thirteen consecutive years.
Ready to Talk?
Bring your injection history to the consult, including what was placed and when. Old filler under the eye is the first thing I look for.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful
