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This article is intended for qualified aesthetic practitioners. It is not patient advice and does not replace product instructions for use or hands-on training.
There is no single best filler for tear trough work. The products that perform well under the eye share a profile: a soft, low-viscosity hyaluronic acid (HA) gel that takes up little water, can be dissolved if needed, and has clinical data in the infraorbital area. Product choice is also only part of the decision. Patient selection, plane and volume explain most of the results that go wrong. This guide takes each in turn, with the published figures practitioners tend to ask about.
The medial lower lid has thin skin, very little subcutaneous fat and a ligament that tethers the tissue to the orbital rim. Sharad's review of tear trough anatomy and technique describes this tear trough ligament, which continues laterally as the orbicularis retaining ligament, and states that low-viscosity HA can be injected safely, while high-viscosity HA and non-biodegradable agents should not be used in this area. Three gel properties follow from that anatomy.
A firm, high-G′ gel built to project a cheek or chin tends to sit as a visible ridge under eyelid skin. A tear trough gel needs to spread along the rim under light pressure and mould easily, not hold a shape of its own.
HA binds water, and the lower lid shows swelling readily. The same review warns against overcorrection for exactly this reason. Manufacturers of periorbital gels have kept HA concentration modest: the two products below that are positioned specifically for the eye area are 15 mg/ml and 20 mg/ml.
Only HA fillers belong in this area, because they can be dissolved. Hyaluronidase is used off-label for that purpose and is a prescription-only medicine, so non-prescribers need a prescriber arrangement in place before they treat, not after a problem appears.
Indications differ between markets, so the instructions for use (IFU) supplied with the UK product govern how you use it. With that caveat, these are the gels with the most published or regulatory data under the eye.
Teosyal Redensity II PureSense is supplied as 2 x 1 ml syringes of 15 mg/ml HA with amino acids, antioxidants, vitamins, minerals and lidocaine. Teoxane describes it as a combination of cross-linked and non-cross-linked HA developed for the eye contour. The company's EYELIGHT study, a prospective real-world study of more than 130 patients in the UK and France, reported visible improvement in over 75% of patients at three months, maintained up to 12 months, with no serious adverse events across nearly 1,000 injections. These are manufacturer-reported figures from a study without a comparator, so treat them as supportive evidence and not as proof of superiority.
Restylane Eyelight is a 20 mg/ml BDDE-cross-linked HA gel with 0.3% lidocaine, supplied in a 0.5 ml syringe. The US instructions for use specify supraperiosteal placement with a 29G ½" needle or a 25G to 27G blunt cannula, and limit treatment to 1 ml per side per session. In the US pivotal trial the responder rate at month three was 87.4% in treated subjects against 17.7% in untreated controls.
Juvéderm Volbella XC, the US presentation with lidocaine, received FDA approval in February 2022 for infraorbital hollows in adults over 21. In the supporting trial 83.1% of treated subjects responded, against 15.6% of untreated controls, and improvement was reported through one year. That is a US label, so check the UK IFU before relying on it.
A 155-patient retrospective series by Puyana and Montes used several products, among them Belotero Balance, Restylane and Volbella. The series did not compare products with each other, so it cannot rank them. It does show that experienced injectors work with more than one gel in this area.
No gel compensates for the wrong candidate. Harley Academy clinical trainer Dr Lindsay Jones describes the ideal tear trough patient as one with good skin quality and simple hollowing, and lists four reasons not to fill: excess skin, poor skin quality, fat herniation through the orbicularis oculi and fluid retention around the eye. Sharad's review also names septal fat herniation and severe elastosis as contraindications.
Two points deserve time in consultation. First, pigment is not volume: Dr Jones cautions that filler will not resolve dark circles in the great majority of cases, so a patient whose main complaint is colour needs a different plan. Second, a patient who reports morning puffiness or has festoons is telling you the area already holds fluid, and adding a water-binding gel is unlikely to help.
The two treatments answer different questions. Filler replaces volume along the orbital rim. Polynucleotides do not fill; they are used for skin quality, which covers crepey texture, fine lines and laxity. In Dr Jones's words, "Polynucleotides can be used to improve the skin quality prior to tear trough filler." Patients with moderate skin quality and true hollowing may be suited to both, in that order.
Periorbital polynucleotide gels such as Plinest Eye are placed intradermally, so the technique and risk profile differ from deep filler placement. Polynucleotides are fish-derived, so ask about fish allergy, and tell patients that results build over a few months.
Published techniques agree on deep placement: supraperiosteal at the orbital rim, beneath the orbicularis oculi, and never above the rim. Sharad's review describes a needle entry point about 1.5 cm below the orbital rim in the midpupillary line, chosen to reduce bruising, and a vertical supraperiosteal depot technique that places 0.02 to 0.05 ml per point at intervals of 2 to 3 mm. The infraorbital foramen and its neurovascular bundle sit close to the usual entry zone, so palpate and mark it.
Mid-face volume loss often contributes to the hollow. Assess the medial cheek first, because supporting it can reduce how much product the trough itself needs.
The evidence does not pick a winner. A systematic review by Rao and colleagues covered 42 articles (20 on needle injection, 12 on cannula and 10 on adverse events) and found no statistically significant difference in aesthetic results, patient satisfaction or adverse event incidence. The authors concluded that an evidence-based preference could not be made.
Individual data sets point in different directions. In the Puyana and Montes series a 27G x 1" cannula was used in 82% of cases. In the Restylane Eyelight US trial, treatment-related adverse events were recorded in 20.9% of subjects injected by cannula and 4.9% of those injected by needle. Use the device you are trained on and audit your own outcomes. For gauge and length options, see our cannula range and the cannula buying guide.
Less than most new injectors expect. Sharad's review cites Kane's range of 0.1 to 0.45 ml per eyelid, with most patients needing 0.2 to 0.3 ml. Puyana and Montes used about 0.45 ml per infraorbital hollow. The 1 ml per side in the Restylane Eyelight IFU is a ceiling for one session, not a target.
The working rule is to undercorrect and review. Sharad reviews patients at 15 days and adds product then if needed. A second small session costs the patient a return visit, whereas an overfilled lid can mean prolonged swelling or a dissolving appointment.
A soft, low-viscosity HA gel with data in the infraorbital area. Teosyal Redensity II, Restylane Eyelight and Juvéderm Volbella each have published or regulatory evidence there. The sources reviewed for this article include no head-to-head trial, so none of the three can be called superior.
The trials behind the US infraorbital indications for Restylane Eyelight and Juvéderm Volbella each compared treatment with no treatment, not with the other product. Their responder rates at three months, 87.4% and 83.1%, come from separate studies and cannot be read as a head-to-head result.
That depends on the cause. Skin quality problems may suit polynucleotides. True eye bags from fat herniation or lax skin are usually a surgical referral. Pigmentation calls for skincare and sun protection, not volume.
Controlled trials report improvement through 12 months. Retrospective data show clinical effect at 18 months, and MRI has shown HA in the deep mid-face fat at 27 months. Plan review appointments around what you see, not the calendar.
Choosing the best filler for tear trough treatment means matching a soft, reversible HA gel to a patient with simple hollowing and good skin, then placing a small volume deep on bone. The evidence supports several products and does not favour needle or cannula. What it does consistently show is that restraint on volume, and a clear plan for swelling, discolouration and vascular events, protect both the patient and the practitioner.
