What are the recommendations for under eye fillers, such as Restylane (hyaluronic acid) or Radiesse (calcium hydroxylapatite), for treating volume loss and wrinkles?

Under Eye Fillers: Clinical Recommendations

Primary Recommendation: Consider Platelet-Rich Fibrin (PRF) as First-Line Treatment

For under eye volume loss and wrinkles, Platelet-Rich Fibrin (PRF) should be strongly considered as the primary treatment option due to its superior safety profile, natural autologous origin, and demonstrated efficacy in periorbital rejuvenation. 1

Why PRF Over Traditional Fillers

• PRF is autologous (derived from your patient's own blood), eliminating risks of allergic reactions, vascular occlusions, and long-term foreign body complications that occur with synthetic fillers 2, 1
• Clinical efficacy is well-established for periorbital wrinkles, hyperpigmentation, skin thickness improvement, and overall skin freshness 1
• Safety profile is superior compared to chemical fillers, which many experienced injectors avoid in the periorbital region due to complication concerns 1
• Patient satisfaction rates are high across multiple studies 1

PRF Treatment Protocol

Initial Treatment Phase:

• Administer 3 treatment sessions spaced at minimum 21-day intervals 1
• Each session involves intradermal injection or microneedling application 2

Maintenance Phase:

• One maintenance treatment every 6 months thereafter 1

Technical Specifications for Safe Administration:

• Use 30-gauge needles for standard PRF injections in the delicate under-eye area 2, 1
• For Albumin-PRF (Alb-PRF) formulation: use 22G × 2 inches (~5 cm) cannula for enhanced safety around the eyes 2, 1
• When using microneedling devices: lower depth to 0.25 mm 2, 1

Patient Counseling:

• Warn about temporary bruising and swelling, which are common but resolve with time 2, 1
• Advise maintaining good home skincare routine and sun protection to enhance results 1

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Alternative Option: Hyaluronic Acid Fillers (When PRF is Not Available or Desired)

Hyaluronic Acid (HA) Considerations

HA fillers (such as Restylane) can be used for under eye hollows, but require careful technique and patient selection due to well-documented complications. 3

Long-term complication rates from a 5-year follow-up study: 3

• Malar edema: 11% of patients
• Blue-gray dyschromia: 31.3% of patients
• Contour irregularities: 30.5% of patients
• Important caveat: 90% of these complications were mild and required no intervention 3

Key Technical Points:

• Use conservative volumes - there is no statistically significant correlation between volume injected and complication severity, but conservative approaches are recommended 3
• Tailor treatment frequency to minimize adverse effects 3
• Consider that HA provides immediate volumization but lacks the regenerative collagen-building properties of PRF 2

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Calcium Hydroxylapatite (Radiesse): Generally Not Recommended for Under Eye

Calcium hydroxylapatite should be avoided in the periorbital region - the evidence base focuses on nasolabial folds and other facial areas, not the delicate under-eye tissue 4, 5, 6

Why CaHA is problematic for under eye:

• Nodule formation is a recognized complication with CaHA fillers 4
• The product is designed for deeper tissue planes and structural support 7, 5
• No quality evidence supports its use specifically in the periorbital hollow region
• The thin, mobile skin of the under-eye area makes CaHA visibility and palpability more likely

Note on CaHA-HA combinations: While mixing CaHA with HA has shown promise for nasolabial folds and jawline rejuvenation (maintaining volume while preventing early CaHA gel absorption), this approach has not been validated for periorbital use 7, 6

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Combination Approaches

PRF + HA Combination Therapy

Emerging evidence suggests combining PRF with HA fillers may provide synergistic benefits: 2

• HA provides immediate volumization
• PRF contributes regenerative growth factors and collagen synthesis
• One RCT showed 50:50 PRP-HA mixture resulted in highly significant improvement in facial appearance and skin elasticity compared to either alone (p<0.0001) 2
• Participants showed 20%, 24%, and 17% increase in FACE-Q scores at 1,3, and 6 months respectively 2

However, this specific combination has not been extensively studied for the periorbital region specifically - extrapolation from facial data should be done cautiously 2

PRF + Other Modalities

• PRF can be combined with neurotoxins and lasers for comprehensive periorbital rejuvenation 2
• When combining with lasers: perform laser treatment first, then apply PRF immediately after (topically, via microneedling, or injectable) 2
• Further studies are needed to determine optimal protocols 2

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Critical Safety Considerations

Common Pitfalls to Avoid

With HA fillers in periorbital region: 3

• Overfilling leads to malar edema and contour irregularities
• Superficial placement causes blue-gray discoloration (Tyndall effect)
• Inject conservatively - you can always add more, but removal requires hyaluronidase

With any filler: 4

• Infection is the most common cause of inflammatory nodules - do not overlook bacterial contamination (including mycobacteria) when nodules develop
• Hypersensitivity reactions are rare compared to infection-related complications
• Use ultrasonographic imaging for persistent nodules to determine precise nature and location of implanted material 4

Vascular occlusion risk:

• The periorbital region has critical vascular anatomy
• PRF's autologous nature eliminates embolic risk that exists with particulate fillers 1
• With HA fillers, always aspirate before injection and use slow injection technique

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Clinical Decision Algorithm

Step 1: Assess patient goals and medical history

• Volume restoration vs. skin quality improvement vs. both
• Previous filler history and complications
• Autoimmune conditions or bleeding disorders

Step 2: First-line recommendation

• Offer PRF for patients seeking natural, regenerative approach with lowest complication risk 1
• Explain 3-session protocol with maintenance every 6 months 1

Step 3: If PRF declined or unavailable

• Consider conservative HA filler with detailed informed consent about long-term complication rates 3
• Use minimal volumes with staged approach

Step 4: Avoid

• Do not use calcium hydroxylapatite in the periorbital region (no evidence base, high complication potential)
• Do not use intraarticular hyaluronic acid products designed for joints 2

Step 5: Follow-up monitoring

• Assess for early signs of complications (edema, discoloration, nodules)
• For HA: have hyaluronidase immediately available
• For PRF: monitor healing and schedule maintenance appropriately