The tear trough deformity is one of the more recently recognized aesthetic facial concerns for many patients. Hollowing under the eyes usually appears with age but some people have it as part of their natural anatomy. It is essentially lost or missing volume underneath the eyelid skin that is most manifest in the inner half of the lid where tissues are naturally thinner. The awareness of the tear trough deformity had come to the forefront, largely because of the widespread use of injectable fillers which offers an apparent easy fix.
Treatment of the tear trough has been done by a wide variety of methods. From injectable fillers composed of hyaluronic acid or autologous fat, lower eyelid fat transposition, to synthetic implants, all share the attempt of creating a volumetric fill. What this spectrum of treatment options indicates, all of which have their proponents, is that there is no one best or magical method. Each one has its advantages and disadvantages. All can have success with good technique and experience and most certainly there is an impact of the type of tear trough deformity the patient has.
Fat injections into the tear trough is not new and has been around as long as such fat transfers have been done. In the past, it was associated with lumpiness, irregularities and even discolorations. In addition, like fat injected anywhere else, it had unpredictable survival and its persistence was far from assured. Besides the issue of long-term volume retention, lumpiness was the number one problem as the thin tissue of the lower eyelids offers little camouflage.
Improved results today with lower eyelid fat injections come from several technical modifications. The first is the understanding that the injections should be thought of as building up the infraorbital rim bone, not a soft tissue injection. Injecting right down onto the bone, as deep as one can go from the eyelid skin, is the best way to avoid overlying visible lid lumps and irregularities. The injections are placed under the orbicularis muscle right down on the periosteum of the bone. Fat injections are not done using an homologous and evenly suspended composite so they rarely have completely even laminar outflow from the injection device.
Fat injections today no longer use needles. Needles have a very sharp beveled edge which leads to more bruising and even the risk of a hematoma from the well vascularized periorbital tissues. Blunt-tipped small cannulas are used instead which create a very low risk of transecting any blood vessels and cause virtually no discomfort if the procedure is done on an awake patient.
Fat harvesting and preparation always plays a role in long-term injectate retention, even if we don’t understand the science of it very well at present. But since the amount of fat needed is so small, meticulous attention can be paid to the process. Maximal concentration into 1cc syringes is used. Whether the fat should be mixed with platelet-rich plasma or a platelet-rich fibrin matrix (Selphyl) is an intriguing question because such small volumes may be profoundly affected by high concentrations of human growth factors.
Fat injections to the tear troughs is an improved technique and can be done with a low risk of lumps. Fat graft survival and long-term retention is still an unknown issue and variability will exist between patients. It is probably best to not view fat grafting yet as a permanent tear trough treatment.
Dr. Barry Eppley