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

Indianapolis, Indiana

One facial area that has caught a lot of attention over the past few years is that of the tear trough deformity. Technically known as the nasojugal grove, it is a skin indentation that begins at the inside of the lower eyelid and extends obliquely downward to the lower rim of the eye socket. While some people have it naturally, most do not and it is usually appears with aging. As the fat of the lower eyelid herniates or becomes protrusive, the depth of the tear trough becomes more apparent and deeper. This leads to the dreaded ‘dark circles’, which often drives patients to some form of treatment.

While the tear trough has been around for a long time and is a well acknowledged  deformity, why does it exist and what causes it? On this surface this question may seem somewhat irrelevant, but effective treatments relay on correcting the underlying anatomic problem.

In the June 2012 issue of Plastic and Reconstructive Surgery, a study evaluated the anatomic basis for the tear trough deformity. Through cadaveric facial dissections, an osteocutaneous ligament was found on the upper part of the maxilla which extends up into and through the orbicularis muscle on the inner aspect of the lower eyelid. This is why tear troughs exist and is know going forward as the tear trough ligament. How much of a tethering effect that this ligament has is one major determinant on how prominent the tear trough deformity appears. Other factors creating or exaggerating its appearance is bulging orbital fat above the ligament and infraorbital/maxillary bony retrusion below it.

The most common treatment of the tear trough deformity are injectable fillers, usually hyaluronic-based materials. (e.g., Restylane, Juvederm) By adding volume beneath the tear trough, the soft tissues containing the ligament are pushed outward, softening its appearance. This volumetric approach works best when the tear trough is mild and is very technique-sensitive. Injecting into the ligament and above it just under the skin will actually worsen its appearance.

A similar effect is seen with medial orbital rim or tear trough implants. Placed beneath the ligament and on the bony rim, they add a permanent volumetric outward push. The placement of implants is also assisted by the subperiosteal dissection used to place them. This inadvertently releases the maxillary origin of the ligament thus eliminating the tethering effect.

In cheek lift procedures, dissection should be carried across to the medial orbit rim to release this ligament. This will help soften the tear trough through the pull of the tissues lateral to the orbit over the cheek. Transposing orbital fat into the released tear trough space will help create a more permanent effect.

The tear trough deformity is more than just a simple skin indentation in the lower medial eyelid area. It is there due to the tethering effect of an actual ligament, which is why it changes in appearance with smiling and squinting. Injectable fillers temporarily efface it by adding volume. This is usually a good place to start for more mild tear troughs. Lower blepharoplasties with fat transposition is useful when substantial lower fat herniation (bags) exists. Tear trough implants can be used when one is younger with deep tear troughs and a flatter midface profile. Cheek lifts and ligament release are used as part of a more extensive facial rejuvenation approach in more advanced stages of aging.

Dr. Barry Eppley

Indianapolis, Indiana