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Archive for the ‘tear trough implants’ Category

The Tear Trough Deformity – Its Anatomy and Surgical Correction

Friday, June 8th, 2012

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

Surgical vs. Non-Surgical Treatment Options for the Tear Trough Eyelid Deformity

Tuesday, June 7th, 2011

One of the very common aging questions that I receive is about undesired changes on the lower eyelid and cheek area. Whether it is dark circles under the eyes, lower eyelid bags, tear troughs or wrinkles, these eyelid problems can make one look tired. Not only do they see it but other people frequently comment on it, furthering their concern about its appearance. People understandably seek a simple solution and hope some over-the-counter cream will make a significant improvement. Given the many creams that are touted and advertised for these aging eyelid problems, they are easy fodder for a sale whose benefit is largely to the manufacturer.

The tear trough lower eyelid problem is one that absolutely will not be changed by any cream or topical therapy.. This lower eyelid indentation or depression runs from the inner aspect of the lower eyelid down along and over the lower edge of the eye socket. It usually causes a shadowing effect and appears darker than the skin above and below it. When the lower eyelid fat is protruding or herniated above it, the tear trough looks even worse. (deeper)

The tear trough problem has risen to a lot of public awareness due to the growing use of injectable fillers. The use of any one of the family of hyaluron-based injectable fillers, such as Restylane or Juvederm, can work well to fill out the depth of the tear trough as an office treatment. By far, this is the most common tear trough treatment done. These injections should be deep to the thin eyelid skin to avoid lumps and irregularities. There is some debate as to whether it should be deep to the orbicularis muscle down to the bone or just above it. Either way, the injected area must be smoothed out after injection by finger manipulation. Because the injections are in the muscle and with the numbers of blood vessels in the eyelid, some bruising is always possible. While each injectable filler has a limited effect, they last longer in the tear trough often up to one year or more after treatment.

In the spirit of filling the tear trough, one’s own natural fat is a surgical option. This can be a good choice when the tear troughs are fairly deep and there is noticeable fat herniation above it. There are two surgical options. The first is the transconjunctival lower blepharoplasty approach where, through an incision in the inside of the lower eyelid, the herniated orbital fat is relocated. It is moved from the bulge down to over the rim of the eye socket bone. This creates a smoother appearance through the counterbalancing effect of reducing the bulge and filling out the depression below. Because the blood supply to the lower eyelid skin is not significantly disrupted, pinch skin removal and laser resurfacing or chemical peels can be done simultaneously for a more complete blepharoplasty result.

Like synthetic injectable fillers, the tear trough can also be treated with fat injections. This is an option if one is in the operating room anyway for an eyelid or any other procedure. Fat is a little thicker than off-the-shelf injectable fillers and its survival is not always assured. But it seems to survive and take fairly well in the orbital region. It is unknown whether fat injection or fat transposition offers a better result.

When significant excess lower eyelid skin is present, the anterior or skin incision blepharoplasty approach can be done. A skin-muscle flap is raised with a fine line incision right below the lashline. This allows direct exposure to the tear trough where a variety of options to fill it exist. Fat can be transposed from a bulge directly, small fat droplet, dermal-fat or cadaveric dermal grafts can be inserted. Even synthetic implants of varying sizes and designs can be used. There is a place for all of these and other factors must be considered including the degree of orbital or cheek bony deficiency as well as the depth of the tear trough. The size of the tear trough deformity and the surrounding bony anatomy determines what type of ‘implant’ is used.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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