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

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The tear trough gives a tired appearance to the eyes and is bothersome to many patients that have them.  They occur as a result of volume loss with aging although some people have them naturally. There are a variety of improvement strategies including injecting them with fat or synthetic fillers or using tear trough implants.

The simplest approach is to use synthetic fillers which can be precisely placed without the need for surgery. While tear trough treatment is associated with the highest rate of bruising of all facial areas treated with injectable fillers, its simplicity usually makes it worth the risk.

While there are many types of injectable fillers, tear trough injections should only be done with hyaluronic-acid based compositions such as Restylane or Juvaderm. Their soft gel consistency makes them ideal for the thin skin of the eyelids and the least likely to have irregularities and lumpiness. How long such fillers will last in the tear trough has not been clinically studied as data has never been collected for any formal FDA study submission. (nor will it likely ever be)

In making an assessment of how an injectable filler will last in the tear, Dr. Alexander Donath and others published a paper on this topic in the May 2010 issue of Plastic and Reconstructive Surgery. Ten patients were studied for over a year after Restylane injections to the tear troughs. They used on average just over 0.2cc per side. The effect  was felt to be significantly maintained at a volume of 85% after one year.

Unlike other facial areas, hyaluronic injections to the tear trough last much longer. This is likely related to the lack of significant motion at this area unlike that of the lips or nasolabial fold. The authors of this study placed the filler not just under the skin but deep to the orbicularis muscle. This may also contribute to its lasting effect. While many injectors place the filler just under the skin, that is a mistake as it is much more difficult to get a smooth correction and the risk of bruising is higher.

Given the ease of tear trough improvement with injectable fillers, this should always be the first approach if no other periorbital surgery is planned. If Restylane can create a tear trough effect that is 3X more long lasting than other facial areas, this would suggest that other hyaluronic fillers will last even longer.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

A very common patient concern is that of dark circles under the eyes. While patients frequently try a variety of creams to improve the dark discoloration that they see, they are usually chasing the wrong ‘rabbit’. Most dark circles problems are really a tear trough deformity, an indentation problem that is creating a shadow effect which casts an image of a tired and older lower eye appearance.

The tear trough affects the inner aspect of the lower eyelid and appears as a visible concavity or indentation. While associated usually with an early sign of aging, some patients have it naturally as a true anatomic ‘defect’. The tear trough is at the junction of the very thin lower eyelid skin with the thicker nasal skin superiorly and slants downward into the cheek area over the lower eye socket bone. Because herniated fat from the lower eyelid may and often exists above it, the tear trough can look quite deep in some patients. Women may often camouflage this area with make-up.

A key question is why does the tear trough exist? In an extremely insightful article written by Dr. Hirmand in the February 2010 issue of Plastic and Reconstructive Surgery, he points out that volume loss is the primary reason. As the face ages, we lose fat and this facial area may be one of the very first to show it given its thin tissues and the lack of any significant fat between the skin and the underlying orbicularis muscles. For those with a more natural or congenital tear troughs, it may be how the complex array of underlying muscles merge and interdigitate that accounts for this triangular medial lower eyelid and cheek deformity.

From a surgical standpoint, this area can be improved by a lower blepharoplasty procedure that either places fat grafts underneath this area or even a medial orbital rim implant. I have done both successfully and the choice of either one is based on the depth of the tear trough. A standard lower blepharoplasty alone will usually not correct it and may make it look worse if significant lower eyelid fat is removed, creating a total lower eyelid hollowing effect. A blepharoplasty approach, even if just a transconjunctival one, is an ideal time to place a small composite or dermal-fat graft.

By far, however, injectable fillers remain the most common treatment method particularly in the younger patient. While many injectable fillers exist, the safest and most versatile are the hyalurons. (e.g., Restylane, Juvaderm, etc) These gels give good and easy flow and that is important when injecting into this thin and delicate area where bruising can easily occur. When  bruising occurs in the lower eyelid, it will likely be three weeks or so before it resolves.

One of the keys to tear trough injections is to not think that it is a ‘single shot’ injection that is placed just under the skin. That will undoubtably lead to both inadequate and poor results with a visible bulge. One has to think of going into and beyond the tear trough area as well as deep to the muscle. The material must go between the muscle and the bone. For this approach, one needs a local anesthetic block to have the patient be comfortable. Topical anesthetic is not enough. Multiple needle passes are needed followed by massage an filler manipulation. A smooth result must exist at the end of treatment.

Interestingly, the length of injection filler treatment of the tear trough is longer than what one experiences in the rest of the face. (e.g., lips or nasolabial folds) This must be related to the lack of any significant motion in this area. Many patients will experience at least a year of sustained improvement. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis Indiana

The tear trough facial deformity is a frequently misunderstood cosmetic problem. The use of the term ‘tear’ trough’ implies that it lies close to the eye but it is easy to confuse it with other lower eye and cheek issues. Because the cheek and eyelid areas are right next to each and the shape of one area affects what lies around it,  accurately defining the tear trough deformity will allow the right treatment method to be chosen to help reduce its prominence.

Tear troughs are sunken in or a hollowed out area below the eye. The hollowness is in the area between the rim of eye socket bone and the side of the nose. One can envision how it got this name as tears would roll down this ‘facial gutter’ from the inside of the eye. The correct anatomic term for the tear trough is the nasojugal fold. a normal anatomic indentation that is present to some degree in most people. But if it becomes aesthetically too deep, usually with aging, it is referred to as a tear trough depression. Such a depression near the eye contributes to a visible sign of aging.

Hollowness below the eyelid (put your finger in the area, if you feel bone then you are on the lower rim of the eye socket) is most typically caused by sagging of the cheek tissues, known as midface descent, or inadequate development of the bone of the upper cheek, known as midface hypoplasia. The patient’s age is usually a key element in determining the cause of this ‘bone’ problem. A younger patient most likely has cheek/orbital rim bone underdevelopment, an older patient more likely has midface descent. Some older patients, however, may have both.

Hollowness above the bone (if you push and feel no bone or slide over the rim of the bone), then the defect is in the eyelid area. This is not a bone problem but a reflection of the amount of fat that surrounds the eye, otherwise known as inadequate orbital volume.

 
It is easy to see how many confuse tear troughs, cheek/orbital rim hypoplasia, and decreased orbital volume. All affect the eye area but the treatments for each are quite different.

DR. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis