Treatment of the tear trough has become quite common since it has been recognized as an aesthetic deformity. A sunken in appearance in the inner aspect of the lower eyelid creates an indentation or trough that creates a shadow and the appearance of being tired or older. Its treatment has become popularized due to the use of injectable fillers. They offer a simple and usually very effective solution for tear troughs by adding volume to the depressed afrea
But even very successful tear trough treatments with injectable fillers is not a permanent solution. While hyaluronic acid based fillers do persist for a year or longer along the orbital rim, they will eventually be resorbed. Fat injections to the tear troughs may offer the potential for longer and maybe even a permanent solution but their take and survival is never a sure thing.
Another approach that offers a permanent solution is that of tear trough implants. Designed to be a bony augmentation implant to fill in the suborbital groove, it is placed through a lower eyelid incision. This makes it a good solution if one is having a lower blepharoplasty or is having other facial augmentations such as cheek implants. While they can be placed as an onlay in a soft tissue pocket, I prefer to secure their position using a small self-tapping 1.5mm screw. It is important to set the the screw into the implant so there is no possibility that it can be felt through the thin lower eyelid tissues.
Tear trough or suborbital implants offer a permanent solution to a recessed orbital rim in the inner half of the lower eyelid. For now such implants need to be placed through a lower eyelid incision. Future developments may allow a tear trough implant to be placed through an intraoral approach
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 acknowledgeddeformity, 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.
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.
Facial implants have come a long way in the past two decades with the introduction of dozens of different styles. One of the expanding facial implant areas is that of the midface. Known commonly as the cheek, it has become recognized that its anatomy is more complex than a single implant design can adequately treat. With the numerous midface implants now available, more patients than ever are being implanted. With increasing numbers of midface augmentations comes complications. The vast majority of these complications are cosmetic in nature, meaning the final result was not what the patient had hoped.
Undesired midface implant results are usually the result of a mismatch between the patient’s aesthetic concerns and the implant type and size. The large number of implant options may seem confusing, but midface augmentation can be thought of as three zones or implant locations. These include the malar, submalar, and suborbital tear trough malar regions. There are more anatomic zones to the midface, but based on desireable facial changes, these three areas can be effectively enhanced.
The malar area is the most midface zone enhanced and makes up the major aspect of the zygomatic or malar bone. This extends from the infraorbital nerve to the middle third of the zygomatic arch. Malar implants create a high, strong cheekbone which is for men who want a more sculpted facial appearance or by younger women who want more of an exotic look.
The submalar area lies below the zygomatic bone. It actually sits on the top portion of the masseter muscle where it comes up and attaches to the underside of the zygomatic bone. This facial area has become recognized as significant because fat is lost in this area with aging. Submalar hollowing can also be created in the younger person with a fuller face by buccal fat pad removal. Augmenting the submalar area can help reestablish a more youthful appearance by building it out again. When introduced over a decade ago, the submalar implant was touted as a substitute for a midface lift by being able to lift up sagging cheek tissues. This probably overstates the effect that it actually does create.
The newest midface zone to be effectively implanted is the suborbital tear trough area. Extending from the medial canthus, over the top of the infraorbital nerve, and along the lateral orbital rim extending into the malar area, this implant fills out suborbital flattening and tear trough depressions. Because of its location, this implant must be inserted from a different direction than all midfacial implants…from above (through the eyelid) rather than from below. (through the mouth)
While these three types of midfacial implants augment areas in close proximity, their effects can produce dramatically different facial changes. Subtle changes in the midface are easily detectable because of their proximity to the eye, a visual focal point in all conversations. The rise in the number of midfacial implants has led to, not surprisingly, an increased rate of complications. Many times the correct zone is augmented but the implant is too big. It is always best to undersize a midfacial implant in most cases. Unless there is a significant facial bone deficiency (e.g., maxillary hypoplasia), large midfacial implants should not be used. What make look like a significant improvement on the operating table can look dramatic in real life afterwards. Other times, the effect the implant created was different than the patient expected. This is most commonly seen with the submalar implant when it is used for a cheek tissue lifting effect and all the patient sees afterwards is unnatural fullness.
The three primary midfacial implants add an effective arsenal to a variety of congenital and age-related midfacial changes. Complications can be avoided by an implant size and type that is suited to the patient’s aesthetic concern. While the midface is one of the hardest facial areas to accurately computer image, such analysis furthers the dialogue between patient and plastic surgeon.
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 in the February 2010 issue of the journal Plastic and Reconstructive Surgery, it is pointed 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. Whenbruising 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.
A tear trough deformity is a deep indentation between the eye and the nose. Technically known as the nasojugal fold, this natural indentation becomes very noticeable if it gets too deep. Some people have tear troughs naturally, while others develop them with aging. Either way, it creates a dark shadow which is cosmetically distracting.
Treatment of the deep tear trough requires adding something between the skin and the underlying bone. Injectable fillers are one easy option which are safe although they are not permanent. The best choice for this area are injectable fillers made of hyaluronic acid or collagen because they flow in smoothly and less likely to be lumpy or irregular. Longer lasting fillers seem like a good idea but they are more prone to unevenness and potential lumpiness. The injections can easily be done in the office but there is a significant risk of bruising due to the large number of blood vessels in this area. I tell patients that about half the time, despite my best efforts, one side will get some bruising. While injectable fillers are quick and easy (at least for the doctor), in the long-term I don’t find them satisfying because it is just a temporary fix for the problem.
Injecting fat works similar to the synthetic injectable fillers from a conceptual standpoint. It can fill out the depression. Fat, however, requires a harvest site, a method for concentration, and must be done in a sterile manner to avoid infection. For these reasons, fat injections are not usually an office procedure. They might be an option if one was going to the operating room anyway for other procedures. Then this ‘natural’ injection method makes better economic sense. The thinness of the skin in the tear trough area is extremely thin, however, so any irregularities from the injected fat may be seen also. The biggest issue with injected fat, however, is that it is unpredictable. No one can tell you how much or if any will survive long-term.
Placement of specially-shaped synthetic implants is another option which does offer permanency of the result. Placed through the mouth and secured to the bone with a small screw, implants provide excellent fullness that will have a smooth outer skin appearance. The key is not to place too big of an implant which may look unnatural. Tear trough implants are a good option if one is having surgery for other facial areas. Then the cost and exposure to anesthesia more thanjustifies this approach. Implants can always get infected but I have yet to see one in this area of the face do so in a cosmetic patient.
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. Fundamentally treatment option for the tear trough include fat injections or synthetic implants.
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.