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