The treatment of tear trough and related nasojugal grooves has evolved over the years to include injectable fillers, fat and infraorbital implants. Each method has their advantages and disadvantages and none of the available treatments are perfect or free of complications. Patients with tear trough deformities can be young or older with the difference in the older patient that they may need an open blepharoplasty due to other eyelid aging issues. The younger patient usually just has tear trough or infraorbital hollow deficiencies without loose lower eyelid skin or muscle or fat prolapse.
For purposes of anatomic clarification, one should understand the differences between the two common infraorbital deformities of the tear trough and nasojugal grooves. A tear trough is a deep groove that commonly occurs beneath the lower lid, near the junction of the eyelid and cheek skin, beginning near the inner canthus and descends obliquely and laterally down the cheek for one or two centimeters. This is to be differentiated from the nasojugal groove which is caused by a natural muscular defect that occurs between the orbicularis muscle and the angular head of the elevator superior labii muscle combined with orbicularis-orbital septal adhesion to the bony orbital rim.
The problem with both injectable fillers and fat is the lack of placement precision, risk of visible lumpiness and lack of permanency. Infraorbital implants address all of these concerns fairly well but have an underutilized role in the treatment of these suborbital defects because it is an invasive procedure. There is also a lack of anatomic knowledge and good technique amongst surgeons in their placement which also leads to a perception that they have a ‘high complication rate’.
For patients undergoing lower blepharoplasty for aging concerns good improvement of tear troughs and nasojugal grooves can occur with release of the lower lid orbicularis muscle attachment to the infraorbital orbital rim combined with cheeklifting and lateral canthopexy anchoring. However, in young patients and in the older blepharoplasty patient an implant adds both volume and serves as as spacer between the muscle and bony rim which provides an assured volume addition effect.
Infraorbital or suborbital implants (commonly called tear trough implants) are commercially available in either standard or extended styles. The lateral provides medial malaria augmentation at the same time with horizontally longer implant shape.
Infraorbital rim implants can be placed through either an external subciliary skin muscle flap or from a transconjunctival (inside the lower eyelid) incisional approach. In the younger patient the transconjunctival approach is preferred. Whether it is done from inside or outside of the lower eyelid, subperiosteal elevation is done on top of the infraorbital rim and onto the face of the upper maxilla/cheek below it. The periosteum is elevated off around the infraorbital nerve which most common is about 7 to 8mms below the rim.
Once the subperiosteal dissection is done (which laterally is really the same as that done for a cheeklift) a notch needs to be cut into the implant whether it is the standard or extended implant style. The implant is passed thorough the incision and is placed along the infraorbital rim. But he implant’s upper edge should not directly parallel that of the infraorbital rim. Rather the medial/nasal part of the implant should fall into the diagonal trough where the nerve exits at the center of the depression that the infraorbital implant now fills.
If enough periosteum is left on the orbital rim implant fixation can be done by suturing the upper edge of the implant to it. I prefer the placement of one single self-drilling screw (1.5mm x 4mm) through the implant to the bone. When a screw is used no periosteal suturing is needed.
It is important to check prior to closure that there is no obvious implant edging through the skin by external palpation. In any edging is felt the implant’s position will need to be adjusted. In most cases no conjunctival sutures are placed for wound closure. If one is concerned about adequate soft tissue closure over the implant, t is possible to close the conjunctiva with an externally anchored trans-cutaneous lower lid pull out suture. This can be removed a few days after surgery.
Infraorbital or suborbital implants are effective for tear trough and nasojugal reduction/eradication. They can be placed either through a transcutaneous or transconjunctival approach. In younger patients with no significant periorbital aging transconjunctival implant placement may be adequate. In older patients a lower eyelid skin-muscle flap approach to implant placement with cheeklifting and lateral canthopexies is a powerful lower blepharoplasty combination. The extended infraorbital implant can also help with malar hypoplasia that often involves the infraorbital rim as well.
It is important to appreciate that these standard suborbital implants augment the anterior surface of the bone and produce horizontal augmentation. They will not be effective for infraorbital hollowing with lid sag and increased scleral show which represents more of a vertical infraorbiral rim deficiency. This is better addressed through custom infraorbital or infraorbial-malar implants.
Dr. Barry Eppley
Indianapolis, Indiana