Why I don’t fill tear troughs anymore…

Article medically reviewed by Dr. Gavin Chan (MBBS, cosmetic physician, liposuctionist)

Dr. Gavin Chan

Templestowe Lower and Berwick Clinics

Dr. Gavin Chan has a background in intensive care, anaesthesia, and emergency medicine. Since 2004, Dr. Chan has provided cosmetic procedures, including anti-wrinkle injections, dermal fillers, liposuction, fat transfer, skin needling, and laser treatments. He is a doctor trainer for various dermal fillers and anti-wrinkle injections.
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Tear troughs, the grooves or hollows just underneath your eyes, have always been a significant cosmetic concern for many people. But if you’ve been staring into a Zoom or Microsoft Teams abyss for the last year or so with not so flattering lighting, you may also be aware that your tear troughs “need work”. It’s no surprise to me that tear troughs are one of the most popular areas on the face to fill with dermal fillers. The idea of a simple nonsurgical procedure to fix what is often a lifelong concern can be alluring for both patients and cosmetic practitioners. However, too much dermal filler in your tear troughs can give you a less than attractive result.

My tear trough filler journey

When I started treating client’s tear troughs with dermal filler, 14 years ago I probably didn’t know what I was getting myself into. To achieve the results my patients wanted, I was very happy to use one syringe of dermal filler for each tear trough. But over time, a startling pattern started to emerge. The patients loved the result after the treatment but a few months later, they’d come back in looking puffy and overfilled. Why was this happening?
Dermal fillers are by nature hydrophilic, that is, they love water and attract many times their weight in water over time. The combination of the hydrophilic nature of hyaluronic acid fillers and the fine skin around my patient’s eyes highlighted and dermal filler imperfections. This resulted in initial puffiness and swelling – a side effect of all dermal filler treatments.
To remedy this, I started to modify injecting techniques, used cannulas instead of needles and used different dermal fillers. But the results were the same. I was also perplexed because the dermal filler companies had indicated that the longevity of hyaluronic acid fillers was between 6 to 18 months. As time went by, I persisted in chasing the elusive perfect tear trough treatment and with hindsight, it was a recipe for disaster!
It’s taken me 14 years of filling tear troughs from 2005 to 2019 before I concluded that I shouldn’t be performing tear trough dermal filler treatment anymore. In fact, today I spend a great deal of time dealing with overfilled or puffy tear troughs (done by myself or others) using a product called hyaluronidase that dissolves fillers.
In a recent video, I shared my journey and experience alongside expert opinions from Dr. Mobin Master, Cosmetic Physician and Radiologist, Mr. Bryan Mendelson, Plastic Surgeon and Dr. Ben Burt, Oculoplastic Surgeon to provide evidence and shed further light on the topic.

How I discovered dermal fillers last a long time

On YouTube in 2019, Dr Mobin Master and I discussed how long dermal fillers last by using MRI as a ground-breaking technique to figure it out. I got in touch with Dr Mobin because patients were presenting with puffy faces, years after I had treated their tear troughs with dermal filler. Some patients thought their appearance was because of the natural ageing process, while others couldn’t work out why there was puffiness in areas that hadn’t been treated with dermal filler.
The research Dr Mobin and I conducted was published as a paper in Plastic and Reconstructive Surgery of America in January 2021 and examines 14 patients that had dermal filler present between 2 and 12 years after treatment. Using MRI scans, we discovered that dermal filler lasts a lot longer than the commonly held industry belief of 6 to 18 months. Perhaps more disturbing was the realisation that dermal filler could migrate from the tear troughs to other areas of the face.
And while dermal filler can be dissolved using hyaluronidase it doesn’t always work. I sent one patient in this study to Dr Mobin because no matter how much dermal filler dissolver we used, the result stayed the same – puffy and bloated tear troughs.
Through MRI scans, we discovered the dermal filler had migrated from the tear trough to underneath the eye globe.
Dr Mobin explains, “the orbital septum is actually a division beneath the eyelid that separates the globe and the intraocular orb in the eye. It’s the actual eye area underneath your actual eyeball. <insert image from video> Disturbingly, this fine film barrier can be penetrated by a fine needle or cannula without the patient or physician knowing what’s happened. If dermal filler migrates into your eye area and creates a puffy and swollen appearance, it’s important that you only consult with experienced and trained physicians who use MRI technology. To dissolve dermal filler in this area, Dr Mobin uses an ultrasound probe with the MRI as a map. This intricate process effectively dissolves dermal filler for patients who have had dermal filler migrate under their eyeball.

Why social media influencers are having tear trough fillers dissolved

It seems I’m not the only questioning whether tear troughs should be treated with dermal fillers. In fact, some social media influencers are showing their followers why they had their tear trough fillers dissolved.
YouTube sensation Alexandra Anele was born with hereditary dark circles under her eyes. After having multiple dermal filler treatments she, “never really got to a point where I really was like satisfied with it. I had to go back a few times to get it evened out…I never looked the way that I wanted to.” Instead of having more and more dermal filler treatments, she opted to have them dissolved and “saw an immediate difference…it was crazy…I finally liked the way I looked!”
Alana Arbucci is another social media influencer who’s chosen to have dermal filler dissolved from her tear troughs. “For the past year, I started noticing really harsh dimples forming underneath my eyes. I spent the past 3 months going in again and again for more dermal filler treatment, but it got worse.” Choosing to dissolve the dermal fillers has resulted in the more natural and attractive appearance she was searching for.

Does your Cosmetic Physician study tear trough anatomy?

Given the prevalence of puffy tear troughs after dermal filler treatment, I started to research the anatomy of the eye and surrounding areas. In 2012, Mr. Bryan Mendelson published a groundbreaking article titled, The Tear Trough Ligament:
Anatomical Basis for the Tear Trough Deformity. Unfortunately, the cosmetic world didn’t heed the warning contained in this paper, that is almost now a decade old. In this paper, through dissection of 24 cadaveric faces, he found a true osteocutaneous ligament attaching skin to bone in the tear trough. That is, the skin of the tear trough groove is tethered to the bone underneath by a ligament, which means logically you can’t lift it using dermal filler.
Mr. Bryan Mendelson’s anatomical approach found the once elusive tear trough ligament that hadn’t been found previously. This explains why dermal filler simply can’t lift the tear trough groove that is held down by this ligament.
In his publication, Mendelson’s conclusion was that dermal filler can be placed underneath the tear trough ligament to support it but should not be placed above or directly into the tear trough as this can aggravate the deformity. Given its tough fibrous nature, I believe that filling directly over or in the tear trough ligament commonly leads to extrusion of the filler to either side of the ligament. This is what causes puffiness in the lower eyelid.

Why lower eyelid surgery may be better than dermal filler treatment

So, if dermal filler treatment can result in puffiness and you want to look fresher under your eyes, what’s the solution? I spoke to Ben Burt, oculoplastic surgeon about the surgical options for tear troughs.
Lower eyelid surgery can be a better option if you’ve got a genetic tendency to have prominent tear trough or if your under-eye bags are creating a large tear trough that affects your appearance. During this type of surgery, the tear trough ligament is detached to create a smoother, more natural look.

Get advice on how to achieve natural-looking tear troughs

Dermal filler injected into the tear trough commonly results in complications and regret. If this blog and accompanying YouTube video has made you question whether your tear troughs could look better without dermal filler, my team and I are here to help. Since 2005, my team of highly trained and experienced Cosmetic Doctors and Cosmetic Nurses have been treating patients with dermal filler injections and when necessary, dissolving them using hyaluronidase. Call our helpful and friendly customer service team today to book your anti-wrinkle injection treatment 1300 863 824.

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Dr. Gavin Chan
Dr. Gavin Chan

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