Article medically reviewed by Dr. Gavin Chan (MBBS, cosmetic physician, liposuctionist)
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.
What are tear troughs?
Tear troughs are the hollows between the lower eyelid and the cheeks. This groove is often an aesthetic concern as it may cause the appearance of tiredness.
What causes tear troughs?
In many cases, tear troughs are genetic and often begin to appear in childhood. Often, the cause is tethering of the tear trough skin to the orbital bone below. The anatomical basis for the tear trough was first found by Melbourne plastic surgeon, Mr. Bryan Mendelson in 2012. He discovered a true osteocutaneous (bone to skin) ligament, the tear trough ligament, that had not previously been discovered through normal dissection techniques.
Ageing can also exacerbate the tear trough deformity as;
- the lower eyelid fat prolapses further forward
- the quality of the lower eyelid skin worsens, resulting in loss of skin elasticity
- the mid-cheek loses bony and fat volume, causing loss of support of the lower eyelid.
How can I treat my tear troughs with dermal filler?
The appearance of and tear troughs can be reduced through the injection of dermal fillers.
A common technique for correcting tear troughs is to inject dermal filler directly in the groove between the lower eyelid and cheek. We no longer recommend filler injections using this method for the following reasons;
2. During this time, the filler may migrate to other areas in the lower eyelid or orbit and cause lower eyelid puffiness
3. The tear trough ligament in many cases strongly tethers the skin to the orbital bone, and this makes it difficult if not impossible to lift with fillers.
4. Filler injection directly into the tear trough can lead to inadvertent injection of filler beyond the orbital septum. The orbital septum is the septum that divides the front and back of the orbit. If filler is injected behind the septum, then essentially the filler is placed under the globe (the ‘eyeball’). This may cause puffiness and a significant amount of difficulty in dissolving the filler with hyaluronidase should this occur. The hyaluronidase would need to be injected also beneath the globe, which could be difficult and dangerous without the assistance of ultrasound guidance.
Loss of volume in the mid-cheek also can cause hollowing between the lower eyelid and cheek and exacerbate the appearance of tear troughs. It is possible to replace volume in the mid-cheek using dermal fillers to help correct this problem. This method was advocated in Mendelson’s 2012 study, instead of filling the tear trough directly, filler could be used in the mid-cheek to help lift and support the tear trough ligament from beneath, reducing the appearance of the tear troughs.
How can I treat my tear troughs surgically?
As an alternative to dermal fillers, fat transfer from another part of the body can be used to fill in any hollows. This involves a minor liposuction to harvest fat from an area such as the abdomen, and then injecting this fat into the mid-cheek or areas of the face that require revolumising. Note that we do not inject directly into the tear trough for the same reasons we do not inject filler there.
The fat that is transferred then regenerates in its new position, and acts in a similar way to a dermal filler to revolumise and smooth the area under the eyes. Fat transfer should be considered as a permanent procedure. Therefore, it is necessary to slightly under-fill the area, as any lumps or excess fat may require further surgery to remove. Fat does have the advantage however of not being hydrophilic (attracted to water), and, once settled in, seem to have less fluctuations in volume in comparison to dermal fillers.
Surgically, a lower eyelid blepharoplasty can be performed to remove the excess skin and fat from under the eyes. The tear trough ligament that attaches the skin to the orbital bone can be released surgically. The fat from the lower eyelid can also be transposed to the tear trough groove to smooth and even the contour of the area. A small amount of skin can be ‘pinched’ and removed to tighten skin of the lower eyelid.
This patient has some herniated fat pads in the lower eyelid, and also tear trough hollow underneath. She had filler in her mid-cheek to support her tear trough ligament.