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 rather than a result of ageing, and often appear even in teenage years. Often in these cases, the cause is due to tethering of the skin of the tear trough 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.
Alternately, tear trough grooves can also be a result of mid-cheek volume loss and therefore support of the lower eyelid. We term this ‘pseudo-tear troughs’. Their appearance is similar to tear troughs, but the difference is that the skin in the groove is not as strongly tethered to underlying structures. Due to the lack of tethering, a lateral pull on the skin of the lower eyelid will correct a pseudo-tear trough. A tethered tear trough will often not be corrected by this manoeuvre. This difference also means a difference in the method of treating these tear trough variants with dermal filler.
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 under eye area or areas of the face that require revolumising. 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. In some cases, removal of the fat/skin under the eyes can cause the eyes to appear more hollow, and worsen the overall appearance of the eyes. Ironically, this may necessitate further treatment to put volume back into the area in the form of dermal fillers or fat.
What type of dermal fillers are used for the tear trough area?
The most common fillers that are used for the tear trough area are made from a substance called hyaluronic acid. Hyaluronic acid is composed of chains of sugar that are cross-linked to give it a gel consistency. Forms of hyaluronic acid are also naturally found in the skin, eyes, and joints in the body.
One of the advantages of hyaluronic acid fillers are their reversibility. A substance called hyaluronidase can be injected into the area to dissolve the filler. This does not affect your normal skin or tissues, and only affects the dermal filler. Left alone, the hyaluronic acid filler will last in the tear trough area for some years.
The difficulties of using hyaluronic acid fillers is their natural hydrophilic nature, that is, they attract water. This can cause difficulties with estimating how much filler needs to be injected into the tear troughs, as the initial appearance post-treatment may be less than the final result. Therefore, it is necessary to underfill the area and estimate the amount of hydration that will subsequently occur.
We do have dermal fillers that are specifically made for the tear trough area. These are fillers that tend to blend well into the area and are less likely to cause puffiness after treatment.
What techniques are used at VCI to treat tear troughs with dermal fillers?
Originally, when we first started treating tear troughs, we used needles to inject the filler. This can be seen in this video
The risk of bruising using this technique was extremely high. Most patients would experience a week or more of significant bruising.
This lead us to using the cannula technique. See this video for a comparison between a needle and cannula;
By using a blunt tipped cannula, it is possible to feed the filler into the tear troughs and push blood vessels aside and reduce the chances of bruising.
What are the difficulties involved with the use of dermal fillers when treating tear troughs / eye bags?
The tear trough is probably the most difficult area in the face to treat with dermal fillers. It is common for patients to become very critical of the area, especially after having treatment done – that is they often want to achieve perfection or perfect smoothness in the area. However, the search for perfection is fraught with problems. Firstly, the skin is very fine here, and any slight imperfections can be seen. Secondly, hyaluronic acid based dermal fillers tend to hydrate and increase in size few days after treatment, which makes judging the amount to inject difficult. Thirdly, placement of the filler is difficult in this area, and perceiving the location and depth of filler placement under the skin is difficult..
It is therefore natural then for practitioners to prefer to underfill rather than overfill the tear troughs. As practitioners, our goal is to make the patient happy and to improve their confidence in their appearance. We do try to advise all patients to underfill, as this is the most ‘perfect’ outcome.Puffiness or swelling from overfilling of the area can promote the appearance of tiredness or make patients appear like they have been crying. Less is best, and the most attractive outcome is a natural (slightly underfilled) one.
The use of dermal fillers in this area needs to be done by experienced practitioners, and even in the best of hands, commonly requires a touch up treatment to further improve the result.
Case Study 1
This patient presented to Victorian Cosmetic Institute with concerns about her tear troughs and eyebags. She felt that she looked tired even when she was not.
1 syringe of filler was injected into the tear troughs and this helped to smooth the transition between the eyelids and cheeks and hide the appearance of her eyebags.
Case Study 2
This female presented to Victorian Cosmetic Institute with concerns about her under eye area. She was concerned about the puffiness under her eyes in particular. Using 1 syringe of filler, her under eye tear troughs were filled, and this smoothed the transition between her under eye bags and her cheeks, effectively camouflaging her eye bags/puffiness.
Case Study 3
This female presents with concerns about her under-eye bags. She was treated with 1 syringe of dermal filler to her tear troughs (the depression just underneath the buldge). It has lifted the tear trough and decreased the apparent appearance of the eye bags by smoothing the transition from the eye to the cheeks.
Case Study 4
This patient presented to Victorian Cosmetic Institute with a strong dislike for her tear trough area, she hated looking sunken and friends and family always saying she looked tired. She like that there was only 1 injection site on each side of her face and experienced no bruising from the treatment.
1 syringe was used with a small amount left over.
Case Study 6
This patient attended for tear trough dermal filler. 2mls of dermal filler was used to significantly reduce the appearance of her eye bags.
Case Study 7
This patient has some herniated fat pads in the lower eyelid, and also hollowing just under this. A total of 1.5ml of dermal filler was used in the tear trough and mid cheek to achieve this lovely natural result.
Case study 8
This patient in her late thirties presented with concerns about looking tired. She had 2mL of dermal filler injected. A ‘base’ layer of a thicker filler was injected into her cheek, and then a finer filler designed for the eye area was injected into her tear troughs. The results show a much refreshed appearance of the eye area.
Case study - tear troughs dissolved and refilled
This patient had her tear troughs corrected many years ago. Often we see the results of filler to this area last many years. In this case, the product used a few years ago had a tendency to shift or swell after some years. The top picture shows this swelling, especially in the right lower eyelid.
We dissolved the tear trough filler from the previous treatment and performed the tear trough filler again with a better product that tends to cause less swelling.
Dr. Natasha Moscato performed tear trough filler on this patient using a specialised filler designed for the eye area. This filler is less hydrophilic (water-loving) than other fillers and tends to cause less concerns such as swelling or lumpiness. This result illustrates the need for under-correction of tear troughs. That is, not attempting to fully fill or correct the problem. Instead, the final result should be natural looking such as the result achieved here.
Why should I choose Victorian Cosmetic Institute as my provider of tear trough filler?
At Victorian Cosmetic Institute, our doctors are experienced in the treatment of tear troughs using dermal fillers. We understand that this is a difficult area to fill and that this problem deeply affects those with the concern. We therefore take additional care and measures to achieve the best and most natural results possible. Understanding the anatomy of the area, utilising cannulas, and appropriate fillers all help to obtain the best and most natural results possible.