What is the tear trough?

The tear trough is a normal anatomical feature of the infraorbital (under-eye) area and is considered part of the mid face, as it joins the upper part of the cheek. The line or crease known as the true tear trough starts from below the medial canthus, where the tear trough ligament descends obliquely down and laterally. Once this crease reaches the mid pupillary line, the true tear trough ends, and it divides into two separate creases that can form false tear troughs:
I. The palpebromalar groove, which curves back up towards the lateral canthus
II. The nasojugal groove that continues in the same oblique manner down and laterally over the upper cheek

How is it relevant to ageing?

Many patients complain of looking tired, despite having enough sleep regularly and show noticeable signs of early ageing in the midface, primarily due to collagen or fat volume loss. The volume loss will reveal the tear trough ligament, and this creates a marked step or discrepancy between the infraorbital area and cheek. This is often the starting point of facial descent and when left untreated, advances ageing considerably throughout the rest of the face.

When is it normally first noticed?

The tear trough is noticed at variable ages and depends on patient factors that may lead to advanced rhytid (wrinkle) formation, fat volume loss or fat pad prolapse. In earlier age groups such as 21-45 the most common reason is a volume loss of collagen or fat. In older age groups (45+), the role of bone resorption should be considered, especially if there are concerns with conditions that affect bone density such as osteoporosis.

Effects on other areas of the face?

Descent from the cheeks and tear troughs leads to subsequent heaviness and advanced ageing effects on the middle and lower face. Many practitioners often treat the tear trough in isolation from the cheeks, or vice versa, due to little available hands-on training for designing or rejuvenating the midface as a complete unit. This inevitably creates limitations in the ability to deal with variable face shapes and anatomy, as one- dimensional approach does not suit all faces.

How is it treated?

Tear trough deformities should be treated due to their underlying cause, which may include exploring surgical options. There is 4-point tear trough criteria that can approximate if treatment with dermal fillers will be favourable, which are:

Richard Umasuthan

I. Thick, smooth and elastic skin
II. A well-defined infraorbital hollow
III. No excessive fat, with little to no herniation
IV. Little to no pigmentation

A true tear trough deformity from volume loss that fulfils the above criteria is the ideal candidate for correction with dermal fillers, of which there are three approaches that can be used in combination for mid facial rejuvenation:

I. Tear Trough Filler – using a needle and/or cannula with a very low-density filler, to fill above and below the orbicularis oculi muscle. There are only two fillers that have been approved by the FDA for this technique, which are Teosyal Redensity 2 and Juvéderm Volbella XC

II. Cheek Filler – using a needle down to bone and injecting a high-density filler to allow tracking up towards the tear trough. This will support the true tear trough and efface the nasojugal groove

III. Pyriform Fossa Filler – using a needle down to bone pointing towards the base of the nose for anterior projection

How long does it last?

The infraorbital area is relatively non mobile and therefore does not encounter muscle interference or breakdown of filler. As the density used in the classical technique under the orbicularis is very light, the cosmetic effects can last up to 9-12 months on average.

What are the benefits vs risks?

The combined treatment of the tear trough and cheek areas are fundamental to restoring the midface and mastering both is essential to provide holistic and individualised results. The benefit in almost all cases is to rejuvenate the midfacial area and reduce signs of ageing, thereby also reducing the perception of looking tired. Despite being safe techniques that are tried and tested, they do not come without risk, as is the case with all facial filling techniques. The main risk of any filler procedure will always be a potential of causing a direct or indirect vascular occlusion, that can potentially lead to necrosis, if unrecognised and left untreated. Other recognised risks of midfacial filling techniques would be:

I. Soreness/Bruising/Swelling/Erythema (expected)
II. Infections
III. Tyndall Effect
IV. Lumps or Delayed Nodules
V. Disturbance of infraorbital lymphatics, leading to cyclical swellings

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