The under-eye area is reason for concern for many men and women. Whether it is because of dark circles, hollowing or puffiness, an increasing number of patients goes to cosmetic clinics for a consult hoping to find a way to fix this issue.
The tear trough deformity, aside from subjective beauty standards, is often cause of misperception: it causes people to think the person with this facial feature is constantly tired, sleep deprived or sad.
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What is the tear trough?
The tear trough from a human anatomy point of view is a deep groove in the nasal portion of the maxilla and in front of the opening of the maxillary sinus; it is also called the lacrimal groove.
What is the tear trough deformity?
First off, the name tear trough deformity is deceiving: while it is not a facial feature we all share, it can also fall within natural variability and although some may not like it, it seems extreme to call it deformity which implies a development abnormality. I’m saying this because although the tear trough deformity is often caused by the physiologic aging process, it can also be present naturally in many young individuals due to their genetics. The latter is sometimes referred to as “true tear trough deformity” and is an anatomical feature which can often be found also in one of the parents.
From a cosmetic clinical setting point of view, the tear trough deformity, simply called tear trough, is a slight depression in the area between the inner corner of the lower eyelid and the cheek (inferior orbital rim), which ends at the virtual vertical line projected from the pupillary axis.
What are the causes of tear trough deformity?
As mentioned previously, this can be either an inherited facial feature, or it can be due to aging and while absent at a younger age it may be developed later in life. With aging we lose collagen, facial fat and bone tissue is resorbed. The dermis also loses other structural components such as elastin which can cause skin laxity and prolapse of other structures such as the fat pads. The muscles of the lower eyelid may become hypertrophic emphasizing the contrast between the elevation of the lower eyelid and the naturally occurring depression of the tear trough region; the ligament may suffer from laxity and cause the muscle to prolapse. Moreover, the dip under the eye can also cast a shadow which makes the under-eye area look darker than it is with the characteristic permanently tired look.
Skin hyperpigmentation, sun damage, surgery to the lower eyelid where excessive fat was removed, and significant weight loss can also contribute to the development of the tear trough deformity.
When the tear trough deformity is present at a young age, this is due to the tear trough ligament, a relatively new anatomical discovery (2012) which in some subjects causes the unwanted feature.
What are the treatment options for the tear trough deformity?
The growing interest in aesthetic appearance in general and in cosmetic procedures in particular has led to an increased number of diagnosis of tear trough deformity. Many doctors have turned to aesthetic medicine which is not a specialty but a field of practice which has very few requirements in terms of knowledge and experience. Injectable fillers are now offered everywhere, from the dentist’s office to the family physician’s practice. When it comes to tear trough deformity treatment, hyaluronic acid fillers are not always the answer, it is not a one size fits all treatment nor it is free from contraindications and side effects, even long-term: only selected patients can benefit from fillers in the tear trough region. In those where the cause of the unwanted feature is ascribable to the tear trough ligament, being a rigid structural component, no amount of filling can fix it, or at least not without causing other unwanted cosmetic outcomes. Treatment for this cosmetic issue can be surgical or non-surgical, and depending on the specific characteristics of each patient the available options are:
- Hyaluronic acid fillers
- Autologous fat graft
- Permanent fillers (although available, I always advise against them)
- Tear trough ligament release surgery
- Lower Blepharoplasty
- Nasal Fat pad transposition
- Orbicularis oculi muscle plication
These treatments may also be combined for optimal cosmetic outcome.
I will talk in detail about the treatment options in other articles.
- Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler.
J Anido – Journal of Cosmetic Dermatology, Jan 2021
- Anatomy and nonsurgical correction of the tear trough deformity.
H Hirmand – Plastic and Reconstructive Surgery, Feb 2010
- The tear trough ligament: anatomical basis for the tear trough deformity.
CH Wong – Plastic and Reconstructive Surgery, 2012
- The Tricky Tear Trough.
SJ Pilkington – Journal of Clinical and Aesthetic Dermatology, Sep 2015
- International Textbook of Aesthetic Surgery
N Scuderi – Springer, 2016