Correcting the Tear Trough Deformity
Tear trough depressions can occur at all ages. Patients come in and complain to me
that they appear tired and try to conceal their lower eyelid hollows with concealer.
Most patients will have a sunken appearance and dark shadows cast over their lower
eyelids. The hollowness is due to the attachments of ligaments around the eye along
with volume loss.
There are various classifications in the literature describing the severity of the deformity.
Hirmandb�s 1 classification includes Class 1, 11, and 111. Class 1 patients have volume
loss in the medial tear trough and flattening extending to the medial cheek. Class 111
represent patients with full depression along the whole orbital rim.
The patients with the most severe depression are the hardest to treat.
There are various treatments including surgery, chemical peels, laser resurfacing,
volume replacement and a combination of procedures.
I am going to talk about treating the area tear trough deformity with fillers.
Patient with bilateral tear trough deficiency. Right lower tear trough being more severe
with a depression along the entire orbital rim.
Picture on right directly after filling of medial and central cheeks with Radiesse and
superior filling of tear trough with Belotero using a cannula.
In the above patient she have volume deficiency in the medial cheeks along with a tear
trough deficiency. In this patient I filled the medial and mid cheek area with Radiesse
using a cannula. I injected in the deep dermal plane in the video that is on my website
but now I inject on top of the bone in the supraperiosteal plane. I inject slowly and do so
like I would inject fat by injecting in small alliquots while I am withdrawing the cannula.
The superior tear trough area was injected very superficially with Belotero which is a
newer hyaluronic acid (HA) filler. Belotero can be injected under the obicularis muscle
but I have found that one can also inject very superficially above the orbital rim due to it
low Gb� of 30 and low viscosity of 9,217. This characteristics of the filler is important
because when injection is very superficial it will spread and there will be no visible
bumps under the skin. One is trying to achieve aB youthful smooth transition betweenB the orbital rimB and cheeks.
Patient with bilateral tear trough deficiency and more wrinkling of lower eyelid than
previous patient. Picture on right immediately after Radiesse filling of medial and mid
cheeks, and Belotero filling of upper tear trough using a cannula.
Some delayed complications can include a orange-brown staining due to deposition of
hemosiderin after bruising. I usually expedite the resolution of this by using the low
level laser on these patients. I will not talk about how the laser works here but I did go
into detail in my second published article that is in PDF form on the website.
Puffiness is usually due to the hydrophilic nature of the HA filler which means that it
binds water. Patients with allergies might experience and increase or decrease of
swelling under their eyes. Increase salt intake can also exacerbate the problem. I
advise patients to limit salt intake the following week and to take antihistamines if they
are prone to allergies.
The Tyndall effect is a well described in the literature that can occur with too superficial
injections. We can get away with superficial injections with Belotero because of itb�s low
Gb� and viscosity. What one sees with this effect is a bluish discoloration to the skin due
to the scattering of blue light spectrum by the particles.
Nodules can also appear under the skin and give an irregular appearance. These can
be treated with message, aspiration or drainage. With Hyaluronidase one can dissolve
the H.A. and hence the nodules will resolve over the next 24-36 hours.
Infections are rare but can occur. Antibiotics readily treat most infections.
Other rare complications include venous compression syndrome, arterial occlusion and
venous occlusion . The later is delayed and both can cause skin necrosis. Retinal
embolus is a severe complication that can cause blindness. To avoid these potential
serious complications I like to use cannulas and inject slowly. One should also be
cognizant of where the large vessels in the face are anatomically. Use caution when
injecting in the region of the angular and supratrochlear artery, and supraorbital and
In conclusion the tear trough deformity can be corrected in patients with fillers. It works
well and is well tolerated with minimal downtown.
J Cutan Aesthet Surg. 2012 Oct-Dec