Eye bags and dark hollows are of significant bother for many people. They can affect any gender and any age; often making people look tired, unwell and aged beyond their years. In fact, a recent survey commissioned by Galderma found that 70% of men and women aged 25 and above felt they look tired and older due to their under-eye shadows. Our increased use of technology is also not helping, with 55% claiming that screen presence reminded them of how tired they look.1
As a result, it’s likely that requests for treatment are common in your clinic. But do you know how to treat the area safely? According to those experienced, intricate anatomy and thin skin make tear troughs one of the most complex areas to treat. So to support you, we spoke to three professionals – aesthetic practitioner Dr Tristan Mehta and consultant ophthalmic and oculoplastic surgeons Mrs Sabrina Shah-Desai and Mr Daniel Ezra – for their best advice.
“Hyaluronic acid (HA) filler to address tear troughs is one of the most requested treatments year on year across all genders and adult age groups, because everybody gets an under-eye hollow,” says Mrs Shah-Desai. She adds, “They believe what’s written on social media – that it’s a quick fix – but all tear troughs are not the same and that’s a big problem.”
Mrs Shah-Desai explains that it can be very easy to assume that every under-eye is going to respond in the same way to treatment but, actually, many variables can occur. A conservative and well-planned approach is therefore essential.
Patient selection
All three practitioners agree that appropriate patient selection is key to successful tear trough treatment. “Patient selection is where many practitioners go wrong,” says Dr Mehta, with Dr Ezra adding that poor patient selection is the cause of most of the complications that he sees from other practitioners.
Dr Mehta outlines the four presentations that he has found are unsuitable for treatment with HA:
- Excess skin under the eye: better addressed with surgery
- Secondary tear troughs: pseudoherniation of fat that pushes down from above; again better treated with surgery
- Malar oedema in the cheeks: signals that the patient’s lymphatics aren’t working effectively and adding HA to the area can lead to more oedema
- Pigmentation: could look like a dark circle – HA won’t necessarily help much, better treated with skin treatments
Mrs Shah-Desai adds that in peri-menopausal women, skin can become so loose that it won’t support the HA that you’re putting in. This can then lead to swelling and festoons, so patients would benefit from undergoing skin tightening before having their tear troughs filled. “We’ve got great energy-based treatments; from lasers, to radiofrequency microneedling, to ultrasound – all these things can help the area. Products I recommend include Sofwave, Tixel and Morpheus8. Once the skin is tightened and the tissue quality has improved, subtle filler placement will help,” she says.
For Mr Ezra, patients with excessive bags under their eyes are a big no-no for non-surgical treatment. “If fillers are administered to patients who have significant bags, then the complication rate gets very high and patients are often unhappy with a very puffy look,” he explains. Mrs Shah-Desai adds, “The minute you see a large bag, then you know you’re in the surgical arena and you should refer accordingly.”
She emphasises that, as a rule of thumb, practitioners should only select patients with hollows who have thick, tight skin; this is generally people under the age of 45. “If you get the right patients, who have genuine volume loss that you can target in the right way, without puffiness, excessive skin or oedema, you’re going to get a lovely results,” reassures Dr Mehta.
Product selection and treatment approach
Dr Mehta and Mr Ezra outline that the tear trough is probably the most complex area to treat because it is interconnected to so many areas of the face. Dr Mehta explains, “There are various anatomical considerations to be aware of and we need to understand the zones of the face that support the tear trough indirectly.”
He continues, “Zoning into the cheek, we have two important fat pads that we need to make sure are adequately revolumised. These are the deep medial fat pad and the medial SOOF as they are the first fad pads that tend to lose volume through ageing.” Dr Mehta notes that the temple should also be volumised, alongside ensuring the zygoma is well structured. He explains, “We want to create good scaffolding first. Once the temples, cheek bone and fat pads are restored and restructured, we can then move on to treating the tear trough itself.”
Mr Ezra says that after poor patient selection, poor product selection is the next thing that leads to bad results. “Filler choice and volume placement are key issues; it’s essential that the filler is of low cohesivity,” he says.
Additionally, Mr Ezra argues that conventional wisdom should be turned on its head when injecting tear troughs. “Rather than providing different layered fillers in different areas, you actually just need to focus on the tear trough itself in very small volumes,” he explains. Of course, once the result has settled, you can add more but, again, only in small volumes, he advises, noting, “I would make sure it’s well tolerated and do a second dose a few months later rather than trying to do it all in one go.”
Mrs Shah-Desai agrees, saying, “You can have two initial treatments depending on the depth and extent of the hollow in the first year and then, as a rule for the vast majority, maintenance should be every year to year and a half.”
In terms of brands, Dr Mehta has been seeing positive results with Neauvia Intense Flux over the six months he has been using it. “It finds its way to the tear trough in the most naturally smooth way I’ve ever seen,” he says, explaining that the product contains two amino acids – glycine and L-Proline that push away water, which reduces the chances of swelling or oedema.3
Mr Ezra uses Teosyal Redensity 2 and also Restylane Eyelight – a new product on the market which launched earlier this year. He says that Eyelight has an excellent safety a profile and fills a key niche, being particularly beneficial in patients with deeper hollows, as it is very cohesive and allows for more lift and elevation with a smaller volume of filler. A study found that 88.6% of people treated with it reported looking less tired, while 94.3% said they would recommend it to a friend and repeat treatment.4
“The minute you see a large bag, then you know you’re in the surgical arena and you should refer accordingly”
Teosyal Redensity 2 is Mrs Shah-Desai’s product of choice. She’s been using it for six years and says, “Redensity 2 has low hygroscopy, which means it has a low swelling factor.5 As it’s been designed for the under-eye area, it’s got a great spreadability. You can inject a small bolus, and it then spreads very uniformly and smoothly.”
All the practitioners agree on using a cannula to inject the tear trough for patient safety, highlighting that the area has a dense network of blood vessels which are more easily avoided with cannula. Mr Ezra has designed his own Three-Point Tangent Technique which breaks down treatment into three cannula passes. He says it has demonstrated good safety and effectiveness in more than 1,000 treatments.
Mrs Shah-Desai also has her own technique, known as Eye-Boost. This involves putting a small amount of filler two planes. She explains, “We know from cadaveric studies that filler starts lying superficially even if we put it on the bone, which is why it needs very light treatment. There are very few people worldwide who do these kinds of biplaner techniques, so they’re not for everyone.”
Of course, there are many other products on the market so the practitioners advise conducting thorough research before adopting one. “If we’re being generic, you want one with a low molecular weight of HA, that’s not hydrophilic,” recommends Mrs Shah-Desai.
Reviewing clinical data is essential, they agree, highlighting that it’s important to pay close attention to the longevity of studies rather than anecdotal cases. “Don’t be afraid to ask filler companies hard questions,” emphasises Mrs Shah-Desai.
Anatomy
Jingo Jiang et al., summarised the tear trough’s anatomy in their study on the area’s deformities and treatment options published in 2016.2
The authors state that the position of the tear trough is most accurately described to be within the boundary of the orbicularis muscle. Normal changes in the insertion of the orbicularis muscle, from medial to lateral, have permitted a better understanding of the anatomy and treatment.
As a result, the term ‘tear trough deformity’ should be applied to the medial periorbital hollow extending obliquely from the medial canthus to the mid-pupillary line. There is absence of fat tissue from the central and medial fat pads subjacent to the orbicularis oculi muscle in the area below the groove.
Volume bone loss of the orbital rim seems to predominate in development of the nasojugal groove and there is advanced volume loss in the central cheek, the medial cheek, and the malar eminence with ageing. The integrity of the septum diminishes with advancing age, such that orbital fat bulging leads to the appearance of bags or fullness in the lower eyelid.
The tear trough deformity associated with ageing has been explained by gravitational descent, such as laxity of the supporting ligaments and descent of the mid-face. The orbicularis retaining ligament creates a V-shaped deformity that correlates with the lid-cheek junction.
One of the reasons that ageing adds to the deformity of the tear trough is attributed to the loose orbicularis retaining ligament. Other research defined the tear trough as the junction of the thin, pigmented lower lid skin with the thicker cheek skin at the medial canthus to the mid-pupillary line. The lid-cheek junction was found to be stable over time and its perceived descent was said to be due to age-related tissue volume changes and not actual movement. The tear trough is often related to underlying bony structure and particularly associated with age-related maxillary hypoplasia. Lower eyelid skin also progressively loses its elasticity and thickness with ageing. Other changes in skin such as hyperpigmentation, and actinic changes also play a role in the tear trough.2
Risks and management
The most common complications that can occur from tear trough treatment are swelling, oedema, lumpiness and bruising. If unsterile techniques have been used, then infection is a risk too. Mrs Shah-Desai notes that some patients are more prone to swelling, particularly those with allergies, which you should establish when taking their medical history. You can therefore pre-empt that they may see this side effect in mild to moderate form after treatment, and prepare them for it. “We can tell patients to massage, and give them oral anti-allergy pills to manage it in advance,” she says.
While these side effects can occur straight after treatment, Mrs Shah-Desai points out that the tear trough skin is very dynamic and is continually thinning. This means that even years after treatment, a complication could occur. “It could suddenly start swelling or the patient will see a blue-grey discolouration under the eye (known as the Tyndall effect) because the skin has become thinner and looser, or as the filler is biodegrading you may see delayed swelling,” she explains.
According to the practitioners, other complications that could occur include malar bags or festoons, which present as a more extreme version of normal under-eye bags. These, along with severe lumpiness or contour irregularities, usually need to be resolved by dissolving the HA. Mr Ezra points out that doing so requires an open and honest conversation with the patient. “It can require difficult discussions about what’s happened, what the implications of dissolving might be and what the final outcome will look like,” he explains.
Mrs Shah-Desai advocates the use of ultrasound to support the management of complications. She says, “Ultrasonography allows me to visualise real-time anatomy and pinpoint the location of the filler to allow for precise ultrasound guided dissolving.”
In his practice, Mr Ezra uses 3D MRI scans to aid complication management. He says, “It gives a very detailed 3D representation of the distribution and extensiveness of filler in patients’ faces. In our studies we’ve found that fillers will often persist for 10 to 15 years after application. The reconstruction tells us exactly where the filler is and how much of it there is. This helps to guide the discussion with the patient around the implications of dissolving it.”
With any injectable procedure there is a risk of vascular occlusion, the worst case scenario being blindness, but the practitioners say that it is extremely rare when treating the tear trough. “Using a cannula, and injecting low volumes with a low pressure, is the best way to keep safe when treating higher risk zones,” advises Dr Mehta.
Mr Ezra adds, “If you are thinking of treating the tear trough, make sure you have clear and rapid referral pathways to an eye specialist or department in case there are any issues.”
Treat carefully and conservatively
“Always be conservative in treatment,” is Dr Mehta’s takeaway tip, while Mrs Shah-Desai emphasises assessment is key and Mr Ezra says be prepared to turn patients away if they are unsuitable or when you know you won’t be able to treat them successfully. He highlights, “It’s not fair to offer filler if there could be better alternatives; if you can’t offer surgery, find someone to refer these patients to.” Mrs Shah-Desai adds that, depending on the concern, you could consider other minimally-invasive treatments, such as mesotherapy, laser resurfacing or peels but, again, thorough research and training is essential. As always, whatever treatment you go with, the practitioners emphasise that it is essential to have the appropriate training in both administering the procedure and managing any complications that could occur.
