Treating the Tear Trough

The area under the eyes presents a common cosmetic concern. Hollowing, shadowing and dark circles are often requests that can lead to patients feeling like they look older or more tired than they actually are. Aesthetic practitioners often try and address these concerns with filler treatment, however it can be a difficult area to treat successfully. In this article, I highlight the things to consider when treating this area, and how to achieve the best results for your patients.

Introducing the tear trough

The tear trough is the area underneath the lower eyelid and above the cheek (Figure 1). The term ‘tear trough deformity’ was first described by Flowers in 1993 to illustrate the concave hollow that can occur in the area.¹ He explained how a shed tear follows the course of the nasojugal groove, which led to the term ‘tear trough’.^1,2 Hyaluronic acid (HA) based dermal fillers are commonly used to try and fill this depression, in an attempt to blend the junction between the cheek and lower lid. It is a unique area to treat within aesthetics, as it cannot only be found as part of ageing changes, but the deformity can also be seen in young patients with a presumed genetic basis.³

Rejuvenation of the tear trough area can be achieved with several treatment modalities, such as surgical, filler-based and skincare-based options, and it is important to recognise the benefits and limits of each. In my practice, I find the most important step to get right is evaluating what is causing the poor cosmesis of the tear trough area. When evaluating the tear trough, one must not only evaluate the morphology of the concavity, but also evaluate the character of the skin, and the presence of ageing changes in the mid-face. Counselling the patient as to multiple factors at play in this area is key, as one treatment modality may be insufficient to fully correct their cosmetic concern. Product selection is also paramount.

Character of the skin

The character of the skin in this area is the first thing I consider when evaluating a patient for tear trough treatment. The periocular skin is some of the thinnest found on the body,⁴ and can be almost translucent, as well as being an area that can be pigmented in some individuals. With age, the amount of connective tissue elements, such as elastin, degenerate^5,6 and this can affect the tone of the skin.⁷ This is important as it will impact how the dermal filler is held within the tissues. Darkening, or hyperpigmentation of the periorbital skin, can also affect this area and contribute to the fatigued appearance that patients complain about.⁸ Whilst any concavity in the tear trough can lead to shadowing, it is important to differentiate this to actual darkening of the skin itself. To do this, have a look at the area under good lighting and at different angles to help to discern whether there is simple shadowing due to a tear trough deformity or whether the skin itself is more pigmented. If the appearance is due to the concavity causing shadowing, this should respond nicely to treatment with dermal filler,⁸ discussed in more detail below.

Those who have hyperpigmentation of the periorbital skin may respond better to skin treatments that aim to lighten the skin.⁹ Some examples include hydroquinone, arbutin and vitamin C. Patients, especially those with hyperpigmentation, should be advised to ensure they protect the area from exposure to ultraviolet (UV) radiation with a broad-spectrum sunscreen.⁸

As the skin is thin in this area,⁴ underlying vasculature can be more visible.⁹ It can also make the area more prone to the Tyndall effect when treated with HA filler.¹⁰ The Tyndall effect is a bluish discolouration of the skin caused by superficial injection of HA.^11,12 It also leaves the skin prone to becoming lax with age, and further key connective tissue elements like collagen and elastin can be lost. In order to improve the skin quality, we have a few treatment modalities that can help. Topical agents aiming to improve the skin can be used. For example, retinoids have been shown to induce epidermal thickening¹³ and promote collagen synthesis.¹⁴ Mechanical treatments including microneedling and platelet-rich plasma (PRP) can also be used to improve the skin quality in the periorbital region.¹⁵ By improving the quality of the skin, any filler treatment that is then carried out is likely to have a better aesthetic result.

Excess skin and/or protruding orbital fat can give rise to bags under the eyes, which may require surgical intervention from an oculoplastic surgeon in the form of blepharoplasty, to remove the excess tissue.¹⁶

Ageing changes of the mid-face

As we age, we lose volume in our mid-face and this can influence the appearance of the tear trough area. From bony resorption of the orbit to descent and reduction of the malar fat pads, loss of support from the cheek area can also worsen the appearance of the tear trough;¹⁷ further contributing to the loss of a smooth transition between the lower lid and cheek.^18,19 Treating volume loss in the mid-face by using a highly cohesive filler and supraperiosteal bolus injections can help provide support to the cheek.^18,19 This can reduce the amount of filler needed to be used in the tear trough itself and carries less risk of side effects.²⁰

Filler selection and application

Due to the delicate skin of this area, and poor lymphatic drainage; it is important to use a suitable filler. Highly cross-linked fillers tend to be more hydrophilic and can interfere with lymphatic drainage resulting in swelling.²¹ In order to prevent the development of an oval bulge in the tear trough, and to prevent the likelihood of causing the Tyndall effect, I use a less hydrophilic filler that is less likely to attract further water, which can result in swelling. My filler of choice is Teosyal Redensity II,²² but other fillers such as Belotero Balance have been shown to be safe to use superficially without causing the Tyndall effect.²³ I would advise under-treating the area and injecting less volume to account for the hydrophilic nature of HA filler. At the consultation stage, I explain to the patient the reason for under-treating the area, because in the weeks following the treatment the filler is likely to attract water and create more volume.²⁴

Considerations

The tear trough is a difficult area to treat well and practitioners should seek further training to ensure they have the required anatomical knowledge and experience with filler treatments before attempting to treat this delicate area.²⁵ Specific complications to be aware of when treating the tear trough include oedema, which can worsen the aesthetic appearance of the area and the Tyndall effect.^10,26

Intravascular injection is also a risk; the blood supply to the eyelid and orbit contains anastomoses between the internal and external carotid arteries.²⁶ This means there is a possibility of vascular occlusion, resulting in blindness or intracerebral injury, as well as skin necrosis.²⁶ Whilst these complications are rare, I would advocate the use of a cannula rather than a needle when treating the tear trough to further mitigate the risk.

Summary

The tear trough is a delicate area which should only be treated by appropriately qualified and trained medical professionals. Ensure that you assess the skin quality of your patients and select your dermal filler products appropriately.