Understanding the Tear Trough: Anatomy First
Anatomical Landmarks: The tear trough is the concavity extending inferomedially from the medial canthus, bordered laterally by the palpebromalar groove and superiorly by the orbital rim.
Structural Contributors: Tear trough deformity arises due to a combination of:
- Herniation of orbital fat through a weakened orbital septum
- Volume loss in the deep medial cheek fat and SOOF (sub-orbicularis oculi fat)
- Bone resorption of the infraorbital rim and maxilla
- Skin laxity and thinning with age
Why It Matters: Correction requires a layered approach that addresses the true anatomical cause—not just the surface appearance.
Option 1: Lower Eyelid Fat Repositioning
Indication: Ideal for patients with significant orbital fat prolapse and a deep tear trough.
Surgical Technique:
- Approach via transconjunctival incision to preserve anterior lamella
- Blunt dissection over the orbital rim to expose the arcus marginalis
- Release the arcus and reposition orbital fat into the subperiosteal plane to fill the trough
- Optional fixation with fibrin glue or sutures to secure fat in position
Advantages:
- Addresses fat herniation and volume deficiency simultaneously
- Preserves lower eyelid structure and minimizes scarring
Tip: Combine with lateral canthopexy in patients with lid laxity to reduce risk of ectropion.
Option 2: Fillers for Tear Trough Correction
Best For: Younger patients with mild deformities and good skin tone
Product Selection: Low G-prime HA fillers with good spreadability (e.g., Teosyal Redensity II, Belotero Balance)
Technique:
- Microcannula approach preferred to minimize bruising and vascular risk
- Small aliquots placed in preperiosteal or supraperiosteal plane
- Avoid superficial injection to prevent Tyndall effect
Option 3: Tear Trough Implants
When to Consider: Structural volume deficiency due to skeletal retrusion or post-traumatic deformities
Material Options: Custom-carved silicone or porous polyethylene (Medpor) implants
Surgical Approach:
- Transconjunctival or subciliary incision
- Subperiosteal dissection over the infraorbital rim
- Implant secured to bone with or without fixation screws
Final Considerations for Comprehensive Management
Combination Treatments: Many cases benefit from multimodal approaches (e.g., fat repositioning + midface lift, or filler + RF microneedling)
Patient Selection Is Key: Evaluate skin tone, orbital fat, bone structure, and patient goals
Long-Term Planning: Consider progressive aging changes and the durability of each option
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