Tear Troughs

The tear trough deformity

The tear trough is the groove at the junction between where the lower eyelid and the cheek. As we age, one of the changes which is commonly noticed and commented on is the appearance and gradual worsening of dark circles under the eyelids. This occurs due to the thinning of the overlying skin and soft tissue over the bony orbital rim. A band of tethering fibrous tissue called the orbitomalar ligament binds the skin underneath the lower eyelid to the underlying bony rim of the eye socket. In youth, due to the surrounding plump fat, thicker overlying skin and soft tissue surrounding this structure, this ligament is usually invisible. However, with age atrophy of the adjacent tissues and thinning of the skin occurs, leading to increased visibility of this deep attachment between the skin and orbital rim- the so called tear trough deformity.

Treatment Options

Various treatment options for the disguising the tear trough deformity exist but all of them are based around two principles.

Either to:

• Plump up the tissue around the ligament (leaving the ligament intact) e.g. using filler or fat injections or to
• Disrupt the ligament altogether i.e. using surgery (lower eyelid blepharoplasty/ lower eyelid bag removal)

Both treatment principles have their advantages and disadvantages and the suitability of each treatment option varies from patient to patient. For example, some patients benefit from a combination of both surgery and filler injections.

Injectable filler (Juvederm, Restylane & Perlane) for tear trough rejuvenation
Tear Trough Filler Treatment

An increasingly popular treatment is the use of injectable implant fillers , especially in patients in their late 30's to 40's, to essentially fill out the trough. Commonly in this age group, the loss of volume at the junction between the upper cheek and lower eyelid, i.e. a worsening tear trough deformity, is the only obvious sign of aging. Therefore simple replacement of this lost volume without the need for surgery can lead to dramatic improvement. In the past, various injectable implants e.g. the patients own harvested fat cells have been used with varying patient acceptability and success. Over the past decade though, injectable fillers such as Restylane & Perlane, which are based on hyalauronic acid- a natural tissue component produced by the body, have been used with excellent safety and effectiveness.

The aim of the treatment is to place the filler deep below the skin and soft tissue around orbitomalar ligament, thereby lifting up the these tissues, making the tear trough appear shallower. In most patients there is an almost immediate improvement with a reduction in the depth and width of the tear trough itself. Dark circles which are often due to shadowing within the trough itself similarly improve. In some patients though, there may remain some residual dark circles due to actual longstanding skin pigmentation built up over many years. In these patients they often notice an enhanced effect from using makeup to mask these lines.

Non Permanent

As with all safe hyalauronic acid based fillers, there is very slow absorption of the injected material over time and these injections can quite safely be repeated if necessary. As one's face slowly changes with time, cosmetic doctors have now recognised that non-permanent treatments are advantageous since they allow them to maintain harmony rest of the patients face. A permanent implanted material such as silicone given to a patient in their 30's may not look as good or harmonious if it still present when the patient is 80. For this reason, patients and their surgeons are seeking non-permanent absorbable injectable implants since they allow for retreatments in the future customised for that patient.

Reversible

Another major advantage of these hyalauronic acid based fillers is that they can quickly reversed if the patient so desires. In the rare situation where the patient is not content with the treatment, a small injection of hyalase into the injected implant, an enzyme drug commonly used during cataract surgery for over 20 years, can be used to quickly dissolve the implant.

No Surgery Required

On the whole, the treatments are very well tolerated, being virtually painless with only a small amount of skin numbing local anaesthetic cream necessary applied to the skin just prior to injection. Patients can feel some mild pressure during the procedure itself. The procedure is usually performed within the outpatient clinic and takes about 5 minutes per side. The recovery time is very quick and although patients do notice some mild swelling over the first postoperative week, most of this would have disappeared within 10 days. The material is still mouldable under the skin over the forthcoming weeks to months and this characteristic is very often useful as patients can often self mould the implant to their own liking e.g. to smooth out any tiny lumps

Minor bruising is uncommon with this procedure and usually disappears over 10 days. Most bruising is superficial and light and is easily concealed with makeup.

A first course of treatment consists of an outpatient clinic visit for treatment, then a follow up clinic review two weeks later to reassess and top up if necessary.
Patients may undergo a repeat course of top up retreatment if desired to replace any filler which has slowly dissolved over time, sometimes 12-18 months later.