What are “Tear Troughs”
The term tear troughs are loosely being applied to a variety of under eye concerns which can include dark circles, a true tear trough deformity or a pseudo-trough secondary to prolapsed fat bags.
Accurate Diagnosis is Essential
When addressing the under eye area the most critical factor is an accurate diagnosis as this must guide the treatment plan. Too often both patients and injectors believe that “just a bit of filler” will or can correct all their concerns. And this is why so many patients are left disappointed or in some cases, worse off than before their treatment.
Who is a good candidate for Tear Trough Treatment?
Not all patients are good candidates for tear trough filler and this depends on a variety of factors including:
- Overlying Skin Quality
- Underlying bone support
- The presence of prolapsed fat bags
- Soft tissue support ( a thin layer of fat immediately under the skin)
- An individual’s unique lymphatic drainage system
- A patients propensity to allergies and or underlying medical conditions
- Medications
- Genetics
- Lifestyle factors
Overlying skin
it is important to look at several factors where the skin is concerned.
Colouring
The skin in our under eye area is the thinnest skin in our body and we can in fact “see” into it for a mm or so, making it possible to see the underlying veins and vasculature.
Not all dark circles are caused by a shadow due to hollowness. An easy way to determine if filler will improve the “coloring” of the under eye is to slightly stretch the skin between two fingers- if the color improves then filler will most likely improve the “darkness”. However, if there is no improvement it is most likely due to other factors. The two main factors are hyperpigmentation and/ or vascular effects.
Hyperpigmentation can be due to congenital dark circles where the darkness affects both the nasal root as well as the upper lids. This condition often has a genetic predisposition and presents itself during the teenage years. Congenital dark circles look worse in certain lighting conditions and are notoriously difficult to treat, filler in no way helps improve this type of discoloration but if there is an anatomical trough it can improve the overall aesthetic of the under eye. Other causes of hyperpigmentation that can affect the under eye include: PIH/ freckles/ Nevi of OTA/ actinic keratosis etc.
Vascularity can manifest as a blue or red coloring. A blue discoloration can be either due to large veins that we can see through the skin or as a diffuse blue color which represents pooling of venous blood in the underlying muscle. The venous return in our under eye area is sluggish compared to the cheek for instance. Red or pinkish discoloration close to the corner of our eyes is capillary perfusion that we can see because the skin is so thin. This is more common in people with very fair skin.
Skin quality
Skin quality is often determined by age, genetics and external factors like sun damage and smoking. Here a “snap test” gives us a good idea of the extent of laxity. Gently pull the skin away from the lid and then when we let go we can look at how quickly the skin “snaps” back to its original position and shape. Often the skin goes back very slowly and this is a bit of a warning sign that someone might not be a very good candidate for filler.
Underlying bone support
Underlying bone support is very important as filler needs to be placed on the bone in the instance of tear trough filler. If you don’t have bone support where the filler is needed, you’re essentially placing the filler in a hammock and you won’t have any projection, defeating the purpose. The size of the orbital cavity varies depending on mane factors incl. ethnicity, gender and age and each person needs an independent assessment to judge their suitability for tear trough filler.
Prolapsed fat bags
Prolapsed fat bags are equally hated by both patients and injectors. They really complicate an already complicated area and their appearance is highly positional- fat bags prolapse more when looking up and can almost completely disappear when looking down. Dermal fillers can’t remove or completely hide the presence of fat bags but their presence.can be disguised Fat bags can affect the entire under eye area although in some cases they’re only present in the medial or less frequently the lateral aspect.
Soft tissue support
Soft tissue support is invariably a blessing in the rare cases that it is adequate. It refers to a thin layer of fat just beneath the skin and is more common in males than females. It diminishes with advancing age.
The Lymphatic drainage system
The Lymphatic drainage system of the under eye area is a particularly fragile one as there are only a few channels leading away from the under eye area into the cheek and pre-auricular systems. These channels are very delicate and can easily be overwhelmed or compromised by the amount of lymphatic fluid that can collect after tear trough filler. Further compromise by anti-wrinkle injections to the orbicularis muscle is common.
Allergies and sinus problems
Allergies and sinus problems. Chronic rubbing of itchy eyes leads to deposition of pigment in the skin, as well as creasing the skin which in turn makes the skin look older. Chronic congestion due to underlying sinus issues may contribute to puffiness under the eyes. Rarely underlying medical conditions like thyroid disease/ kidney disorders and adrenal insufficiency can lead to fluid accumulation under or fat deposition behind the eyes.
Medications
Medications like Ace-inhibitors (used for blood pressure control or heart failure modification) can also rarely cause puffiness under the eyes.
Hollow under eyes
Some patients have naturally deep tear troughs or hollow eyes. This can also be described by some as “deep set eyes”.
Flatness of Front Cheeks
Flatness of Front Cheeks is something that is just the patient’s natural face shape. What happens when a patient has flat front cheeks is that the lid cheek junction is extremely low on the face, making the tear troughs seem very long. Tear troughs lengthen as we age as well, so this will become a very noticeable issue on those who are starting with long tear troughs.
Genetics
Genetics is often the most important factor in young people that present with fat and or fluid bags or hollowness. It’s a genetic tendency and it’s not rare for a patient to make the observation that this is an unwanted gift from Mom or Dad!
Lifestyle factors
Lifestyle factors including our diet, sleep, stress levels, salt and alcohol intake, exercise, smoking, women’s menstrual cycles, menopause and many more all play a role as well. It is indeed a very sensitive area of our bodies and often reflects more about our health and wellbeing than we realise.
Treatment options
Now that we’ve had a look at all the compounding factors we can discuss possible treatment options specifically addressing the above mentioned issues.
Overlying skin
Treatment options for overlying skin issues, which includes hyperpigmentation, vascularity and skin quality.
Hyperpigmentation
Congenital dark circles may respond to products like Hydroquinone and other skin lightening topical treatments and certain lasers that target pigment. Certain types of pigment may return over time and the treatments will be ongoing (similar to injectables). A new skinbooster launched in Australia at the end of 2019 includes Glutathione ( a strong antioxidant with anti-melanogenic properties) Vitamins A B C ,and a host of other ingredients that can improve this stubborn pigmentation. We recommend a series of 3 treatments then 1 at 3 months and then 1 every six months.
Post inflammatory hyperpigmentation
Post inflammatory hyperpigmentation responds well to Hydroquinone and other skin brightening topicals.
Freckles/ sun spots
Freckles/ sun spots and birthmarks can effectively be addressed with a variety of light based devices including IPL and other energy based devices which have the appropriate target
Vascularity
Red and blue veins are often a contributing factor to dark circles. Any and all contributing factors to the under eye area should be treated in patients presenting with “dark circles” and this includes both periorbital veins, as well as, telangiectasia visible in the area. Our laser of choice is the Excel V which is a designated vascular laser by Cutera. There are wavelengths on this device that are able to target the blue veins and the red ones. The procedures are quick, relatively painless and downtime is truly minimal.
Skin Quality
The gold standard for non-surgical treatment of skin quality is and probably always will be ablative lasers. This is an absolutely fantastic way to rejuvenate the under eye area and can also be combined with Radiofrequency Microneedling and or IPL on the same day!
The drawback of this treatment is the downtime which can be 3-10 Days
The same treatment can be performed less aggressively, minimizing the downtime to 3 days but a series of treatments might be necessary in these cases.
For people with good skin quality that want to maintain and still improve their under eye skin non-ablative lasers are a great option, and have minimal downtime. Radiofrequency microneedling is a bit of a favourite of mine as it is safe on ALL skin types, has virtually no complications and downtime is almost negligible. A series of 3-6 treatments is a must though.
RF Microneedling or needling is another safe and reliable treatment. Again a series of 3-6 treatments is required.
Injectable treatment options include micro-muscle relaxant (only suitable in certain candidates) PRP and our new skinbooster which contains 52 vitamins, minerals and antioxidants, as well as Glutathione. The downtime with PRP is 2-3 days and with the skinbooster it ranges from a few hours to maybe 1 day.
Underlying bone support
The issues of bone support is compounded by the inevitable reabsorption and loss of bone as we age. By the age of 60 years old we have lost 30% of the total bone tissue in our skull. resulting in less soft tissue support with inevitable sagging. Filler can be used to mimic the support of bone.
Prolapsed fat bags
As our orbits enlarge the fat tissue that cushions our eyeballs spill/ bulge forward and become visible as an “eyebag.” The prolapsed bulge then creates the false illusion of hollowness underneath or in people who already have a hollow teartrough it aggravates the pre-existing hollowness. The gold standard of treatment for prolapsed eye bags is a blepharoplasty with fat bag removal. The under eye area might be quite hollow after such a procedure so it is often combined with fat transfer or dermal filler once the area is healed. Dermal filler around a fat bag needs to be placed very carefully and meticulously. Small amounts placed in the deep planes can help to disguise the fat bag but won’t completely hide it. Fat bags are also dependent on the position of the eyeball, and can look good when you’re looking in a downward direction but looking up makes them stand out even more. Good temple volume and midface cheek support is also very important when eyebags are being addressed.
Soft tissue support
Often the “tear trough patient” has poor soft tissue support.. Sometimes younger patients and male patients still have a thin layer of fat between the skin and the underlying muscle but unfortunately in most patients it feels like skin on bone in this area. Most injectors are tempted into sprinkling/ fanning/ dusting a tiny amount of filler into this layer and it might look very good for a month or so but then this filler may swell or become visible or lumpy or have a bluish tinge to it. This complication may not resolve quickly and the offending filler may need to be dissolved.
Flat Front Cheeks
A long tear trough secondary to lack of support in the front cheek ie flat or concave or minimally convex front cheeks can be well treated by filler in the cheeks
Hollowness
Filler can be used to treat deep tear troughs and hollow under eyes.
The lymphatic drainage
The lymphatic drainage of the under eye is a very very delicate system and whilst some people have no problem with this whatsoever it is truly a nightmare for others. People with poor lymphatic drainage in this area really are not good candidates for conventional tear trough filler. It is better to give deep support to the midface. A tiny bit of well placed lateral orbital rim filler and maybe, just maybe, a drop in the deep medial tear trough. This needs to be decided on a case by case basis. These patients also have prolonged swelling after their tear trough filler and they have to be prepared for 4-6 weeks of puffiness around their eyes. Oral prednisone may be a useful adjuvant for these patients.
Allergy and sinus problems
Hyperpigmentation and or chronic redness caused by continuous rubbing of the eyes is a difficult problem to treat and an allergy specialist is warranted. Once the causative factor has been addressed the skin discoloration can be treated in the same ways as conventional PIH and or redness described above. Sinus problems lead to congestion which in turn leads to puffy under eyes, again it is best to have these conditions addressed and resolved by a specialist before undertaking cosmetic procedures. The same goes for underlying medical conditions. Patients with stable outo-immune conditions can safely be treated with anti-wrinkle injections as well as dermal fillers. In some instances your injector might ask you to get approval from your specialist for injectables.
Medications
Whilst it is possible for certain medications to cause puffiness under the eyes, this is extremely rare and it would be up to your treating physician to change or adjust your medication.
Genetics
Genetic factors include congenital dark circles. This condition often presents in the teenage or early adult years. Rarely it can present in childhood. Genetic dark circles affect the under eye area as well as the root of the nose and the upper lid. The appearance of the skin is very much affected by the lighting and this phenomenon is called shadowing.