Tear Trough Deformity

1. Before tear trough treatment. 2. After 1ml dermal filler to tear troughs. 3. After 2mls dermal filler to tear torughs (thankyou to patient for supplying images

Tear Trough Deformity Case Study

Treatment of tear trough deformity is common in our Sydney practice. Here is a case of a patient whose eyes are her signature feature. They are stunning, large and beautifully proportioned, with perfect width between them, and also that extra bit of projection compared to the average person (which I personally find gorgeous!)

The problem with tear troughs, is that they are the frame of the eye, and when they are dark or hollow or long, it makes the frame look messy and distracting to the onlooker, with the eyes seeming more obscured and less obvious, with too much going on around them to notice their beauty.

What happens when we fill a tear trough is that the distracting and messy frame is removed from around the picture, the frame becomes simple and allows the eye (the picture) to shine.

This is really obvious in the case above.

Thankyou to the generous patient, who provided the image series associated with her treatment:)

What are tear troughs?

Tear troughs are a normal part of anatomy. A tear trough deformity is where there is loss or lack of volume in the area. Tear troughs are the depression/fold  in the skin  that travels from the inner corner of the eye outwards and downwards. They are the valley that occurs beneath the “eyebag”. They are at the lower orbital rim

As a patient ages, the bone in the cheek underneath the tear troughs dissolve and they get deeper and longer. With  ageing there becomes a greater demarcation between the lower eyelid and the cheek. The tear troughs  get longer diagonally down the face, changing into the extension of the tear trough or mid-cheek line/fold. The thing that also happens is that the length between the lower lashes and the orbital rim/ tear trough below it going straight down is increased. I find that if patients are long in this distance from an early age (often genetic) then they will present for tear troughs early.

Tear trough patients are a breed. They obsessed with their eyes. They may have many other flaws, but this is the one on which they focus. When they look at their face, they zone in on this area like a laser.

Common themes with tear trough patients

1. Patients who are upset about their tear troughs talk about different lighting, and how it affects the appearance of their troughs. If I could tell you how many times I have heard patients say “your lighting is really good here, but in my bathroom at home, they look really bad” etc

2. Something really annoys me and it happens almost every day of a cosmetic doctor’s working life these days, and this is that patients come in to have their tear troughs treated purely because so many people continuously say to them “you look tired”. These poor patients are sick to death of hearing this, because the problem is, it is so often said to them when they are not tired. I wish people would keep this unhelpful comment to themselves. Tear trough patients always complain about this, saying things like “it’s socially unacceptable to insult people’s appearance, eg you’d never tell someone that they looked fat, but the one thing that people feel comfortable “insulting” is about someone looking tired.

3. The tear troughs are genetic. The parents or siblings will also be affected.

4. The patient’s unhappiness with their tear troughs has been present since a young age. I have even had a patient who was teased as a child and called “sleepy”

5. The patients are very motivated to improve their tear troughs. They are willing and keen to go through with the  procedure, even despite being aware that it is the dermal filler treatment with the lowest satisfaction rate and highest rate of revision.

Treating tear troughs

Treating tear troughs can be technically difficult. It is better to perform multiple treatments with gradual improvement than to attempt to achieve a perfectly filled-to-flat tear trough hollow in one treatment. The risks of tyndall effect, lumpiness and swelling can occur.

Advice for patients who are contemplating dermal filler injections in their tear troughs

  • Try not to be dysmorphic about your tear troughs. In the majority of cases, no one thinks your tear troughs look as bad as you think they are.
  • Become informed, do a lot of research into the problems which can occur with the dermal filler tear trough treatment. Take time to make your decision. Don’t make it quickly.
  • Be patient: Tear troughs weren’t corrected in a day:)
  • Don’t give your doctor a hard time, they are taking on a difficult job. I know quite a few injectors who just won’t inject tear troughs because they don’t want the headaches. I am jealous of them.
  • Be realistic. The amount of times that we have had patients come to us with already over-filled tear troughs (ie a raised area over the tear trough) from prior treatment, asking for further treatment, is surprising. If there is no trough, i.e. no depressed area, in the actual tear trough, there should be NO FILLING in that area. Other areas to support the tear trough may be injected though.
  • Make sure it is your tear troughs that are the problem. We have had patients who have requested that we treat their tear troughs, because they have been told that they look tired, but it is not the tear trough that is the main problem. It may be the anterior(front) cheek, the extension of the tear trough, dynamic lines requiring a muscle relaxant, brow droop, or even too much muscle relaxant in the forehead which is the cause of the tired appearance.
  • For your first treatment at least, make sure you are prepared for bruising, as it is extremely common with tear trough injecting. Make sure you don’t have any special events
  • Remember that Perfect is the enemy of good, and as Shakespeare warns in his tragedy, King Lear, of “striving to better, oft we mar what’s well” in other words, be happy with significant improvement, and don’t push it too far, as you could end up with problems.

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