Tear Trough Myths

Before and after front cheeks and tear troughs asian
Before and after front cheeks and tear trough filler treatment

What are tear troughs ?

Tear troughs (or nasojugal groove ) are a naturally occurring anatomical facial feature more obvious on some people than others.  It is where there is a deep crease between the lower eyelid and cheek.  It starts in the inner corner of the eye (medial canthus) and extends laterally/outward from there to the mid pupillary line (pupil). 

The area is characterised by thinner skin, less fat and in some casesdiscolouration.  

Is it true that there are different types of tear troughs?

True tear trough deformity

Yes.  In-fact there are “true tear trough deformity” which is evident in youth so is not a part of the aging process and is an anatomical feature. It is where the skin is tethered to the underlying tissue and bone. It is a genetic predisposition.

Pseudo Tear Trough

a ‘pseudo tear trough’– is a feature of aging and is evidenced by a loss of volume/support in the mid/lateral/anterior cheek and can contribute to someone feeling they look really tired/old/ unwell. With the pseudo tear troughs, a treatment to support the mid cheek will improve the look of a tear trough.  

What do you mean ‘loss of volume/support’?

As we age, we have resorption of bone which in turn means there is less support for both deep and superficial fat pads in the face. This causes descent of the fat pads which will cause shadows on the face and contribute to making a person look older or tired.

(long distance runners tend to have this look as they have little to no fat on their body let alone their face)

The fat on the face, unlike that on our body, tends to shrink and disappear (the eye area and lateral face being the first to go) which causes tissue to ‘crowd’ the mid face – causing ; tear troughs, jowls, nasolabial, marionette, accordion lines.  

Can everyone have tear trough filler?

 Nope.  Not everyone is a good candidate for tear trough filler. why?

  • They may not need the tear trough to be filled – they may gain significant improvement from mid face/cheek fillers and sometimes temporal or forehead filling. 
  • Patients who have skin laxity around the under eye are also not good candidates for tear trough filling.
  • Patients who attract water around the eye may not be suitable. The nature of the product (hydrophilic) means that we will attract water to the area and cause unsightly bulges/oedema.
  • Fine skin and incorrect placement of filler can cause the Tindall effect, The  Tindall effect is the name given to a ‘bluish hue’ that can occur if the filler is placed superficially under the skin instead of the muscle. 
Tear trough filling with patient with skin laxity
Tear trough filling with patient with skin laxity
  • On the outer corner of the eye there is another groove: The palpebromalar, this connection becomes more obvious with ageing and associated fat/volume loss, sun damage all contributing to exposure of the orbital rim (the bone protecting the eye). Sometimes this can be disguised but it depends on the bony support. 

Issues with tear trough filling

  • Unnatural looking swelling in the area ; potentially from over filling the area. It is important to remember that there should be a demarcation from the bottom lid to upper cheek and we want to maintain these natural curves and shadows on the face.
  • Discolouration of the under eye skin
  • A sausage of filler/inappropriate placement of the filler.
  • The area is highly prone to bruising and swelling. The bruising can sometimes last significantly longer than a week.

I have a fat bulge under my eye that I would like to place filler in to disguise.

Cases of this type of tear trough issue may be more suitable for surgical intervention.

I’d like to tighten the loose skin under my eye with tear trough filler.

Unfortunately, this type of skin will make tear trough filler more difficult, The nature of filler means that it attracts and holds onto water to volumise and if the skin is lax it will just increase the look of a ‘bag’ rather than fill the trough.  

Tear trough fillers always look best with tighter skin under the eyes overlying the filler

The options for treatment of lax skin under the eye are as follows:

Tear troughs before and after
Tear troughs before and after