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Aesthetic Injections for Tear Trough: Types, Causes, and Advanced Treatments


The tear trough, an anatomical concavity stemming from orbital fat, manifests prominently due to hereditary anatomical variances and the aging process. Attaining a natural facial rejuvenation has been effectively pursued through the strategic application of hyaluronic acid gel or autologous fat for the augmentation of soft tissues, coupled with the meticulous repositioning of fat via arcus marginalis release.


This observable 2 to 3 cm depression, situated inferiorly to the pseudo herniated orbital fat of the lower eyelid, is emblematic of a complex anatomical structure. Its hallmark is the sunken appearance of the lower eyelid, imparting a discernible shadow over the nasal lower eyelid, thereby endowing the individual with an overtly fatigued visage. Tear trough deformities pose a formidable challenge within the domain of facial rejuvenation, necessitating a comprehensive understanding of diverse anatomical variations to objectively evaluate the deformity.


Treatment options encompass a spectrum of interventions, including filler injections, autologous fat grafting, lower blepharoplasty integrated with fat repositioning, or the amalgamation of fat grafting specifically within the tear trough region. The discerning selection of these interventions is contingent upon a nuanced comprehension of the tear trough anatomy and the skillful integration of varied treatment modalities for optimal outcomes.


In this blog, we will delve into the intricacies of tear troughs, exploring their nature, various types, underlying causes, and advanced treatment options for effective resolution.


Understanding the Tear Trough


The tear trough and lid-cheek junction represent intrinsic anatomical features that undergo accentuation with the inexorable passage of time, primarily attributable to dermal and periorbital transformations. Progressive age manifests as a discernible depression originating at the medial canthus, precisely parallel and slightly inferior to the infraorbital rim. Concurrently, cutaneous and adipose tissue atrophy, coupled with periorbital structural attenuation, facilitates the herniation of orbital fat, engendering heightened shadowing. The prominence of the tear trough and lid-cheek junction is exacerbated by superimposed pigmentation, alterations in skin texture, and modifications in shadow dynamics. This phenomenon elicits significant concern among patients who frequently articulate a perceived "fatigued" or "aged" subocular appearance that eludes mitigation through conventional measures such as rest, hydration, or topical therapies.


Anatomy


Diverse theoretical frameworks have been posited and previously expounded upon in the elucidation of the orbitomalar sulcus. The multifaceted etiology of tear trough deformities is intricately intertwined with various anatomical considerations. Prior investigations delineated the tear trough deformity as a triangular concavity delimited by the orbital segment of the orbicularis oculi (superiorly), the levator labii superioris (laterally), and the levator labii superioris alaeque nasi muscle (medially). However, contemporary studies have, in some instances, contradicted these erstwhile anatomical depictions. A more precise characterization locates the tear trough within the confines of the orbicularis muscle, elucidated through alterations in the medial-to-lateral insertion of said muscle. Consequently, the nomenclature "tear trough deformity" should be reserved for the medial periorbital hollow, extending obliquely from the medial canthus to the mid-pupillary line. The region below this groove exhibits a dearth of fat tissue within the central and medial fat pads subjacent to the orbicularis oculi muscle.


The intricate interplay of volumetric bone loss along the orbital rim predominates in the genesis of the nasojugal groove, culminating in advanced volume depletion in the central cheek, medial cheek, and malar eminence with the inexorable march of time. The age-associated diminution of septal integrity precipitates orbital fat bulging, imparting the appearance of bags or fullness in the lower eyelid. Gravitational descent, characterized by the laxity of supporting ligaments and the descent of the mid-face, is implicated in the aging-related manifestation of the tear trough deformity. The orbicularis retaining ligament assumes significance in this context, delineating a V-shaped deformity concomitant with the lid-cheek junction. Age-related structural laxity of this ligament contributes to the accentuation of the tear trough deformity.


Lambros, in his elucidation, defines the tear trough as the convergence of the thin, pigmented lower lid skin with the thicker cheek skin from the medial canthus to the mid-pupillary line. Notably, he posits that the perceived descent of the lid-cheek junction is more an outcome of age-related tissue volume alterations than actual anatomical displacement. The tear trough, often correlated with underlying bony structures, particularly associates itself with age-related maxillary hypoplasia. The aging lower eyelid skin experiences progressive loss of elasticity and thickness, while concomitant alterations such as hyperpigmentation and actinic changes also contribute to the multifaceted tapestry of tear trough evolution.


Causes and Factors


Primarily, genetic predispositions contribute to the structural configuration of the periorbital region, influencing the development of tear trough deformities. Inheritance patterns govern the anatomical variations in the orbital fat compartments, orbicularis oculi muscle insertions, and the integrity of the septal structures. Consequently, individuals may exhibit inherent susceptibility to the concave morphology of the tear trough, which becomes more pronounced with the natural aging process.


A pivotal factor in tear trough deformities is the dynamic process of aging, characterized by intricate changes in the skin, subcutaneous fat, and supportive structures around the periorbital region. The aging-related attenuation of the periorbital tissues, including skin laxity, subcutaneous fat atrophy, and diminishing septal integrity, contributes significantly to the manifestation of tear trough deformities. Moreover, gravitational descent, encompassing laxity of supporting ligaments and mid-facial descent, amplifies the sunken appearance of the lower eyelid, further accentuating the tear trough.


Notably, volumetric alterations within the infraorbital region and maxillary hypoplasia associated with aging play a pivotal role in tear trough deformities. Loss of bone volume along the orbital rim and the progressive thinning of lower eyelid skin exacerbate the concavity, resulting in a noticeable depression below the pseudo-herniated orbital fat. Concurrently, changes in the insertion of the orbicularis muscle from medial to lateral aspects elucidate the dynamic nature of the tear trough deformity.


Environmental factors, such as chronic sun exposure, can induce cutaneous changes, including hyperpigmentation and actinic alterations, contributing to the complex tapestry of tear trough deformities. Moreover, variations in the elasticity and thickness of lower eyelid skin further modulate the appearance of tear troughs, emphasizing the dynamic interplay between intrinsic and extrinsic influences.


Tear Through Types



In the realm of clinical observation, the tear trough pattern manifests across a spectrum, allowing for nuanced categorization into three distinctive classes.


  • Class I delineates a tear trough presence unaccompanied by protruding orbital fat or surplus lower eyelid skin. This class is characterized by mild periorbital volume loss and a discernible flatness of the mid-face.

  • Class II is associated with a mild to moderate prominence of orbital fat, while still devoid of excess lower eyelid skin. Within this class, patients exhibit mild to moderate periorbital volume loss, concomitant with a flattened mid-face profile.

  • Class III represents a more advanced manifestation, marked by pronounced periorbital volume loss. In this class, patients present with severe orbital fat bulging and an excess of lower eyelid skin. The tear trough depression is notably extensive, circumferentially extending along the orbital rim from the medial to lateral aspects.

These refined classifications offer a comprehensive framework for clinicians and experts to discern the varying degrees of tear trough patterns, providing a foundation for tailored diagnostic and treatment approaches.


Treatments


Aging, a dynamic rather than linear process, involves intricate interactions among diverse anatomic structures. Recognizing hereditary anatomical variances and the transformations inherent in the aging process is imperative for optimizing periocular treatment outcomes. Customizing surgical plans for tear trough deformities necessitates a meticulous understanding of the anatomical intricacies involved. Accordingly, tear troughs are categorized into three groups based on groove formation mechanisms and external manifestations, rooted in inner anatomical relationships. Rejuvenation objectives in tear trough deformity surgery diverge among these groups.


Volumetric enhancement of the infraorbital rim or deep medial cheek proves most efficacious in addressing tear trough deformity. Classes I and II benefit from hyaluronic acid gel or autologous fat injections, while class III requires fat repositioning through arcus marginalis release. Deep nasojugal groove cases within class III are further treated with autologous fat injection during fat repositioning lower blepharoplasty, supplementing volume added by the repositioned fat.


Hyaluronic acid fillers, globally prevalent, are favored for tear trough treatment due to their perceived simplicity, safety, and reversibility. However, their effects are temporary, limiting their suitability for certain candidates with large fat pads or excess lower eyelid skin. Transplanted fat, offering more lasting volume enhancement, outperforms hyaluronic acid fillers. Autologous fat, with its capacity to adapt to physiologic changes, presents advantages, including local improvements in skin quality.


Despite the benefits of fat transplantation, challenges persist. Precise placement is paramount, given the thin skin and soft tissue overlying the tear trough area, as imprecise placement may result in palpable and visible contour irregularities. Potential complications include a sausage-shaped deformity and unpredictable fat absorption. Nevertheless, the less invasive nature of fat transplantation, along with customizable injection volumes and ready availability, provides certain advantages over open surgical volume enhancement.


Loeb's revolutionary approach preserved periorbital fat, transforming blepharoplasty by smoothing the nasojugal groove. Early blepharoplasty primarily focused on tissue removal, yet the removal of fat alone can exacerbate a hollow appearance. Fat repositioning proves beneficial for patients with adequate orbital fat and a significant tear trough depression, though limitations exist. A synergistic effect between autologous fat injection and fat repositioning lower blepharoplasty has been observed, enabling more comprehensive treatment of tear trough depression and the eyelid-cheek junction, yielding improved aesthetic outcomes.


Complications and Adverse Events


Adverse events (AEs) stemming from tear trough treatment typically manifest as mild and self-limiting occurrences, with bruising and swelling being the most prevalent. Intriguingly, age and dermatological attributes such as wrinkles and hyperlaxity did not exhibit correlations with complications. However, a history of blepharoplasty was linked to a heightened incidence of AEs, particularly edema. Of notable concern is the Tyndall effect, characterized by a blue–gray skin dyschromia, which may be exacerbated in individuals with pre-existing hyperpigmentation. Injectors have underscored the significance of maintaining deep injection planes to mitigate the risk of the Tyndall effect. Furthermore, deep periosteal injection has been advocated to reduce the likelihood of blocked lymphatic drainage and intravascular injections, thereby minimizing edema and ecchymosis.


Inadequate injections can result in severe and irreversible consequences. For instance, injections performed too inferiorly at the mid-pupillary line pose a risk of intra-arterial injection, potentially leading to blindness. While no such cases were reported in our analyzed studies, documented instances of blindness secondary to filler injection in the periorbital region exist in the literature. Complications have been reported with various dermal filler products and diverse treatment areas (e.g., nasal dorsum, nasolabial folds, glabella). Diplopia, arising from inferior oblique muscle restriction, has been reported following tear trough deformity correction. These adverse effects, including bilateral lower eyelid swelling, were successfully managed with hyaluronidase.


While catastrophic events are rare with proper technique, practitioners are strongly urged to possess a profound understanding of relevant anatomy, employ optimal injection techniques, and master effective complication management strategies.


Past Research


1. Tear Trough Deformity: Different Types of Anatomy and Treatment Options


In a retrospective clinical investigation spanning from May 2009 to September 2014, Guangdong Women and Children’s Hospital undertook a comprehensive analysis of 78 consecutive patients (69 females and 9 males) afflicted with tear trough deformities. The study, ethically sanctioned by the Human Subjects Review Board at Guangdong Women and Children’s Hospital, enrolled participants aged between 25 and 62 years (mean: 38.26 ±10.0 years) who voluntarily provided informed consent.


Evaluation of tear trough anatomy and aging dynamics involved a meticulous scrutiny of physical examinations and preoperative photographs, emphasizing three critical variables:

(1) volume loss,

(2) orbital fat herniation,

(3) excess of the lower eyelid skin.


Among the 78 cases, 10 were categorized as Class I, 18 as Class II, and 50 as Class III. Patients falling into Class I or Class II received treatment, with 18 cases opting for hyaluronic acid gel and 10 cases undergoing autologous fat injections. The administration of hyaluronic acid gel, specifically Matrifill (EME China), employed a 27-gauge needle through a serial technique, creating column-shaped deposits within the orbicularis oculi muscle. Alternatively, fat grafting involved careful preoperative marking, harvesting fat from the thigh area, and deploying blunt cannulas to deposit small amounts of fat in criss-crossing tunnels.

Class III cases were subjected to fat repositioning via arcus marginalis release (50 cases), wherein an animated evaluation of patients aided in understanding tissue rearrangement. Subciliary incisions, orbicularis-retaining ligament dissection, and fat herniation across the infraorbital rim were pivotal aspects of this approach. Further, 11 patients with deep nasojugal groove in Class III received autologous fat injections during fat repositioning lower blepharoplasty.


Subsequent assessments, covering a 3 months to 5 years' follow-up, revealed consistent improvement in tear trough deformities across all classes. Patient satisfaction, determined through interviews, indicated high contentment levels. Noteworthy results included the maintenance time of hyaluronic acid gel treatments and the effectiveness of hyaluronidase in addressing complications like lump formation. The study highlighted the nuanced approach to tear trough deformity management, considering individualized treatment modalities and comprehensive postoperative care.


2. Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review


A systematic inquiry into the existing body of knowledge was executed, adhering to the stringent guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The exploration of literature transpired in January 2021, encompassing renowned databases such as PubMed, Embase, and ScienceDirect. Employing Medical Subject Headings (MeSH) terms, the search was tailored to encompass themes of "tear trough," "infraorbital," "malar," and "dermal filler," including variations such as "hyaluronic acid," "poly-L-lactic acid," "calcium hydroxyapatite," "Restylane," "Radiesse," "Perlane," "Juvéderm," and "Belotero." Diverse permutations of these terms facilitated the identification of pertinent studies.


Inclusion criteria comprised studies reporting patient data on dermal filler utilization for tear trough rejuvenation, published between 2000 and 2021, and involving more than 10 subjects. Exclusion criteria encompassed studies in non-English languages, those involving nonhuman subjects, abstracts, book chapters, review articles, studies managing pathologies with fillers, those addressing areas beyond the face, procedures beyond the scope, and those involving fillers not commercially accessible in the United States.


The screening process involved an independent assessment of titles and abstracts by two investigators (L.N.T. and S.E.G.), with any disparities resolved by a third investigator (A.G.). Full-text evaluations ensued for selected articles, augmented by an analysis of reference lists for potential studies meeting the predetermined criteria. The resultant studies that met the stipulated criteria were assimilated into the analysis.


The initial exploration identified 526 articles, with an additional six discovered through references. Subsequent removal of duplicates (325) led to the screening of 307 studies, culminating in the elimination of 258 based on stringent inclusion and exclusion criteria. A thorough review of the full texts of 49 articles yielded a final inclusion of 23 articles for analysis. The breakdown of the literature search is illustrated in Fig. 1, with Table 1 presenting a summary of major findings.


The analysis encompassed a cohort of 2,048 patients, with 1,409 females and 239 males, covering a diverse age range from 21 to 90 years (mean age: 46.3). The follow-up periods ranged from 10 days to 5 years, with an average of 13.7 months. The publication years of the articles spanned from 2005 to 2021, featuring 13 prospective studies, nine retrospective studies, and one combining both study designs. Geographic diversity was observed in the origin of studies.


All studies reported on patient satisfaction, with six studies integrating the Global Aesthetic Improvement Score (GAIS) scale, and one incorporating three-dimensional (3D) imaging. The collective patient satisfaction post-treatment ranged from 85% to 90%. HA fillers exhibited an average duration of effect lasting 10.8 months, while calcium hydroxyapatite (CaHA) demonstrated a longer effect of 15.4 months. Three-dimensional imaging revealed a mean duration of volume augmentation with Restylane at 14.4 months, with 85% volume retention observed at an average follow-up of 15 months. Notably, older patients exhibited a higher likelihood of dissatisfaction with their outcomes (61 vs. 52 years, p < 0.01).


Reference:

Tear trough deformity: different types of anatomy and treatment options (2016)

Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review (2021)

Tear Troughs Eye Filler (2021)

 A prospective study on safety, complications and satisfaction analysis for tear trough rejuvenation using hyaluronic acid dermal fillers (2020)

Hyaluronic acid injections for correction of the tear trough deformity (2007)


 

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