Combination Injectable Therapies for Tear Trough Deformity: Deep Cannula and Needle Injection Techniques
Anido J, Fernández JM, Genol I, Ribé N, Pérez Sevilla G. Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler. Journal of Cosmetic Dermatology. 2021;20:6–17. https://doi.org/10.1111/jocd.13475
Introduction Tear trough deformity is a common periorbital concern caused by changes in bone support, fat compartments, retaining ligaments, skin and soft tissue. Hyaluronic acid (HA) filler can improve the lower eyelid–midface transition, but treatment is technically demanding because of the region’s thin tissue envelope, superficial lymphatics and nearby vascular structures.
Anido et al. emphasise four key considerations for treatment: anatomical assessment, patient selection, appropriate filler choice and precise injection technique.
Anatomy The tear trough is a depression of the medial lower eyelid extending from the lacrimal region towards the midpupillary line. As shown in Figure 1A, it lies around the transition between the preseptal and orbital portions of the orbicularis oculi, where the orbitomalar ligament contributes to soft-tissue fixation along the orbital rim. The suborbicularis oculi fat (SOOF) lies deep to the orbicularis, while the zygomatic cutaneous ligament defines its lower boundary.
Figure 1B shows the periocular vascular and neural anatomy. The angular artery and vein course close to the medial treatment region, while the infraorbital nerve and accompanying vessels emerge below the orbital rim. Their proximity makes precise control of injection depth and direction important.
The periocular fat compartments are illustrated in Figure 1C. The lower eyelid contains medial, central and lateral fat pads, and changes in their projection or position may accentuate the tear trough. The visible hollow may therefore reflect not only volume loss but also contrast with adjacent fat prominence.
Figure 1D demonstrates periocular lymphatic drainage. These vessels lie predominantly within superficial tissue planes and drain towards the preauricular, parotid and submandibular lymph nodes. Because superficial filler placement may interfere with lymphatic drainage and contribute to oedema, the authors emphasise careful deep-plane placement.
Figure 1. Key anatomical structures relevant to tear trough treatment. A: Orbicularis oculi, orbital septum, SOOF and retaining ligaments. B: Angular vessels and infraorbital neurovascular structures. C: Periocular fat compartments. D: Periocular lymphatic drainage.
Causes of Tear Through Deformity
A visible tear trough does not always represent simple volume loss. Anido et al. describe several contributing anatomical changes, including orbital fat prominence with septal laxity, recession of the inferior orbital rim, changes in SOOF volume or position, musculocutaneous thinning and local oedema.
Figure 2 demonstrates these different presentations. Most may be considered for HA treatment in appropriately selected patients, whereas local oedema requires a different approach.
The key principle is to identify the underlying anatomical cause rather than simply filling the visible depression.
Figure 2. Anatomical causes of tear trough deformity.
Patient Consideration Patient assessment should consider fluid retention, fat pad prolapse, skin quality, eyelid laxity and pigmentation to determine suitability for tear trough HA filler.
Ideal candidates have a localised hollow, good skin quality, minimal orbicularis hypertrophy or pigmentation, absent or mild fat prominence, and no significant fluid retention.
The authors’ clinical scoring framework guides selection:
<2: Ideal candidate.
2–8: Assess individually.
>8: HA treatment not recommended; consider surgical assessment.
This framework is not a universally validated prediction tool. Contraindications listed by the authors include filler hypersensitivity, immune-system disorders, active skin disease or unhealed lesions, pregnancy or lactation, and previous permanent filler in the area.
Figure 3. Characteristics of the ideal candidate for HA filler for tear trough deformity
Injectable Fillers and Skin Biostimulators
Injectable selection should reflect the underlying anatomical concern and whether the treatment goal is volume correction, improvement in skin quality or both. Structural hollowing and changes in the overlying skin require different considerations.
HA Fillers for Volume Correction
Anido et al. focus on HA fillers for correcting tear trough volume deficits. Relevant product characteristics include HA concentration, cross-linking, particle properties, rheology and water absorption. These properties require particular attention because the periorbital tissues are thin and susceptible to swelling.
The authors specifically discuss Teosyal Puresense Redensity II within their recommendations. This product-specific discussion reflects the clinical and regulatory context at publication and does not establish superiority over other available fillers.
Polynucleotide Injectables for Periocular Skin Quality
Beyond the scope of the Anido et al. paper, polynucleotide-based injectables such as Rejuran i may be discussed as a separate approach to periocular skin rejuvenation. PharmaResearch identifies Rejuran i as a PN-based injectable intended for areas including the eye region. Its role should be distinguished from the structural volume correction provided by HA fillers.
Skin boosters and biostimulatory products are not interchangeable. Their composition, intended treatment area and supporting evidence differ, and the deep cannula and needle techniques described for HA filler in this article should not automatically be applied to other injectables.
Where both hollowing and skin-quality concerns are present, any combined treatment plan requires individual assessment and product-specific guidance. Selection should follow locally approved indications and instructions for use.
Injection Technique
Anido et al. describe both cannula and needle techniques, with the same core principles applying to both: deep placement, slow injection, conservative volume and minimal tissue trauma.
Cannula Entry Point
Figure 4 shows two methods for locating the cannula entry point using the lateral canthus, zygomatic bone and nasojugal fold as anatomical landmarks.
For cannula treatment, the authors describe creating an access point with a 23G needle before introducing a 25G or 27G cannula. The cannula is advanced in a deep plane towards the periosteum and tear trough, while avoiding passage across the orbitomalar ligament.
HA is then deposited gradually using a retrograde technique, followed by gentle massage where appropriate.
Figure 4. Cannula entry-point localisation.
Figure 5 demonstrates the anatomical boundaries of the treatment area, including the lacrimal region, orbital rim, orbicularis muscle, zygomatic ligament and nearby vascular structures.
These boundaries reinforce the importance of controlling both injection depth and direction.
Figure 5. Anatomical limits of the tear trough treatment region.
Cannula Technique
The authors describe creating the access point with a 23G needle before introducing a 25G or 27G cannula. The cannula is advanced in a deep plane towards the periosteum and then directed towards the trough. Resistance around the orbitomalar ligament is used as an anatomical cue, and the ligament should not be crossed.
Once appropriately positioned, HA is deposited in a retrograde manner while the cannula is withdrawn. The authors describe gentle massage after placement to homogenise the filler within the treated contour. The objective is not superficial filling of the visible line, but controlled restoration of the underlying deep volume transition.
Needle Technique
The authors also describe a deep needle technique close to bone and beneath the orbicularis oculi.
As shown in Figure 6, the product is deposited using a linear retrograde fanning technique. The diagram also highlights the importance of avoiding excessive medial advancement towards the neurovascular structures.
Figure 6. Needle entry points and linear retrograde fanning technique for tear trough treatment.
Clinical Results
Figure 7 presents examples of tear trough treatment across different anatomical presentations, including fat prominence, septal laxity, musculocutaneous thinning, SOOF changes, medial SOOF volume loss and bone recession.
Both needle and cannula techniques are represented. These cases illustrate how treatment may vary depending on the underlying anatomy, although they should be interpreted as clinical examples rather than comparative evidence between techniques.
Figure 7. Clinical examples of tear trough deformity of different aetiologies before and after HA filler treatment.
Complication Management Adverse outcomes following tear trough filler may include bruising, transient or persistent oedema, contour irregularity and the Tyndall effect. Management begins by identifying the likely cause, particularly whether the issue relates to tissue trauma, superficial placement, excessive volume or impaired lymphatic drainage.
Minor bruising and transient swelling are generally self-limiting and can be monitored during recovery. Persistent or severe oedema requires reassessment of filler depth, injected volume and pre-existing fluid retention, as superficial or excessive HA may further compromise lymphatic drainage.
Visible superficial filler or a blue-grey Tyndall effect suggests that the product has been placed too close to the skin and may require corrective treatment. Similarly, contour irregularity should be distinguished from early post-treatment swelling before further correction is considered. The authors recommend reassessment after 7–15 days and avoiding additional filler for 28 days within their protocol to reduce the risk of overcorrection.
Anido et al. do not provide a detailed protocol for vascular occlusion or visual complications, noting that complication management falls outside the scope of their recommendations. Because periocular filler treatment carries a potential risk of vascular and ocular injury, suspected vascular events require management according to current emergency protocols.
Conclusion
Tear trough filler treatment should be based on the underlying anatomy, not simply the visible depression.
Successful treatment depends on identifying the cause of the deformity, selecting an appropriate patient, choosing a suitable HA filler, maintaining the correct injection plane and using conservative volumes.
The main clinical message from Anido et al. is that accurate diagnosis and patient selection are as important as injection technique. Recognising when HA filler is appropriate—and when anatomy, oedema, skin quality or fat prolapse makes another approach more suitable—is central to safer and more predictable treatment. Reference
Anido J, Fernández JM, Genol I, Ribé N, Pérez Sevilla G. Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler. Journal of Cosmetic Dermatology. 2021;20:6–17. doi:10.1111/jocd.13475.
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