ATLANTA — Understanding the anatomical basis of the tear trough deformity provides a foundation for choosing appropriate techniques that will successfully correct this common cosmetic complaint, says Mark A. Codner, M.D.
The tear trough deformity is defined as a groove below the medial canthus and the nasolacrimal crest that runs from the medial portion of the lower eyelid along the side of the nose and angles toward the cheek. It lies over the inferomedial orbit, where the skin and muscle layers are very thin and there is minimal fat.The deformity can be corrected nonsurgically with soft tissue augmentation or surgically with blepharoplasty. The choice between these techniques depends on whether the patient presents with lower eyelid bags and excessive skin laxity in addition to the tear trough deformity. It also depends on the patient's desire for a more permanent correction.
"Some patients who present with complaints about a tear trough deformity are fairly young, in their late 20s or early 30s and have concerns about looking tired or sad, but have no other signs of periorbital aging. While they may benefit from soft tissue augmentation alone, surgery may be a reasonable option considering the need for repeat filler injections," Dr. Codner says. "There is also a role for filler and fat transfer at the time of lower blepharoplasty to improve results of surgery alone."
OPTING FOR FILLERS Augmentation can be performed by injecting either an alloplastic filler or autologous fat along the orbital rim to add volume. Dr. Codner says he prefers hyaluronic acid fillers, because any overcorrection or irregularity can be reversed with injection of hyaluronidase (Wydase), and he has a preference for a particular hyaluronic acid product (Prevelle, Mentor) because of its flow characteristics.
"This hyaluronic acid formulation is thinner than other fillers, which makes it particularly useful for achieving a natural result with a reduced risk for the development of contour irregularities or a Tyndall effect in this area where there is minimal soft tissue coverage over the bone," Dr. Codner says.
The correction provided using this hyaluronic acid filler usually lasts for six to 12 months. Other hyaluronic acid fillers offer slightly greater longevity of improvement, and autologous fat injection can provide permanent correction, although Dr. Codner says particular care must be taken with the technique used when injecting fat in this area of the face.
"The fat must be injected in multiple, very small aliquots using a fine 25-gauge cannula, and a blunt needle is recommended with any injection in this area to minimize bruising and the risk of inadvertent intra-arterial injection," he says.
Whether using fat or a hyaluronic acid filler, the injections must be delivered deep, to the preperiosteal level, because injection that is too superficial may result in the material being visible or palpable. It is also important to inject only to the desired level of correction, rather than overcorrecting in anticipation of resorption, because resorption is minimal at this site compared with other areas of the face, Dr. Codner says.