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Best Approach for Tear Troughs?

asked 3 years ago by david_k in UK
Latest answer by Mark Samaha, MD
Question viewed 22,174 times
Tags: tear trough, male, best, technique

I am 30 year-old male with tear trough at lower eyelids, like dark circles. Last year, I developed some small bags that make the dark circles worse. I have no excess skin. I visited some plastic surgeons, and I was offered Restylane injections or arcus marginalis release with fat reposition (not transconjunctival, since bulging fat is very close to tear duct and hard to deal with through that approach).

Is this correct? How close to the bone and inner corner of eyelid can Restylane injections go? My grooves start from the very inner corner next to tear duct.

35 answers to Best Approach for Tear Troughs?

+4

Many options

Our preferred option for your situation might be to do a transconjunctival blepahroplasty with fat repositioning and slight fat reduction, followed by fillers (usually Restylane or Prevelle). Pure fat transposition procedures can be prone to relapse of lower eyelid fat bulges as the attached fat contracts with healing, visibility of the transposed fat, or lumpiness in this very thin skinned area. Extensive deep use of fillers are also possible around the eyes and may be the least... more
Brent Moelleken, MD

Beverly Hills Plastic Surgeon

www.drbrent.com

+5

Tear trough correction

Restylane or Juviderm, being soft and clear, is an excellent way to treat the tear trough alone.  If there is also bulging fat, a transconjunctival blepharoplasty with fat repositioning will be more appropriate.  You surgeon can tell you what you need.
Randy J. Buckspan, MD

Austin Plastic Surgeon
+4

For Best Results - Enhance Facial Volume

The key to understanding why a face appears "older" or tired is to look at what happens to facial volume over time. By studying MRI images of the aging face, we have learned that fat and bone are reabsorbed by the body slowly over the years. In time, this leads to sunken, hollow looking cheeks, especially the upper cheeks. This can often lead to a deep valley, right underneath the lower eyelid, causing the lower eyelid to look like it is bulging out. Previously, almost all... more
Ilya Reyter, MD

Beverly Hills Dermatologist
+3

Transconjunctival arcus release is best option for tear troughs

I have been doing the transconjunctival arcus marginalis release and fat grafting and repositioning for the past 6 years, and transcoinjunctival blepharoplasty with fat removal for 14 years and have never had a problem or injury of the tear duct--it just is not a problem. I also recommend against tear tear trough implants. They can extrude, and placement through transconjunctival incision is difficult. They also can be visible because the skin is thin. Whole autologous fat grafts or fat... more
Brooke R. Seckel, MD

Boston Plastic Surgeon

www.drseckel.com

+2

Tear Troughs

I prefer the transcutaneous approach to release the arcus marginalis and reposition the available fat.  Juvederm is an option. The downside is that it is temporary.  Also, the periorbital region is the least forgiving place to inject fillers.  The skin in this region is thin and will potentially demonstrate any irregularities in the filler.  When performed well, a lower blepharoplasty is a much longer lasting resolution. 
Jason R. Hess, MD

San Diego Plastic Surgeon
+2

Tear trough abnormality can be fixed by injection or lower eyelid surgery.

A "tear trough" abnormality is a small indention in the bone of the nose near the lower lid.  The depression can cast a shadow that often is unwanted.  Dermal fillers can be used periodically to fill the depression.  During lower eyelid surgery, fat that might otherwise be removed can be transferred to the depression to fix the problem permanently.
Vincent N. Zubowicz, MD

Atlanta Plastic Surgeon
+2

Approach for tear troughs

The approach to the tear troughs is a complex question and is dictated by the patients individual anatomy and characteristics.  Common techniques that are approached by themself or in conjunction include: Correction with filler (fat, HA) (See below weblink for just filler) Reposition of fat Removal of fat lower eyelid All of the above are extremely technique sensitive and both the choice and application of the technique are surgeon dependent....
Anil R. Shah, MD

Chicago Facial Plastic Surgeon
+2

Fat Grafting for under eye hollows

It is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin. In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the... more
Michael Law, MD

Raleigh-Durham Plastic Surgeon

michaellawmd.com

+2

You need more volume for tear troughs

David, This is a very intreresting and challenging case you have brought into this arena. I think you have many great answers here... From your pictures, it looks like you have a real lack of fat. There is fat missing, not only in your tear troughs, but in your cheeks. Restylane injections can be placed on the orbital rim, and all the way up to the medial canthus (inner corner) if the injections are placed in the correct plane. Restylane injections may do wonders for your... more
Behrooz Torkian, MD

Beverly Hills Facial Plastic Surgeon
+2

Tear Trough Hollow

Hi David, I would fill your hollow conservatively with Restylane initially, have you return to the clinic in about 10-14 days for a possible touch up. The entire lower and lateral periorbital area needs to be in balance, usually there may be some feathering injections around the main defect to blend the entire area. Restylane lasts surprisingly long in this area as there is little movement. Patients vary, but one year to eighteen months is common. There is some new collagen laid down... more
Michael A. Persky, MD

Los Angeles Facial Plastic Surgeon
+2

No right answer

The best thing to do is discuss this with some one that has had experience with all of the techniques. Here is an analogy. If you consult with a person and the only tool they have is a hammer, they will treat everything like a nail. If you discuss your options with a plastic surgeon that does injections as well as blepharoplasty procedures you can make an informed decision and not have to hear a sales pitch for their technique. Filler injections are a great option and they can be done at... more
Marcus L. Peterson, MD

Saint George Plastic Surgeon
+2

Best solution requires examination

There are a number of options available, as you can tell from the previous answers. The bottom line is that no one can tell what your best option is without seeing you personally, although the picture is helpful. My guess is that your best choice for the long term would be the fat repositioning option, though you may be able to "buy some time" with fillers such as Juvederm (Ultra Plus) or restylane/Perlane.
Richard Baxter, MD

Seattle Plastic Surgeon
+2

Your doctor needs to know there anatomy.

Dear David: Yes there are all sorts of important structures in this area. That is why your doctor really needs to know their anatomy. The absolute deepest part of the dark circle is actually just at or a little below the bony orbital rim. At the bony rim, there are essentially no important structures and no large vessels. There are three predominant lower eyelid filling methods: DeepfillTM: This is the method I developed. The key is using the bony as the deep land mark. This places... more
Kenneth D. Steinsapir, MD

Los Angeles Oculoplastic Surgeon
+2

Tear troughs

Fortunately, modern cosmetic surgery offers options for correcting various facial problems. For your tear troughs, I would consider injectable fillers (I like Restylane for the tear troughs) or fat transfer (about 10cc of fat is usually harvested from the abdomen or hip region). Fat transposition in conjunction with a blepharoplasty would be a secondary choice although one would need to examine you to really understand your anatomy. Fat transposition can be performed through a... more
Frank P. Fechner, MD

Worcester Facial Plastic Surgeon
+2

Use a conservative approach first for tear troughs

Looking at your pictures, I would suggest a very conservative approach. From the pictures you do have some fat herniation, which causes there to be worsening of the dark circles. I would caution about rushing into a lower eyelid surgery, as your eyeball position is slightly forward. This may cause a very hollow appearance after eyelid fat removal. A nice option is using a filler to soften the transition from the lower eyelid fat pocket to the upper cheek. I would suggest a reversible filler... more
Benjamin Bassichis, MD

Dallas Facial Plastic Surgeon
+1

Fillers or blepharoplasty for tear troughs

Examination in person would help determine whether you have excess fat above your tear troughs or not. Either way, Hyaluronic acide fillers such as Restylane or Juvederme Plus give nice results in this area with a good longevity. I would avoid thicker fillers such as Perlane or Juvederme Ultra Plus as they are more likely to cause irregularities in a thin-skinned area such as the tear trough. Fat is also an option that requires a great deal of experience on the part of the sugeon in an... more
Mark Samaha, MD

Montreal Facial Plastic Surgeon
+1

A transconjunctival approach to remove / reposition some of the excessive lower eyelid fat which is creating this shadow effect

The dark circles in your lower eyelids are due to a combination of a shadow effect, as the light hits the puffiness in your lower eyes, along with some loss of soft tissue volume in the infra-orbital rim region.  Puffiness in the lower eyelids causes a shadow effect adjacent to where the puffiness is which accentuates the impression of a “dark circle”.  I would, in fact, use a transconjunctival approach to address your concerns.  Through this approach, some of... more
Michael R. Macdonald, MD

Bay Area Facial Plastic Surgeon

www.drmmacdonald.com

+1

Best Approach for Tear Troughs?

Fillers Can only be used sparingly in this region because the tissues are thin and there is a risk of irregularities and visible product. It's temporary, so re-injections are necessary (this can quickly become costly) Surgery This can be performed with an external incision just below the lower lash line or underneath the lower eyelid. Both heal very well. The choice depends on whether excess/droopy skin needs to be removed. In a young patient with tight... more
Anand D. Patel, MD

Austin Facial Plastic Surgeon
+1

Fillers Work for Tear Troughs, Hollows, Bags, and Dark Circles

Tear troughs are dark, indented lines that course between the lower lid and the upper cheek. In youth, no significant separation is typically noticeable there. However, with the passage of time, resulting from the shrinkage of the cheek fat pad and its slippage downward, most people begin to notice the appearance of tear troughs by their late thirties and forties. Age thirty is a bit young and an inherited tendency may be a factor in this particular instance. Like a balloon that has been... more
Nelson L. Novick, MD

New York Dermatologic Surgeon
+1

Filling the Tear Trough

Lower eyelids should really just look like an extension of the upper cheek.  To accomplish this we need to get rid of the deep groove under the eye or the "tear-trough".  Filling the tear-trough can be a challenge.  Fat repositioning and arcus release are affective but limited, especially for the more severe cases.  I frequently use an implant in conjunction with fat repostioning and arcus release.  This is done through the inside of the eyelid and... more
Louis W. Apostolakis, MD

Austin Facial Plastic Surgeon

www.dr-apo.com

+1

How to correct a tear trough deformity

A transconjuctival blepharoplasty with fat repositioning or fat injection along with a release of the arcus marginalia is the best approach for your particular anatomy and concerns. Transconjuctival blepharoplasty has a lower incidence of abnormal scarring that can pull your lower lid than the open transcutaneous blepharoplasty. To learn more, please visit the link below or consult with a board certified plastic surgeon.
Ankit Desai, MD

Jacksonville Plastic Surgeon
+1

Lower blepharoplasty with fat repositioning

The photo you included is not ideal, but you appear to be a candidate for a lower bleph with fat repositioning. I believe that if you just have a traditional bleph that will only reduce the fat, you are being set up for a hollowed appearance. Fat repositioning will reposition the fat to allow for a much smoother transition between your lower lid and the upper cheek. It should make the tear trough much more shallower. Once you've healed from the surgery, you can then assess to see if you... more
Edmon Pierre Khoury, MD

Dubai Facial Plastic Surgeon
+1

Implants or fat repositioning

It is not a good idea to put Restylane around the tear troughs since there are complications associated with it, and it is only temporary. Your best options are tear trough-style cheek implants or fat repositioning through a lower eyelid blepharoplasty.
William Portuese, MD

Seattle Facial Plastic Surgeon

www.seattlefacial.com

+1

Tranconjunctival blepharoplasty can be an excellent approach for tear trough deformity

Correcting the tear trough deformity can be performed via the transconjunctival lower blepharoplasty. After conservatively removing excess fat in the central and lateral areas of the lower eyelid region, the fat stalk from the medial component can be stretched out to fill the tear trough and offers excellent long term correction of that area. In patients that I have performed this procedure on over the last three years, I have seen no recurrenc of the tear trough deformity and believe that... more
Scott Trimas, MD

Jacksonville Facial Plastic Surgeon
+1

Tear troughs

 You actually can have both. You can have a transconjunctival fat removal or redraping, release of the arcus marginalis and if needed at a later time, some filler along the arcus to camouflage better.
Steven Wallach, MD

Manhattan Plastic Surgeon
+1

Restylane can work for tear troughs

Both of those options can help. I think Restylane would be a better alternative to replace the volume that you have lost in the lower eyelid and cheek area. That is essentially what has happened -- a loss of volume. The only thing is that restylane will last only 6-9 months. Fat repositioning can help the condition but there are limitations. It can leave you looking hollow and it can impact the position of your eyelids and can have complications. I don't prefer the fat repositioning... more
Philip Young, MD

Bellevue Facial Plastic Surgeon
+1

Best approach for tear troughs

For your specific problem I would recommend transconjunctival blepharoplasty with a pedicled fat repositioning with adequate arcus marginalis release. The pedicle maintains circulation to the fat graft, which is contoured to the tear trough deformity and secured with absobable pull-through sutures, usually 3-4. These are removed in 3-5 days. There is more swelling and bruising, but a superior and more consistent result is achieved. I personally don't like fillers except for short... more
Harrison C. Putman III, MD

Peoria Facial Plastic Surgeon
+1

Contour Lower Lid Blepharoplasty

In selecting a technique, I have evaluated all options to determine the best approach to lower lid contour issues, and I believe we have developed the best solution (in my hands). Because there is a bulge and a hollow in many patients like you, we reduce the bulge surgically and then fill the rims with microfat grafts or filler. We have done this for the past few years with impressive results and high patient satisfaction. If there is excessive skin redundancy, we pursue this through an... more
Richard Gentile, MD

Cleveland Facial Plastic Surgeon

www.facialplastics.org

+1

Surgical and nonsurgical treatment choices for tear troughs

As you can see from the below answers, all the physicians are in agreement that the problem can be treated nonsurgically with a filler, either fat or dermal injectable, such as a hyaluronic acid or calcium filler. Injectable fillers need to be placed deep along the bone and placed slowly and carefully. These will last about one year. Surgical treatment requires repositioning the fat in the lower eyelid over the rim and into the tear trough defect. I have performed this both through... more
Joseph M. Perlman, MD

Houston Plastic Surgeon

doctorperlman.com

+1

Transconj is the way to go.

Check out my blog as I just addressed this at hessplasticsurgery.com. The transconj. approach is the only way to go to do redraping. This may be an option for you if the fat is good. I would not use a hyaluronic acid filler, such as Restylane. It can be somewhat lumpy if it's too shallow. I prefer Radiesse as it can be injected deeply and shaped. Both transconj. surgery and a filler are both good options.
Christopher L. Hess, MD

Fairfax Plastic Surgeon
+1

Two related problems

You have described, and your pictures demonstrate, two related problems. One is the pronounced tear trough and the other is the bulging fat ( eye bags). The tear trough issue may be addressed in several different ways, a couple of which you have mentioned in your inquiry. I would treat this problem with Radiesse injected deep in the trough. This will not affect the tear duct system. The bags can be addressed with a fat re-draping either transconjuctivally or through a skin incision... more
Talmage J. Raine, MD

Chicago Plastic Surgeon
+1

Surgical and non-surgical approach for tear troughs

There are two approaches to address the tear trough area and the lower lid/cheek junction: 1. Non surgical: Injection of fat or other fillers to camouflage the bony orbit(since what you see as a groove is the orbital rim with little soft tissue coverage. The advantage of this approach is to avoid lower lid surgery and it is easier and more affordable. 2. Surgical: reposition of the orbital fat with orbicularis muscle repositioning. The plus is the longivity of the repair. Hope that helps! more
Hisham Seify, MD, PhD

Los Angeles Plastic Surgeon
+1

No easy answer, but fat injections probably best.

To david_k, Hi! It's fascinating to me how sophisticated patients have become so quickly. Two years ago, nobody knew what a tear trough is. The two solutions you propose are effective. An even better solution is fat injections to create a smooth plane. The goal is not to be able to tell where the lower eyelid ends and the upper cheek begins; it's all one surface. The problem is that all 3 techniques are quite difficult (and Restylane is temporary). So the best answer for you is: What... more
George J. Beraka, MD

Manhattan Plastic Surgeon
+1

Tear trough multiple procedures to improve tired look

Tear Troughs can cause us to have a very tired look. Luckily, they can be greatly improved. Restylane works beautifully to camouflage the tear trough. It takes approximately 30 minutes for a well trained cosmetic physician to perform this complex injection. It lasts approximately 18 months time. Some patients have mild to moderate swelling after the procedure. Other fillers like Sculptra and fat can also be used within this area. If you are looking for a looking for a procedure that will... more
Mark Berkowitz, MD

Sterling Heights Oculoplastic Surgeon
+1

Several options for tear troughs

Though it is difficult to tell from the picture you provide, it appears that you have fullness just above the tear trough that makes it appear to look deeper. Speaking generally, when encountering a situation such as this, it can be approached with either surgery or fillers. To answer your questions: 1) Arcus marginalis release with fat transposition refers to relocating the position of the lower eyelid fat pads over the orbital rim. This can be performed by either the trancutaneoous or... more
Jacob D. Steiger, MD

Boca Raton Facial Plastic Surgeon

www.drsteiger.com

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