Age 40 & at a loss for deep tear troughs - what can I do? (Photos)

The photos are not enough to determine what’s going on, but you may have lower eyelid fat bags and edema, malar edema, skin laxity, flat cheeks, and possibly a negative vector eye morphology. You also have a strong demarcation of the tear-trough and this likely represents the ligamentous attachments and may be exacerbated in appearance because of the flat cheeks and eyelid edema.

I would start with thoroughly dissolving all the filler and evaluating you for various medical conditions that could cause eyelid edema, such as thyroid eye disease.

I would then evaluate you for surgical lower blepharoplasty with fat repositioning, addressing the ligamentous attachments and improving the deep tear-trough. There are other procedures you may also need.

I would also consider you for skin tightening, but unlikely a skin pinch as that could make things worse. Rather possibly a CO2 laser resurfacing procedure.

My Undereye Weekend Lift is a way to improve the cosmetic appearance in patients who don’t want surgery. You can access my videos on this platform.

See an Oculoplastic surgeon for a proper evaluation and recommendations.

I agree with the replies regarding tightening the skin. The best treatment is a laser. I prefer Erbium YAG Sciton because it has less tendency for hypopigmentation than the older CO2 lasers. I am sure providers can dial back the CO2 settings to minimize risk of hypopigmentation, but I am not sure if it will maintain the same effectiveness. The full ablative laser will give the best tightening. The fractionated laser will give good tightening and be easier to recover from than the full ablative laser (middle of the road option). Radiofrequency microneedling is another way to tighten the skin, although it will likely take a series of 3 treatments to do so. The recovery is easier than laser, but results are not quite as good.
Secondly, I recommend either nanofat or exosomes. In the US, exosomes are not FDA approved for injection treatment (approved for topical treatment), though we have had good off label success doing so. A comparable regenerative treatment is nanofat which uses your own stem cells and requires fat harvesting typically from the abdomen. These treatments help the tissue with color and volume by supporting the body in healing itself. I think one of these is a better option than fat grafting, although that can give nice results. Uncommonly, fat grafts can be associated with lumpiness. Even if fat grafting is done well, unfortunately, fat grafts can grow with body weight so it depends on guaranteeing that you will never gain weight in the future.
If unsatisfied with the previous 2 steps alone, then it is reasonable to treat the cheeks. Cheek treatment can be approached from the addition of volume and/or with lifting. Adding volume can give nice results. It can be done with fat grafting, filler, or submalar implants. A midface lift from a temporal incision can reposition cheek soft tissue back where it originated and give a nice, refreshed look. This often also helps the under-eye area.