Treatment for Tear Troughs and Thin Undereye Skin?

I went to a doctor out of town for correction of my tear troughs, he told me that since I had such thin skin underneath my eyes, Restylane might not work well, and find somewhere closer to home in case of complications. Now I'm wondering if a filler or fat grafting would never be able to fix it, and if I have to live the rest of my life looking tired and older than my actual age? Also I've heard of laser treatment that thickens the skin underneath the eye. Is that really safe, and if so, what is it actually called?

Doctor Answers 19

Treatment of the Tear Trough

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Not necessarily. Tear trough can be fixed with fillers that are placed deep to the muscle over the bone, so it is not a matter of how thin the skin is. Also a more permanent procedure may be to have a lower eyelid surgery but to have the fat transposed to the tear trough to smoothen the transition from the eyelid bags and the tear trough.

Orange County Plastic Surgeon
5.0 out of 5 stars 88 reviews

Tear troughs and thin eyelid skin

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Restylane for correction of the tear trough area when injected in the correct location can still work well in people with thin eyelid skin. Loose/thin eyelid skin can be tightened and somewhat thickened with fractional laser (CO2 or Erbium) or chemical resurfacing. Depending on your skin type, to avoid lines of color demarcation, full face resurfacing might be appropriate. I would seek consultation with a physician who will take the time to walk you through the potential complications in addition to the benefits of these procedures.

Good luck.

Bryan K. Chen, MD
San Diego Dermatologist

It is a shame that you have to be in a position of directing your own treatment

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Dear Flagirl

My father always told me "if the butcher tells you the meat's bad, you should listen."

Too often when a doctor says that something can't be done, it means they have not figured out how to do it themselves. It does not necessarily mean that it can't be done. Before you give up on the best treatment option for the lower eyelid hollows, I suggest that you get some other opinions. In particular, you might look specifically for a cosmetic dermatologist who does the lower eyelid treatment because they are less likely to pressure you to do surgery.

Will surgery be right for you? Well for many, filling with Restylane is the best option. How about laser resurfacing? Generally, this can be a perfectly awful choice with the creation of a demarcation line and permanent textural changes in the the skin. Fat transfer is also less than idea in the tear trough hollow.

Again, your best bet is to do your homework and find someone in your area who makes a lot of sense.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

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Tear trough hollowness, a tough problem.

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The tear trough is a very tricky area. The skin is quite thin and almost anything you do other than hyaluronic acid fillers has a good chance of producing lumpiness.

For around the eye area, we prefer Prevelle, a hyaluronic acid filler that lasts about 3 months. I have never seen swelling of any signifance from this filler. Restylane is also fine for patients who aren't too sensitive. Patients should always allow a little recovery time after Restylane. Juvederm around the eyes tends to swell in some patients.

For the permanent fixes, we prefer a superficial cheeklift, limited or ultrashort incision (USIC) combined with conservative LiveFill (TM), an autologous nontraumatized graft. We have found this to be more predictable than fat injection. An additional advantage to LiveFill (TM) is that it is placed in one specific anatomic location, so if for some reason you didn't like it, it would be readily accessible. We caution patients that not all the hollowness will be gone. Rather, it is likely to be reduced. They might need small amounts of filler if they require even more smoothness.

Semipermanent fillers or fat injection typically extravasate, or travel into several areas, making modification very difficult and sometimes technically impossible.

Any surgery around the eye should be very carefully and conservatively performed. It is a shame to be the recipient of a permanent, undesireable result.

Patients should be very cautious and seek surgeons with considerable experience in the lower eyelid and midface. They should also be cautious of doctors promising perfection, since even the bery best doctors in the world get irregularities from time to time. They just don't get it often.

Remember, this is your face, after all.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 194 reviews

Laser resurfacing can thicken skin, fillers work, and fat injections may be the key

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The tear trough is a tough area. This area is located between the nose and the lower eyelid and is situated not above the bone as most people believe but above the soft tissue of the eye socket and eyelid. People have tried repositioning of the eye socket fat into that area.

This can work but has been shown to lead to eye position abnormalities and problems with dry eyes, etc. Fat grafting can work in this area and may be the most natural way to rejuvenate this area. It does have some issues related to survival of the fat. But is the fat survives past a year it will likely stay in the area for many years, sometimes 10-15 years.

Fat grafting requires a lot of skill and knowledge of fat survival techniques. Fillers can fill up the volume loss that has lead to the tear trough appearance and I've done that many times and have a lot of patients that get this done. The key is being able to fill up the area without leading to bumps and ridges. This requires some skill and with a surgeon's experience it can be done to look very nice and satisy your clients.

Fillers can look not as natural as fat, it can lead to a translucent type of appearance and some dark appearance of the filler within the skin. But, in general >95% or more patients are very, very happy that they had filler placed to treat the tear trough area. Lasers can create a layer of collagen underneath the eyelid skin to camouflage the dark appearance of the muscle underneath the skin. It can also tighten the skin and reduce the unwanted wrinkles in the lower eyelid. However, lasers will not replace the volume that is lossed with aging around the lower eyelid area. This is where fillers and fat injections come into play.

Philip Young, MD
Bellevue Facial Plastic Surgeon

A combination of Restylane and a laser often work well

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The tear troughs are a common problem area and there are multiple options for improvement. My personal preference is to use Restylane to fill the trough, followed by either a laser or chemical peel to smooth and tighten the skin. Together, this produces a very reproducible and safe result in most patients.

I would recommend talking to several surgeons with experience with this technique about your options before selecting the one to perform your procedure.

Shahram Salemy, MD, FACS
Seattle Plastic Surgeon
4.9 out of 5 stars 155 reviews

Fillers may work well in this area

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The tear trough area can be challenging to deal with. One minimally invasive way to address this area is by using soft tissue fillers (Restylane, Juvederm). This procedure has been gaining in popularity however, should be done by someone who is experienced injecting in this area.

My recommendation would be to consult with a board certified plastic surgeon to see if you are a candidate.

David A. Robinson, MD
Munster Plastic Surgeon
4.7 out of 5 stars 46 reviews

Fillers, especially fat, work well under eyes

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I would recommend fat injection to improve the tear troughs and lower lid-cheek area. This is a procedure that requires experience. Make sure you find someone who does this regularly and look at his results. If done properly, this is a wonderful procedure with beautiful results and is minimally invasive. Alternatively, fillers such as Restylane and Juvederm can be used but will need to be repeated more frequently.

Parham Ganchi, PhD, MD
Wayne Plastic Surgeon
4.8 out of 5 stars 172 reviews

Treatment of the tear trough

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Tear troughs are often treated by doctors injecting underneath the muscle so that the thin skin is not an issue. There are risks with any procedure and it would be a good idea to have it done closer to home in case you need to see your physician afterwards. Laser treatments can help build up the collagen. Fraxel RE:store and Portrait plasma are good collagen regenerators. Fraxel RE:pair and Carbon Dioxide lasers require more healing time and carry greater risk of complications. Despite having multiple treatments, with any resurfacing, the skin may never have the thickness or elastic properties you had hoped for. Be sure to have realistic expectations after you consult with your local physician who specializes in these procedures.

Ronald Shelton, MD
Manhattan Dermatologic Surgeon
4.9 out of 5 stars 39 reviews

Lower lid treatment

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In order to get good results in the tear trough region, you have to find a qualified doctor who treats this area frequently so that it can be done correctly.  

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.