Best Approach for Tear Troughs?

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 meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.
Structural fat grafting is a technique in which small amounts (less than 0.1 cc at a time) of fat are carefully microinjected in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist. If this process of blood vessel ingrowth (neovascularization) does not occur, then the injected tissue cannot truly be considered a 'graft' and is instead just another 'soft tissue filler' of limited duration.
Fat Grafting requires specialized training and specialized surgical instruments, as well as patience and attention to detail on the part of the surgeon. When performed properly, permanent improvements in facial plastic surgery are possible. Structural fat grafting can be performed on eyelid hollows, to fill sunken cheeks, for filling sunken hollows under eyes eyes and is often used for blepharoplasty correction when too much skin and or fat has been removed in an eyelid surgical procedure. Some people who have experienced fat loss as a result of procedures such as IPL or Thermage can also benefit greatly from permanent fat injections.

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.

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 lower eyelid bulging was treated by surgically removing the lower eyelid fat. This eliminated the bulging, but somehow caused the face to appear even older as the person aged. Young faces look full. Older faces look skeletonized an hollow. So, by further hollowing out the face, the patient looked even older. Quite the opposite of what many patients were trying to accomplish.

Having understood the connection between fat loss and the aging face, many doctors are using new techniques for treatment of this condition.

One such technique is fat transfer. Having taught fat transfer for years at the University of Southern California Keck School of Medicine, I know this to be an incredibly powerful procedure. It can be performed using just local anesthesia in a doctor's office. The fat is harvested almost painlessly from the thigh or abdomen, and injected into the face using a tiny needle or cannula. The fat fills the valley in the upper cheek, and feels soft and natural. Sure, some fat may be absorbed by the body, and a touch up fat transfer may be necessary, but a touch up is easy to do, and takes very little time.

Another good option is using a hyaluronic acid filler such as Restylane. This works just like fat transfer, by filling the valley where the lower eyelid meets the upper cheek. The advantage, however, is that Restylane is very quick and easy to do, and eliminates the need for fat harvesting. I do this quite often, and have developed a technique that leads to very little pain or bruising. It is quite remarkable how often patients can avoid surgery just by doing this procedure.

In regard to your question about where Restylane can be placed, it depends on technique. With proper experience, it is possible to place Restylane almost anywhere along the lower eyelid. There is always the risk of injecting Restylane directly into a blood vessel, and this can lead to retinal artery occlusion and blindness. However, this is such a rare occurrence, that only very few instances were ever reported, despite the popularity of these types of injections. I feel quite comfortable performing these types of injections, and would also feel comfortable having this performed on me or my family members (and in fact, I have performed this on many of my family members!)

Should the lower eyelid bulging be severe enough to warrant surgical correction, again, the key is volume preservation. There is a trend developing toward preservation and repositioning of lower eyelid fat as opposed to removal of the fat. By repositioning the fat, the surgeon can avoid the hollow, skeletonized appearance that can result as a person ages after having lower eyelid surgery done. I almost always use this technique for lower eyelid surgery.

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 repositioning is your best choice.

From your picture, you are an excellent candidate for this procedure.

The transconjunctival approach is much safer for addressing the tear trough because the anatomical approach is much more direct and easy.

Working in the area of the arcus and lower orbital rim through an external lower eyelid incision risks the occurance of ectropion and inferior migration of the lower lid margin.

I do not do filler injection in the tear trough--visible grey lumps are frequent--the lid skin is so thin the filler can show through. There has been a case of blindness reported in England following filler injection around the eyes. It just is not worth the risk in my opinion. I know many doctors do it, but I have only seen the complications.

See before and after pictures of arcus release and fat grafting through transconjunctival approach: Set 1, Set 2, Set 3

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 invasive, most predictable method.

There is a single large vessel at the bony orbital rim which of course must be avoided or bruising can be significant, so knowledge of the anatomy is important.

It is also possible to place fat injection, with its usual pluses and minuses, or LiveFill, nontraumatized fat-fascial grafts, precisely in the tear trough. Any graft must go through an incorporation stage, so will be somewhat firm and may need to be nursed along.

All these advanced lower eyelid procedures are technically complex and warrant a thorough knowledge of procedures of the lower eyelid and midface.

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. 

Both treatments you described will work.  At age 30 I would recommend trying the injectable first.  It has decreased risks and minimal downtime and can be reversed if needed.  You also can always do the more invasive procedure if you are not satisfied.  Good luck.  Donald R. Nunn MD Atlanta Plastic Surgeon

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.

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.

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 tear troughs, but will certainly be insufficient for the cheek volume that you will also need replaced.

Fat transposition surgery is also great for tear troughs, but again, be aware that there will still be a depth, and a lack of volume in your cheeks that will not correct with fat transposition lower eyelid surgery.

What you would probably benefit from the most (based on your age) is fat grafting to your face. The process involves removal of fat using liposuction techniquest and grafting or implanting of the fat in your face. This process is very customized as fat can be replaced to the degree needed in the places you need it.

If you were older, I would suggest fat transposition lower lid blepharoplasty at the same time. Had you only had tear troughs without such a loss of fat in the cheeks, I would suggest restylane, but the picture above looks like more volume would be needed.

I hope this helps, and don't hesitate to contact my office or email me for more information.

Dr. T