Tear trough assessment before technique
Three different causes of the same infraorbital hollow, and why choosing the wrong one produces the results that make patients regret filler.
The infraorbital hollow is the most requested and least forgiving treatment on the face. Most poor outcomes there are assessment failures rather than technical ones.
The anatomy that makes it difficult
The tear trough marks the tear trough ligament, an osteocutaneous attachment from maxilla to dermis. Above it the skin is the thinnest on the body, with almost no subcutaneous fat and orbicularis oculi directly beneath. Below sits the medial cheek fat.
Lymphatic drainage in the region is sparse. The angular and infraorbital arteries are nearby, and the region appears in the published series of filler-induced vision loss.
Three presentations, one appearance
Ligamentous tethering. The groove is a fixed boundary held down by the ligament. Filling into it fights the tether; product tends toward lumpiness and prolonged swelling.
Midface deflation. The hollow is a shadow cast by lost medial cheek volume, not a defect at the rim. Restoring the cheek frequently improves the trough without any product being placed in it.
Pseudoherniated orbital fat. Orbital fat bulges forward through a lax septum, and the “hollow” is the relative depression below a convexity. This is a surgical problem. Adding filler below a herniation increases total volume in a region that is already too full, and the result is worse than the starting point.
Assessment
Palpate the rim to find where bone actually is. Examine upright and supine — a hollow that fills when the patient lies down is behaving as deflation; a bulge that increases is orbital fat. Press gently on the globe: if the bulge accentuates, it is herniated fat. Look under different lighting. Ask about morning puffiness, thyroid disease, previous surgery and prior filler, all of which change how the region will behave.
What goes wrong when it is filled anyway
Tyndall effect — superficial hyaluronic acid under thin skin reads blue. Persistent malar oedema — sparse lymphatics plus a hydrophilic gel can produce swelling lasting months, sometimes only resolving after dissolution. Visible product — lumps that were invisible on the day appear as swelling settles. Vascular events — uncommon but reported, and this region connects to the orbit.
If treating
Deep, supraperiosteal, medial, conservative. A low-hydrophilicity product. Small volumes with a second session rather than a full correction at once. A cannula in preference to a needle. And the midface addressed first, since it frequently removes the reason for treating the trough at all.
