Tear trough assessment
Distinguishing the causes of an infraorbital hollow — ligamentous tethering, midface deflation, orbital fat pseudoherniation — before deciding whether filler is the answer at all.
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The commonest error in infraorbital treatment is procedural rather than technical: filling the hollow before establishing what is causing it. Three distinct presentations look similar and respond entirely differently.
Ligamentous tethering. The tear trough ligament holds the skin against the orbital rim. The groove is a fixed boundary. Filling directly into it fights the tether and tends to produce lumpiness and prolonged swelling; supporting the tissue below is more effective.
Midface deflation. The hollow is a shadow cast by loss of medial cheek volume, not a defect at the rim. Restoring the deep medial cheek fat 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 the bulge. This is a surgical problem. Filler added below a herniation increases total volume in a region that was already convex, and the result looks worse.
Assessment therefore precedes product: palpate the rim, assess in upright and supine positions, observe in animation, and press the globe gently to see whether the bulge increases. Skin quality, existing pigmentation and lymphatic history determine how forgiving the region will be.