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Tear Trough Deformity : Review of Anatomy and Treatment Options

Ross L. Stutman and Mark A. Codner
Aesthetic Surgery Journal 2012 32: 426
DOI: 10.1177/1090820X12442372

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Oculoplastic Surgery

Aesthetic Surgery Journal

Continuing Medical Education Article 32(4) 426 440
2012 The American Society for
Aesthetic Plastic Surgery, Inc.
Tear Trough Deformity: Review of Anatomy Reprints and permission:
http://www. sagepub.com/

and Treatment Options journalsPermissions.nav

DOI: 10.1177/1090820X12442372
www.aestheticsurgeryjournal.com

Ross L. Stutman, MD; and Mark A. Codner, MD

Abstract
The lower eyelid can be a challenging area in facial rejuvenation. While lower eyelid bags are commonly the reason that patients present for lower eyelid
rejuvenation, a separate entity known as a tear trough deformity may occur in conjunction with lower eyelid bags or alone. In this article, the authors
outline the current understanding of the tear trough anatomy; describe multiple classification systems, which provide an objective means of evaluating
the deformity and aid the surgeon in choosing appropriate treatment options; and review surgical and nonsurgical techniques for correcting the tear
trough deformity. Treatment options include hyaluronic acid filler, fat grafting, skeletal implants, and fat transposition. Each procedure is associated with
advantages and disadvantages, and each should be considered more complex than traditional lower blepharoplasty alone. While lower blepharoplasty
removes excess fat and may tighten the anterior lamella, tear trough procedures require the addition of volume to the underlying depression. These
procedures requiring release of the ligamentous structures and orbicularis (of which the tear trough is composed), as well as fat transposition or fat
grafting, are associated with additional complications, which are also reviewed.

Keywords
tear trough deformity, nasojugal depression, blepharoplasty, oculoplastics

Accepted for publication January 13, 2012.

While lower lid bags are more commonly caused by pro-
truding orbital fat, there may be a concave deformity cau-
dal to the orbital fat that is noticeable as a result of
inherited anatomic differences and aging.1 This concave,
obliquely-oriented groove has been named the tear trough
deformity (Figure 1).2 Patients presenting with tear trough
deformity often complain of dark circles or a tired, aged,
and/or aesthetically-displeasing depression in that region.
The aesthetically-attractive lower eyelid should display a
relatively-smooth transition between the preseptal and
orbital portions of the orbicularis oculi muscle and con-
tinue into the upper malar region without a definable
transition point. There has been some debate regarding
the contributing anatomy of tear trough deformity and
the appropriate treatment options. In this review article,
we discuss the anatomy of the tear trough region and
describe the most common surgical and nonsurgical treat-
ment options.
orbicularis oculi and angular head of the quadrates labii
superioris muscles.3 The term nasojugal fold was first
introduced in 1961 by Duke-Elder and Wybar; it was
defined as running downwards and outwards from the
inner canthus, the junction of the loose tissue of the lower
lid with the denser structure of the cheek, marking the line
along which the fascia is anchored to the periosteum
between the muscles of the lid and those of the upper
lip.4 Later, Loeb and Flowers better defined this area
in an effort to clinically improve the deformity. Loeb
Dr. Stutman and Dr. Codner are plastic surgeons in private practice
in Atlanta, Georgia.
Corresponding Author:
Dr. Mark A. Codner, 1800 Howell Mill Road, Suite 140, Atlanta, GA
30318 USA.
E-mail: macodner@gmail.com

Anatomy Scan this code with your smartphone to

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In 1932, Whitnall first described the lower eyelid depres- www.aestheticsurgeryjournal.com.
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Stutman and Codner 427
Figure 1. This 29-year-old woman presented for
blepharoplasty with tear trough deformity.
hypothesized that the naso-jugal groove was caused by
the following: (1) fixation of the orbital septum at the level
of the inferomedial portion of the arcus marginalis, (2)
existence of a triangular gap limited by the lateral portion
of the angular muscle on one side and the medial portion
of the orbicularis oculi muscle on the other, and (3) the
absence of fat tissue from the central and medial fat pads
subjacent to the orbicularis oculi muscle in the area below
the groove.5 Flowers, who coined the term tear trough
deformity, described several factors associated with
the development of a tear trough, including descent of the
cheek, loss of facial volume, underdevelopment of the
infraorbital malar complex, and a muscular defect between
the orbicularis muscle and angular head of the quadrates
labii superioris muscle.1
Several reports have described and illustrated the tear
trough deformity as a triangular defect bordered by the
orbital portion of the orbicularis oculi (superiorly), the
levator labii superioris (laterally), and the levator labii
superioris alaeque nasi muscle (medially).6-8 However,
results from more recent investigations have contradicted
past anatomic descriptions. The position of the tear trough
is most accurately described to be within the boundary of
the orbicularis muscle.9,10 Normal changes in the insertion
of the orbicularis muscle, from medial to lateral, have per-
mitted a better understanding of the anatomy and treat-
ment.11,12 As a result, the term tear trough deformity
should be applied to the medial periorbital hollow extend-
ing obliquely from the medial canthus to the midpupillary
line. Lateral to this, the depression is better referred to as
the palpebromalar groove, nasojugal groove, or the
lid-cheek junction (Figure 2).
Haddock et al9 performed anatomic dissections of the
lower eyelid and midfacial regions and identified two dis-
tinct tissue layers contributing to the tear trough and lid-
cheek junction: the subcutaneous plane and the deep
plane. In the subcutaneous plane, there was no distinction
or separation between the tear trough and the more lateral
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lid-cheek junction. Superficially, the tear trough was found
to correlate with the junction between the preseptal and
orbital portions of the orbicularis oculi muscle, with
changes in skin texture and underlying fat as contributing
factors. In the deep plane, the authors found a separation
between the tear trough and lid-cheek junction. Medially,
the orbital orbicularis was firmly attached to the maxilla
at its origin, while a ligamentous attachment was identi-
fied laterally between the maxilla and the orbicularis.
The ligamentous attachment found in the deep plane was
first identified by Kikkawa and termed the orbital malar
ligament.13 He defined it as a fibrous structure extend-
ing from thickened periosteum along the inferior orbital
rim through the submuscular fat, becoming lamellar in
nature while passing through the orbicularis oculi mus-
cle, and subsequently inserting into the skin. More
recently, Mendelson referred to this as the orbicularis
retaining ligament, due to the attachment to the under-
lying zygoma, caudal to the arcus marginalis at the
orbital rim.10
Muzaffar et al noted that the orbicularis oculi is inte-
grated with the superficial musculoaponeurotic system.11
Furthermore, they described multiple retaining ligaments
in the periorbital region, similar to the previously-described
retaining ligaments of the face.14-17 They also identified the
direct attachment of the orbicularis oculi muscle medially
from the anterior lacrimal crest to the level of the medial
corneoscleral limbus. Lateral to the corneoscleral limbus,
the orbicularis muscle was attached to the periosteum
indirectly through the orbicularis retaining ligament. The
orbicularis retaining ligament continued superficially to
separate the preseptal and orbital portions of the orbicula-
ris oculi muscle. The orbicularis retaining ligament length
was greatest at the level of the arcuate expansion of the
orbital septum, measuring 10 to 14 mm and 1.5 to 5 mm
in thickness. The length of the orbicularis retaining liga-
ment decreased as it extended farther laterally, until it
became negligible at the lateral orbital thickening. The
retaining ligament created a V-shaped deformity that cor-
related with the lid-cheek junction (Figure 3). With age, a
combination of soft tissue atrophy and orbital fat hernia-
tion can exacerbate this deformity. Similarly, Haddock et
al found this ligamentous attachment farthest from the rim
at the midpupillary line (4 to 6 mm) and terminated closer
to the rim near the lateral canthus (2 to 4 mm).9 Thus, it
is theorized that the tear trough deformity becomes accen-
tuated with age due to attenuation of the orbital septum,
which allows fat to herniate through the lax palpebral
orbicularis.
Hwang et al aimed to build on the previous work of
Muzaffar and Mendelson by providing precise anatomical
detail of the periorbital ligaments in terms of breaking
strength and histological characteristics.18 They confirmed
the presence of a definite retaining ligament between the
orbital rim and orbicularis oculi muscle in 76.4% of dis-
sections. This ligamentous structure, which they termed
the periorbital ligament, was separated into a medial
and lateral component. Histologically, they described the
periorbital ligament as a thick fibrous band stretched from
428 Aesthetic Surgery Journal 32(4)
Figure 2. Tear trough anatomy.
Figure 3. This 54-year-old woman demonstrates a
V-deformity.
the arcus marginalis to the skin through the orbicularis
oculi muscle at the medial canthus, with a thickness of 0.2
to 0.4 mm. Centrally, thin fibers extended from the arcus
marginalis through the orbicularis oculi muscle. At the
lateral canthus, a thick fibrous band (1.0 mm thick) was
attached to the periosteum spanning between 3 and 4 mm
and 10 and 11 mm lateral to the arcus marginalis, with
several fibers extending to the skin through the orbicularis
muscle. In terms of breaking strength, the medial and lat-
eral periorbital ligaments were both significantly-stronger
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than the central component, supporting the anatomic
basis for the V-deformity.
Lambros studied the tear trough deformity through
closely-matched photographs of patients at differing ages.
He defined the tear trough as the junction of the thin,
pigmented lower lid skin with the thicker cheek skin at the
medial canthus to the midpupillary line. He found the lid-
cheek junction to be stable over time and said that its
perceived descent was due to age-related tissue volume
changes and not actual movement.19 He believes that the
unmasking of the tear trough and lid-cheek junction is
related to soft tissue volume deflation with age.
The frequent patient complaint of dark circles is often
caused by tear trough deformity; however, this pigmented
change can be multifactorial. Changes in skin thickness
and laxity, hyperpigmentation, and actinic changes also
play a role. Thin skin or prominent subcutaneous venous
pooling accentuates the periorbital darkening. Additionally,
prolapse of orbital fat may indirectly cause a shadowing
over the lower lids.19,20
Goldberg described three main periorbital hollows21:
the septal confluence, the orbital rim hollow, and the
zygomatic hollow. The orbital rim hollow corresponds
with the location of the orbitomalar ligament, the tear
trough medially, and nasojugal fold laterally. It is bound
by the prominence of the orbital fat above and the subor-
bicularis oculi fat and cheek fat pads below. In the same
Stutman and Codner 429

article, Goldberg described a triangular pendant similar to

the V-shaped deformity described by Muzaffar.11 However,
Goldberg defined this triangular pendant as bound cen-
trally overlying the bony depression of the inferior orbital
nerve foramen and the origin of the levator labii superio-
ris. It is his opinion that the orbital hollow is a result of
volume loss in the areas of bony attachments that mimic
gravitational descent.
While the tear trough is a common cause of periorbital
hollowing, additional anatomical contributing factors
must be evaluated for proper treatment of the patient pre-
senting with lower eyelid bags. Goldberg et al22 described
six main components of eyelid bags: orbital fat prolapse,
eyelid edema, tear trough depression, loss of skin elastic-
ity, orbicularis prominence, and the triangular malar
mound. The authors characterized the tear trough by loss
of subcutaneous fat with thinning of the skin over the
orbital rim ligaments, combined with cheek descent.
Furthermore, they stated that the tear trough is often
related to underlying bony structure and particularly asso-
ciated with age-related maxillary hypoplasia. In analysis of
all six components, they noted that the tear trough was
also accentuated with loss of skin elasticity, whereby the
thin skin unveiled an underlying depression. Their study
included a uniqueness score to specify whether one
particular anatomical area was a primary reason for the
eyelid bags. While most bags were a result of more than
one variable, the two most common reasons for eyelid
bags were orbital fat and the tear trough. Additionally,
when separating patients by age, patients over 50 were
more likely to have eyelid bags caused predominantly by
skin laxity and tear trough depression.

Classification Systems
Multiple classification systems have been introduced to
provide an objective means of evaluating the tear trough
deformity and to aid the surgeon in choosing appropriate
treatment options.
Figure 4. Hirmand classification of tear trough deformity.
In 2010, Hirmand proposed a classification system of
Adapted from: Hirmand, H. Anatomy and nonsurgical
the tear trough deformity based on clinical evaluation (see
correction of the tear trough deformity. Plast Reconstr Surg
Figure 4).7
2010;125(2):699-708.

Class I patients have volume loss limited medially

to the tear trough. These patients can also have
mild flattening extending to the central cheek.
Class II patients exhibit volume loss in the lateral
orbital area in addition to the medial orbit, and
they may have moderate volume deficiency in the
medial cheek and flattening of the central upper
cheek.
Class III patients present with a full depression
circumferentially along the orbital rim, medial to
lateral.
Barton et al23 proposed a grading system based on ana-
tomic analysis in an effort to objectively analyze their
postoperative results:
Grade 0: Absence of medial or lateral lines demar-
cating the arcus marginalis or the orbital rim and
a smooth, youthful contour without a transition
zone at the orbit-cheek junction
Grade I: Mild, subtle presence of a medial line or
shadow; smooth lateral transition of lid-cheek
junction
Grade II: Moderate prominence of a visible demar-
cation of the lid-cheek junction, extending from
medial to lateral
Grade III: Severe demarcation of the orbit-cheek
junction, with an obvious step between the orbit
and the cheek

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430 Aesthetic Surgery Journal 32(4)
Sadick et al developed the Tear Trough Rating Scale by
objectively and subjectively evaluating the clinical appear-
ance of the tear trough with regard to depth of the trough,
hyperpigmentation, volume of prolapsed fat, and skin
rhytidosis.20 A numerical score was then assigned with
respect to severity:
Depth of the tear trough: distance from the anterior
lacrimal crest to the depth of the trough; each
millimeter of depth is given one point
Hyperpigmentation: dyspigmentation, while not
directly contributing to the depth of the trough,
creates an illusion of depth; no hyperpigmenta-
tion is given one point, mild is given two points,
moderate hyperpigmentation is given three
points, and intense or deep hyperpigmentation is
given four points; subdermal dark casting caused
by venous pooling can also be graded as hyper-
pigmentation
Prolapse of nasal fat pad/pockets: prominent pro-
lapse of the nasal fat pad accentuates the depth
of the trough and is rated as mild (one point),
moderate (two points), or severe (three points)
Rhytidosis: lower eyelid skin rhytidosis accentuates
the fatty prolapse and the depth of the trough;
skin rhytidosis is rated on a scale of one to four
(mild, moderate, advanced, and severe, according
to Glogaus scale) and the rating corresponds to
the number of points assigned
Nonsurgical Treatment Options
Correction of a tear trough deformity with nonsurgical
techniques presents unique challenges. Unlike other facial
hollows (such as the nasolabial folds, which are easily
camouflaged), the tear trough requires more technically-
demanding treatment due to the breadth of the hollow,
skin quality changes (thinning), and the presence of adja-
cent orbital fat pads.
Lambros stressed that when one engages in nonsurgical
treatment for tear trough correction, it is important to
evaluate the following factors:
1. skin quality, as patients with thick, smooth skin
will have better results than those with thin
extremely-wrinkled skin;
2. definition of the hollow, since a more defined
hollow is more amenable to filler;
3. the orbital fat pad, as larger fat pads are more
difficult to correct due to puffiness caused by
the injection; and
4. the color of the overlying skin, since filler may
improve shadowing but will not improve dark
pigmentation.24
It is important that any nonsurgical option address
these important variables.
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Hyaluronic Acid Filler
In a 2006 multispecialty consensus recommendation arti-
cle, the tear trough was listed as the most challenging
area to treat with hyaluronic acid (HA).25 The currently-
popular HA fillers are produced by bacterial fermentation
(Streptococcus strains) and stabilized by chemical cross-
linking. The nonanimal-derived products have substan-
tially decreased allergic reactions.26 The products all differ
in their cross-linking methods, concentrations, and parti-
cle sizes.27,28 These variations determine the products
resistance to degradability, ease of injection, and gel solid-
ity. HA fillers are most often recommended in the tear
trough area, as undesired results can be reversed with
injection of hyaluronidase. This has led to a sharp fall in
the placement of bovine collagen-based fillers in this area
due to increased rates of absorption, hypersensitivity reac-
tions, and irregularities that are often difficult to correct.29
Several other semipermanent filler materials are available
for tear trough injection and have shown good results,30,31
but the nonanimal HA products remain most popular.
Lambros technique.25 After application of an ice pack to
the lower lid and cheek, local anesthetic consisting of 0.5%
lidocaine with epinephrine (0.2 to 0.4 mL) is injected into
the orbicularis within the tear trough boundaries. Finger
pressure is applied to flatten the injection area. A half-inch,
30-gauge needle is inserted through the skin at the most lat-
eral extent of the tear trough, advancing fully and potentially
indenting the skin with the hub for full reach. The HA is
then injected deep to the dermis as the needle is withdrawn.
This process is repeated above and below the original injec-
tion site. The area is then inspected, and additional passes
are made as needed to yield a smooth contour. Last, the area
is massaged lightly, compressed with finger pressure, and
rolled with a cotton applicator. In his description of the tech-
nique, Lambros stressed the importance of not forcefully
compressing the product during massage, as this can dis-
place the product into the cheek and exaggerate the tear
trough. Postinjection care involves applying ice to the area
the night of procedure, and patients are instructed to refrain
from massaging the area.
Kane technique. 32 After evaluation and marking of the
tear trough, Betacaine topical anesthetic ointment is
applied to the lower eyelids at least 20 minutes before
injection. After skin preparation with alcohol, a 30- or
32-gauge needle is inserted for injection. The deepest por-
tion of the medial tear trough is treated first. The needle is
threaded below the surface of the skin above the orbicula-
ris oculi. Parallel threads of filler are injected cephalad and
caudad to the tear trough. The raised area of the filler
is then tapered off medially along the nasal sidewall
superiorly at the most cephalad significant rhytid, inferiorly
at least abutting or immediately caudal to the thick cheek
skin, and laterally to at least the junction of the medial and
lateral third of the inferior orbital rim.
If the tear trough is deep, the direction of the needle is
changed throughout the injection so that filler is applied
in a crosshatched fashion. For some patients, more than
100 needle passes may be required. The volume range is
Stutman and Codner 431

Figure 5. (A) This 37-year-old woman presented for treatment of a tear trough deformity. (B) The patient is shown during
nonsurgical treatment with HA filler. (C) Fourteen days postinjection.

0.1 to 0.45 mL per eyelid, with most patients requiring
0.2 to 0.3 mL.
Kane recommends that patients stop taking all aspirin
and nonsteroidal drugs for two weeks preinjection.
Postinjection, all patients are instructed to rest, with strict
head elevation position and cold compresses applied for
two days. Kane also discourages patients from massaging.
Authors preferred technique.6 Due to the thin skin overly-
ing the tear trough, caution is advised when treating a tear
trough deformity with filler. Favorable results can be
achieved with proper patient selection, but patients should
be counseled that HA injection alone will not address skin
pigmentation changes.
With the patient seated, the tear trough deformity and
lid-cheek junction are marked with easily-removable white
eyeliner. The patient is advised to apply ice packs to the
area several minutes before injection to minimize bruising
and for anesthetic purposes. After the markings are con-
firmed with the patient, HA is injected deep in the prepe-
riosteal plane, to reduce visibility of the product. The HA
is placed beneath the insertion of the medial orbicularis
muscle at the maxilla and continues laterally inferior to
the orbicularis retaining ligament. A combination of
crosshatching and linear threading is utilized with a
30-gauge needle with care not to inject superficially. The
product is lightly massaged with cotton-tipped applica-
tors to disperse any visible irregularities. After injection,
the patient is instructed to apply ice to the area over the
next 24 hours as needed to decrease edema and ecchy-
mosis (Figure 5).
Filler complications. Reported complications of HA filler
include:
ecchymosis and swelling, which can be decreased
with application of ice packs33 and infiltration of
local anesthesia containing epinephrine;
pain and erythema at injection site, which is usu-
ally self-limiting;
irregularities, which usually can be massaged
away either at the time of injection or several
weeks laterhowever, more significant irregulari-
ties can be dissolved with hyaluronidase (10 units
of hyaluronidase per area);

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432 Aesthetic Surgery Journal 32(4)
discoloration, which may result from superficial
injection that renders a faint bluish tint to the skin
(Tyndall effect); and
patients lack of perceived effect, which can be
resolved through review of preinjection photos,
since these will serve as a visual reminder for pa-
tients and often alleviate their concerns.
Filler results. The duration of efficacy for HA filler in the
tear trough has been reported from six months to two
years.25,32,34,35 Donath et al36 quantified residual HA in the
tear trough with a three-dimensional camera and found
that, despite the small sample size, 85% of aesthetic result
was maintained at 15 months. This long-lasting effect was
hypothesized to be a result of the relative lack of soft tissue
movement in the area as compared to the nasolabial folds or
lips.
Excellent aesthetic results can be achieved when HA
filler is injected with good technique in appropriately-
selected patients; previous studies have reported an 85%
to 88% aesthetic improvement.37,38 Patient selection is
critical, as patients with thick skin, minimal pigmentation
changes, and moderate deformity are the best candidates
for HA filler correction of the tear trough deformity.
Patients with more significant deformities and lower lid
bags require lower lid blepharoplasty.
Fat Grafting
The use of autologous fat has been advocated in facial reju-
venation due to its ready availability and ease of harvest in
most patients.39-41 Additionally, the absence of foreign mate-
rial and potential for permanent effect are particularly attrac-
tive to many patients. Fat grafting can be performed
nonsurgically by lipoinjection or by direct placement in con-
junction with open surgical techniques for lower eyelid reju-
venation. Coleman is a proponent of the lipoinjection
technique, citing the fact that fat often migrated when graft-
ing was combined with open approaches.42
When one performs lipoinjection, it is recommended
that an 18- or 19-gauge blunt cannula be attached to a
1-mL syringe for transfer.43 The cannula is introduced
into the lower lid via a stab incision, camouflaged later-
ally into a natural crease in the crows feet area. The
fat is then laid down from the medial to lateral lower
eyelid in the supraperiosteal plane.6 While volumes of up
to 3 mL per side have been described, injection sizes of
1 mL or less should be considered to maximize safety
and minimize complications, depending on the depth of
the tear trough. To avoid palpability or contour irregu-
larities, it is recommended that the deformity not be
overcorrected.
A relatively-unpredictable resorption rate, frequent
requirement of several procedures, and risk of permanent
contour irregularities are the main drawbacks for fat
grafting the tear trough deformity.44 A report by Coleman
recommended treatment with massage, direct excision,
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suctioning, and injection of steroids, phosphatidylcho-
line, or deoxycholate for cases of contour irregularity or
overcorrection.45 However, some reports caution that
surgical correction is required (through a blepharoplasty
incision) for correction of contour irregularities resulting
from fat grafting,44 which defeats the original intent of a
nonsurgical approach. Additionally, the potentially-dev-
astating complication of blindness, while never described
specifically with fat injection into the tear trough, has
been described in treatment of other periorbital areas,
specifically the glabellar frown lines.46-48 To decrease the
risk of this disastrous complication, it is advisable to
limit the amount of material or bolus injected in one
site, in addition to the recommended use of blunt nee-
dles, superficial plane of injection, and minimal pressure
upon injection.49
Surgical Treatment Options
Blepharoplasty has evolved from the old paradigm of pure
fat and skin removal50 to the modern practice of preserv-
ing orbital fat with limited resection to restore a youthful
contour.51-53 Similarly, techniques aimed at treatment of
the tear trough now address midfacial fat atrophy and
descent. Fat transposition and grafting are useful in filling
the tear trough and rendering a more youthful lid-cheek
junction without causing a periorbital hollow.
Rohrich et al54 proposed a five-step lower blepharo-
plasty that addresses both the tear trough and the lid-
cheek junction. This approach systematically treats both
elements by evaluating and addressing the following: (1)
deep malar fat augmentation, (2) orbicularis oculi muscle
preservation with conservative fat pad removal, (3) selec-
tive release of the orbicularis retaining ligament, (4) lateral
canthopexy, and (5) conservative skin excision. Regardless
of the particular technique utilized, it is important to
evaluate each of these five steps to optimally treat the tear
trough deformity.
Transconjunctival Approach
Goldberg technique.55 Following preoperative marking of
the tear trough deformity, a standard transconjunctival inci-
sion is made from the caruncle to the lateral fornix to begin
the Goldberg procedure. The lateral and central fat pads are
conservatively excised. Dissection is then carried medially,
with transection of the arcus marginalis and with subperi-
osteal dissection extending beneath the preoperatively-
marked tear trough. The medial fat pad is then transposed
as a random-pattern flap into the subperiosteal dissection.
The central fat pad can be added for increased volume after
it is freed from the inferior oblique muscle. The transposed
fat pads are then secured with three or four externalized,
lazy loops of 6-0 suture, which are removed after three to
five days. The subperiosteal plane is preferred, due to its
relative avascularity and ease of dissection (Figure 6). Addi-
tional filler may be required, depending on the amount of
Stutman and Codner 433
Figure 6. Goldbergs transconjunctival approach for tear
trough correction with fat transposition.
Adapted from: Goldberg RA. Transconjunctival orbital fat
repositioning: transposition of orbital fat pedicles into a sub-
periosteal pocket. Plast Reconstr Surg 2000;105(2):743-748.
fat absorption that takes place. Goldberg acknowledged that
use of a supraperiosteal plane may provide transposed fat
with a more favorable blood supply, as well as yielding a
more natural contour. Therefore, he did caution that his
technique can cause hardening of the fat pedicle during the
first three months postoperatively, which he attributes to a
combination of fibrosis, liponecrosis, and lipogranuloma
formation.
Kawamoto and Bradley technique.56 Kawamoto and Brad-
ley also use a transconjunctival technique, termed the
TROUF (transconjunctival repositioning of orbital
unpedicled fat). The TROUF technique is similar to Gold-
bergs, except that a supraperiosteal (suborbicularis) plane
is dissected beneath the tear trough and the fat pedicles
are secured internally with a 5-0 plain gut suture in a hori-
zontal mattress fashion. The supraperiosteal dissection is
performed by blunt scissors, spreading to avoid injury to
the angular vessels and decrease bleeding. Kawamoto and
Bradley reported high rates of patient satisfaction with this
technique, with no patients exhibiting lower lid retraction.
Adverse events were few and consisted of temporary skin
irregularities.
The tear trough deformity presents unique challenges
in patients of Asian descent. Kawamoto and Bradley
observed an increase in revisionary procedures to remove
additional periorbital fat after using their technique. As a
result, they recommended that surgeons utilize fat resec-
tion in addition to transposition in this patient population.
However, the same trend was not observed by Momosawa
et al.57 They specifically studied the effect of transconjunc-
tival lower eyelid fat transposition without resection on
young Asian patients presenting for correction of the tear
trough deformity. In their prospective study, 90% of
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patients had an excellent result, as graded by two experi-
enced plastic surgeons uninvolved with treatment. No
significant complications were observed in this study;
therefore, the Momosawa data provide support for the
safety and efficacy of fat transposition without resection in
the Asian lower eyelid.
Hidalgo technique.58 Hidalgo prefers a transconjunctival
approach that includes both conservative fat resection and
transposition. After a standard transconjunctival incision,
excess fat is resected from the medial, central, and lateral
fat pads. The arcus marginalis is released, and subperi-
osteal dissection is performed approximately 4 mm caudal
to the infraorbital rim, extending laterally to transect the
orbicularis retaining ligament. Fat is then transposed into
the subperiosteal pocket to fill the tear trough deformity.
Hidalgos technique differs from Goldbergs in that he does
not develop extensive pedicles of fat. In contrast, the
suture is passed through the substantive portion of the
medial and central fat pads and sutured transcutaneously
without extensive flap development, using 4-0 plain gut
suture tied over bolsters (Figure 7). The bolsters are left in
place for at least six days postoperatively. Hidalgo also rec-
ommends, if needed, simultaneous conservative lower
eyelid skin excision, canthal support, and skin resurfacing
with 30% trichloroacetic acid to improve hyperpigmenta-
tion and fine rhytides.
Freeman technique.59 Freeman also employs a transcon-
junctival approach; however, his technique utilizes elevation
of the suborbicularis oculi fat rather than orbital fat transpo-
sition. Observations from a cadaver study and intraoperative
experience were the basis for Freemans theory that the for-
mation of the tear trough involves both descent of the malar
fat pad and a paucity of suborbicularis oculi fat tissue at the
level of the arcus marginalis. His technique involves supra-
periosteal dissection with elevation and securing of the
suborbicularis oculi fat to the infraorbital rim periosteum at
the level of the arcus marginalis. Freeman has reported the
results of this technique in 64 patients, with good to excel-
lent correction of the tear trough and without significant
postoperative complications.
Transcutaneous Approach
Hamra technique.60 Hamra advocates lower lid blepharo-
plasty through a transcutaneous approach with a skin
muscle flap. In an effort to avoid a hollowed out or oper-
ated appearance, his technique stresses the importance of
preserving lower lid fat. To address the progressive expo-
sure of underlying skeletal anatomy that occurs with age,
the arcus marginalis is released with transposition of orbital
fat, similar to the technique originally described by Loeb2
but adding anterior reset of the orbital septum. Hamra rec-
ommends minimal removal of fat and septum with
repositioning. The remaining fat is then sutured well below
the infraorbital rim with multiple interrupted 5-0 Vicryl
sutures (Figure 8). Hamras report of 152 cases demon-
strated a low incidence of postoperative complications and
secondary revision procedures. One patient required
434 Aesthetic Surgery Journal 32(4)

Figure 7. Hidalgo transconjunctival technique with fat transposition for tear trough correction.
Adapted from: Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg 2011;127(1):386-395.

evacuation of a periorbital hematoma, and only two early
patients underwent secondary removal of excess medial
fat.
Hamras technique is often employed with his compos-
ite rhytidectomy, which also involves repositioning of the
orbicularis muscle and cheek fat. Hamra has advocated
the usefulness of this technique for primary and second-
ary blepharoplasty, especially for patients presenting
with a hollowed-out appearance. This technique has
also proved beneficial in the correction of malar implant
visibility, which can occur as a result of continued facial
fat descent with age.
Since this technique places inferior tension on the sep-
tum, the theoretical risk of ectropion should be considered,
as the septum inserts into the tarsoligamentous sling.
Excess tension, scarring, or hematoma may contribute to an
increased risk of lid malposition.
Barton technique.23 Barton et al performed an objective
analysis of their experience with arcus marginalis release,
fat excision, and septal resetsimilar to the technique
described by Hamra60for treatment of tear trough
deformity (Figure 9). In an effort to reduce potential middle
lamellar shortening, their technique included the addition
of orbital septum irrigation with 0.5 mL of triamcinolone
solution (5 mg/mL), placement of a traction stitch during
septal advancement, and routine postoperative upward
lid-stretching exercises. Results were analyzed with an
anatomic grading system applied to pre- and postoperative
photographic comparisons (the classification system was
described earlier). Overall, 95% of patients included in the
study improved at least one grade postoperatively. The
authors concluded that this technique was safe, with the
most common complication being prolonged edema. Addi-
tionally, no incidence of middle lamellar shortening or
contracture was observed.
Carraway technique.61 Carraways technique for correc-
tion of the tear trough incorporates two aspects: treating
the paucity of tissue between the tear trough and orbital
rim and addressing the bulkiness of the orbicularis
muscle, both cranial and caudal to the deformity. His pre-
ferred technique involves lower eyelid blepharoplasty
through a subciliary incision with a subcutaneous skin or

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Stutman and Codner 435
Figure 8. Hamra technique with a transcutaneous approach,
fat transposition, and anterior septal reset.
Adapted from: Hamra ST. Arcus marginalis release and
orbital fat preservation in midface rejuvenation. Plast
Reconstr Surg 1995;96(2):354-362.
Figure 9. Bartons transcutaneous technique with fat
transposition for treatment of the tear trough deformity.
Adapted from: Barton FE Jr, Ha R, Awada M. Fat extrusion
and septal reset in patients with the tear trough triad: a
critical appraisal. Plast Reconstr Surg 2004;113(7):2115-2121.
Downloaded from aes.sagepub.com at ALLERGAN PHARMACEUTICAL on May 1, 2012
Figure 10. Carraway technique of transcutaneous
blepharoplasty with direct lipoinjection into orbicularis
muscle for treatment of tear trough deformity.
Adapted from: Carraway JH. Volume correction for nasojugal
groove with blepharoplasty. Aesth Surg J 2010;30(1):101-109.
skin muscle flap, depending on the amount of periorbital
rhytids and excess lower lid skin. Carraway advocates par-
tial removal of herniated fat pads with a strip of superficial
preseptal orbicularis and release of the suborbicularis
fascia about 2 mm above the arcus marginalis. Direct fat
grafting is then performed through a 20-gauge needle to fill
the deformity directly within the orbicularis muscle and
slightly caudal to the infraorbital rim (Figure 10). He
emphasized that fat grafting must not extend past the
lateral one-third of the orbital rim, as the thin skin in
this area is more prone to contour irregularities. Addition-
ally, he prefers to inject fat harvested from the lateral
hip or thigh, which he observed is often more dense and
firm than fat from the abdomen, thus making it more suit-
able for the tear trough area. After skin redraping and
closure, any irregularities are massaged with finger pres-
sure or a blunt instrument. Secondary revisions can be
performed as needed with either HA filler or percutaneous
lipoinjection. Overall, he reported that two-thirds of
patients demonstrated good to excellent results with this
technique.
Periorbital Skeletal Augmentation
Several studies have identified age-related changes in the
bony orbit. These changes are clinically evident at the
436 Aesthetic Surgery Journal 32(4)
Figure 11. Yaremchuk infraorbital rim implant.
Adapted from: Yaremchuk MJ, Kahn DM. Periorbital skeletal
augmentation to improve blepharoplasty and midfacial
results. Plast Reconstr Surg 2009;124(6):2151-2160.
inferior orbital rim and lead to a loss of midfacial skeletal
projection.62-65 Tear trough deformities can be accentuated
by atrophy and/or descent of midfacial soft tissue, com-
bined with infraorbital rim retrusion. Therefore, periorbi-
tal skeletal augmentation is another method of treating the
tear trough deformity. Yaremchuk recommends infraorbi-
tal periorbital augmentation for improvement of the globe-
lid relationship, cheek deflation, lower lid lengthening,
widened palpebral fissures, and the anterior outline of the
lid-cheek junction.66,67 In patients with a negative-vector
globe/orbital rim relationship, the implant can serve as a
stable, supportive framework from which suspension of
the cheek soft tissues can be advanced (Figure 11).68
Redraping soft tissues over the implant further aids in
disguising the tear trough deformity.
Flowers recommends examining the tear trough with
the side of ones finger. If a bony furrow is evident, then a
direct tear trough (suborbital malar) implant is advised for
correction.1,69 His technique involves placement of the
implant in a subperiosteal pocket accessed through a
blepharoplasty incision, a transconjunctival incision, a
transoral approach, or a direct incision if skin and festoon
reductions are also required. Subsequent to implant place-
ment, fixation is accomplished with either a self-tapping
screw or a 6-0 Vicryl suture (Ethicon, Inc.; Somerville, NJ)
secured to the periosteum. After identification of the
infraorbital nerve, an eyelet section is removed from the
implant to ensure that pressure is not applied directly over
the nerve (Figure 12). Closure is completed with a lateral
canthopexy and insertion of a closed-suction drain that is
removed one day postoperatively.
Terino and Edwards70 reviewed their experience with
an extended suborbital tear troughmalar implant.
Excellent contouring of the lid-cheek junction was accom-
plished in all cases. The most common complications
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Figure 12. Flowers infraorbital rim augmentation.
Adapted from: Flowers RS, Nassif JM. Aesthetic periorbital
surgery. In: Mathes SJ, ed. Plastic Surgery. Vol 2.
Philadelphia, PA: Saunders Elsevier; 2006:77-126.
were chemosis and self-limiting lower eyelid retraction.
Furthermore, there were no reported symptoms related to
the infraorbital nerve.
Authors preferred surgical technique. The tear trough
deformity is marked with the patient in a seated position
before induction of general anesthesia. After induction,
2% lidocaine with epinephrine is injected into the lower
eyelid to the level of the tear trough and lid-cheek junc-
tion. As described previously, we prefer a transcutaneous
subciliary approach, with development of a skin-muscle
flap in a stair-step approach, leaving the pretarsal orbicu-
laris muscle undisturbed.71 Dissection then proceeds
anterior to the orbital septum to the level of the infraorbi-
tal rim. The medial origin of the orbicularis muscle is
released from the maxilla, with lateral extension through
the orbitomalar ligament in the supraperiosteal plane by
cutting cautery. We believe that the supraperiosteal plane
more effectively releases the medial insertion of the
orbicularis and orbitomalar ligament attachments. After
confirmation of the tear trough depression, a small strip
of orbital septum is excised. A conservative resection of
fat from all three lower lid compartments is performed on
an individualized basis. The resected fat is kept in a moist
sponge for possible later fat grafting. The medial and cen-
tral fat pads are then transposed caudally into the
supraperiosteal dissection plane. With appropriate supra-
periosteal dissection, the senior author (MAC) has found
suture fixation unnecessary. In cases of residual depres-
sion, the previously-excised orbital fat is minced with
scissors and placed directly into the defect as free fat
grafts (Figure 13). We routinely advocate providing lat-
eral canthal support and have previously reported
excellent postoperative lid contour with this technique.72
To complete the procedure, the skin-muscle flap is
Stutman and Codner 437

Figure 13. The senior authors (MAC) preferred technique with fat transposition and free fat grafting.

redraped with conservative excision of preseptal orbicu-
laris muscle and lower lid skin (Figure 14).
A video of the surgical procedure is available at www.
aestheticsurgeryjournal.com. You may also use any smart-
phone to scan the code on the first page of this article to
be taken directly to the video on www.YouTube.com.
Potential Surgical Complications
While there are several options for surgical correction of
the tear trough deformity, as described, all can be success-
ful in the right hands. Each technique has a learning
curve, and each has its own advantages and disadvan-
tages. All of these techniques should be considered more
advanced and complex procedures, beyond the scope of a
traditional blepharoplasty alone and with longer recovery
periods. All of the techniques listed have potential for
complications, and surgeons are advised to proceed with
caution, as improper technique and patient selection can
lead to poor results and complications. What follows is a
list of common complications.
Chemosis is often reported, due to a combination of
postoperative periorbital lymphatic obstruction and dry-
ness of the conjunctiva. Mild to moderate chemosis is
often successfully treated with antiinflammatory and ster-
oid eye drops and ointment. Some patients may benefit
from patching the eye closed to prevent exposure. Severe
chemosis can be treated with the addition of conjunc-
tivotomy and vasoconstrictive eye drops. Persistent che-
mosis is often caused by lid malposition, which must be
treated to correct the chemosis.
Lid malposition can range from minimal scleral show to
ectropion, and it may occur as a result of either transcutane-
ous or transconjunctival approaches. Scleral show can often
be corrected conservatively with early postoperative lid mas-
sage and taping. Postoperative ectropion should be classified
as either early (first postoperative week) or late (first postop-
erative month). Early ectropion is the result of canthopexy/
canthoplasty fixation failure, and treatment requires early
surgical correction. Late ectropion will usually present with
gradual worsening over the course of the first or second
month postoperatively and is a result of anterior or posterior
lamellar scarring. The level of scarring can be evaluated by
attempting to manipulate the lower lid with the examiners
finger. If the lower lid can be elevated and is mobile, the scar-
ring is within the anterior lamella. However, if the lower lid
cannot be manually elevated and is fixed to the orbital rim,
the scarring is within the posterior lamella. Treatment of late
ectropion should initially start with a trial of six to eight

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438 Aesthetic Surgery Journal 32(4)

Figure 14. (A) This 29-year-old woman presented for correction of tear trough deformity. (B) Four months after bilateral lower
blepharoplasty with fat transposition and free fat grafting with skin-muscle flap (authors preferred technique).

weeks of conservative management. However, if the ectro-
pion persists, anterior lamellar scarring should be surgically
resected, and posterior lamellar scarring often requires the
addition of a spacer graft.
Overdissection in the nasojugal area should be avoided
and may result in injury to the buccal branch of the facial
nerve. This can result in difficulties with blinking and eyelid
closure or decreased tone of the lower lid, and it may affect
the eyelid pumping mechanism for the lacrimal apparatus.
Persistent dark circles from periorbital hyperpigmenta-
tion are best treated with topical skin care, such as
hydroquinone.
Postoperative edema and ecchymosis are to be expected
in the early postoperative period. Additional dissection
and manipulation of the tear trough may result in more
substantial areas of ecchymosis and edema than those
seen with less extensive blepharoplasty procedures. The
patient should be informed of this possibility preopera-
tively. While the edema and ecchymosis will resolve with-
out treatment, supportive care in the early postoperative
period with ice packs, head-of-bed elevation, abstinence
from salty foods and alcohol, and avoidance of strenuous
activity is advised. The authors also recommend a regi-
men of preoperative and postoperative oral supplements
Arnica montana and bromelain.
Conclusions
Lower eyelid rejuvenation with treatment of the tear
trough deformity can be a challenging endeavor.
Thorough review and anatomic dissection of the anat-
omy has clarified the location and underlying causes of
the deformity. Knowledge of this anatomy, along with a
critical evaluation of surrounding periorbital anatomy, is
essential for proper treatment. Both surgical and nonsur-
gical options exist to correct the tear trough deformity.
While each method has advantages and disadvantages,
the surgeon should base treatment decisions on patient
anatomy and surgical preference. Patients with thick
skin, minimal skin discoloration, and mild to moderate
defects without excessive periorbital fat herniation may
be good candidates for HA filler or fat grafting alone.
However, patients with more pronounced deformities
and fat herniation are often better served by lower eyelid
blepharoplasty and either fat transposition or grafting.
Treatment of patients with tear trough deformity is com-
plex; however, aesthetically-pleasing results are possible
through knowledge of the underlying anatomy and
proper treatment selection.
Disclosures
Dr. Codner receives educational grants and is a paid con-
sultant for Mentor Corporation and receives royalties for
books published by Quality Medical Publishing and
Elsevier Publishing Company. Dr. Stutman has nothing to
disclose.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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