Tear trough treatment guide

The tear trough is a common cosmetic concern that causes a hollow at the junction between the cheek and the lower eyelid. The term “tear trough deformity” refers to a periorbital hollow extending obliquely from the mid-pupillary line to the medical canthus. Depressions that are lateral to this area are known as nasojugal groove, lid-cheek junction, and palpebromalar groove. While sometimes caused by the natural aging process, tear trough deformity is more commonly caused by genetic factors and it usually starts in the patient’s 20s. Being the first thing that others notice, tear trough deformity can be a cause of distress and self-consciousness. Due to the infraorbital hollowing, patients with tear through deformity often have a fatigued and tired look (despite being well-rested). Tear through treatment is a complicated, hard-to-master procedure that requires extreme expertise. At the same time, practitioners performing the treatment should have a good understanding of the rheological properties of fillers.

There are a number of classification systems for tear trough deformity (and its etiology). Tear Trough Rating Scale (TTRS), 1 of these classifications, measures the depth of the tear trough, volume of prolapsed fat, hyperpigmentation, and skin rhytidosis. It allows doctors to quantitatively assess the tear trough deformity and can be used as a tool for managing the patient’s expectations. TTRS helps patients to understand the expected results of a tear trough augmentation treatment. For example, if the degree of pigmentation is higher than the depth of tear through, the patient may be more suited to different treatment approaches, such as topical tyrosinase inhibitors (to be applied on a daily basis) and skin peels. These treatments tend to be more effective in treating pigmentation.

In the following section, we will analyze a case study of a patient treated for tear trough deformity using fillers. We will also discuss about techniques used to rejuvenate the tear through area. 


In a recent case study conducted by Dr. Tayyab Bhatti, a female patient sought to reduce the appearance of a dark line under the eyes. The patient had tried to remedy the dark circles using over-the-counter products, but to no avail. After careful examination, the patient was found to have a clearly demarcated tear trough deformity of mild-to-moderate severity. The deformity appeared more prominent when the patient gazed upward. A palpebromalar groove was also present, further accentuating the dark circles. A degree of skin hyperpigmentation was observed at the under-eye area.

The patient was instructed to sit upright, at a 45° angle, and to keep her eyes open throughout the procedure. This allowed the tear trough to be accurately demarcated.  Teosyal Redensity II (a 15mg/g filler consisting of both non-crosslinked and cross-linked hyaluronic acid) was used in the treatment. Due to its low hygroscopic behavior, the filler is unlikely to swell in the periocular area. The palpebromalar groove was treated using small bolus injections. The physician started from an area 0.5cm lateral to lateral canthus then to the palpebromalar groove. A total of 3 bolus injections was performed along the groove. Using a 30G needle, the dermal filler was injected deep into the internal part of the orbital septum, helping to increase the volume.

Due to the delicate nature of the treatment area, a needle was used to ensure precise administration. Around 1ml of the filler was administered.

Cannula vs needle

In younger patients, injectors tend to prefer serial point injecting using a 30G needle. Patients over the age of 50 tend to respond better to treatment using a 25G or 27G (38mm) cannula, which helps to reduce bruising. Patients should be warned about the risk of ocular blindness, although rare, when receiving tear trough injections. Injury can occur if you do not avoid the angular artery. It is important to assess the patient thoroughly, as anatomical variations can occur.

In the case study, the injector specified that a cannula could have also been used. In this case, the length of the cannula would need to sufficient in order to reach the canthus region. If the cannula shaft is tenting, the injection depth is too superficial.


Due to the risk involved, tear trough treatment should only be performed by qualified, experienced doctors. Inappropriate injection techniques can potentially lead to severe complications such as blindness and necrosis. In order to prevent complications, doctors performing the procedure should be familiar with the injection anatomy.

Disclaimer: These articles, and any views and opinions expressed, are not endorsed by Raskel Medical. The articles are strictly for informational purposes and should not be considered medical advice. Raskel Medical does not check or edit the content of these articles for medical accuracy. Contact your medical practitioner for any medical advice needed.