tear trough

Many factors can complicate treating tear trough deformities using facial fillers. A recent Taiwanese study identifies an algorithm to simplify this process.

As we age, our skin begins to lose its moisture and elasticity, thins out, and much of the soft tissue begins to atrophy.  Unfortunately, in the aging face, these changes don’t happen in a uniform fashion; some areas undergo atrophy in greater degrees than others, hence the characteristics of an “old face”.

Countless patients consult their plastic surgeons or dermatologists for what has been called the “tear trough” deformity. The tear trough deformity refers to the loss of fullness that occurs under the eyes and continues down just lateral to the nose, in the direction where tears fall. Some approaches to address these deformities include filling in or replacing the lost bulk, which involves injecting fillers made of hyaluronic acid. This is the most popular procedure because hyaluronic acid injections can be safely done in the clinic, without the downtime that may arise from surgery.

Difficulty treating the tear trough

The results after treating the tear trough are not perfect because there are many factors to take into consideration. It is not as simple as puttying up the notches in your drywall; fillers injected “just to fill in the gaps” leads to mediocre outcomes.

The face is essentially a dynamic mechanism, where muscles can pull different structures in different directions. External forces like gravity also affect where the injected filler can settle down. Among some of the possible unpleasant outcomes includes the filler going into unintended areas, or that deformities can be magnified when one squints or smiles.

Devising an algorithm to create standard treatment protocols

Recognizing these different factors, Taiwanese doctors have devised an algorithm to create standard treatment protocols for the tear trough. Published in the January 2018 edition of the Journal of Cosmetic Dermatology, the protocol categorizes patients according to whether the presenting appearance is due to loss of bulk (atrophy), bulging areas, or looseness of skin (laxity).

A simple six-step evaluation determines which categories the patients fall under, which can be determined by moving the skin both passively and actively to identify the predominant deformity. Each category, in turn, has specific protocols regarding where to inject, how deep to inject, and how much to inject.

The physicians hope that the proper categorization of these patients, as well as the proper injection protocols, will lead to better results from hyaluronic acid injections. The next step is to validate this algorithm by testing it on more patients. If the results pan out, this may mean outcomes that will lead to fewer tears over the tear trough.

Written by Jay Martin, M.D.

Reference:  Peng, P.H., Peng, JH.  “Treating the tear trough:  A new classification system, a 6-step evaluation procedure, hyaluronic acid injection algorithm and treatment sequences.”  Journal of Cosmetic Dermatology. 11 January 2018.  DOI:  10.1111/jocd.12514.

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