Dr. Gurnam Virdi-The Art of Perfecting Tear Troughs

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The tear trough deformity is characterised by a sunken appearance of the eye that results in casting of a dark shadow of the lower lid, which in turn creates the illusion of a tired or aged face. Here we look at peri-orbital anatomy alongside various treatment modalities including dermal fillers, skin boosters and PRP.


Varies classifications exist in this field but the most common one is Hirmand classification:

  • Class 1 – volume loss medially
  • Class 2 – extension of volume loss laterally
  • Class 3 – full depression circumferentially along orbital rim

There are also other classifications like Barton and Sadick.

Contraindications in this area are unrealistic expectations, infection near site of injection, known allergy or hypersensitivity to filler\lidocaine and severe elastosis e.g. large eyebags.

You should mark the infraorbital foramen (medial to mid-pupillary line in line with medial limbus below orbital rim. Remember to test the location of this area and insert cannula approximately 4cm diagonally from medical canthus. Lateral entry point is safer, the preferred tool for doing tear trough is 25G cannula.

Patients should avoid strong or extended pressure within the treated area and strenuous exercise/activity after being injected. Immediate complications are pain, erythema, swelling and bruising, asymmetry and migraine. Delayed complications are:

  • Orange-brown staining – deposition of hemosiderin associated with bruising/trauma. Use of pre-treatment ice packs may help
  • Post-inflammatory hyperpigmentation – seen in darker skin types due to bruising/hematoma
  • Puffiness – sue to overcorrection allowing for hydrophilic nature of filler to take effect
  • Infection
  • Tyndall effect – filler injected too superficially
  • Nodules – can occur with superficial infections. Treated with local massage, hyalase or incision & drainage
  • Blindness – rare, due to migration of filler embolus through the central retinal artery

Skinboosters, scaffolding technique, sandwich technique and PRP can also be used for rejuvenating the infraorbital region.