History

While traditional lower lid blepharoplasty has been performed in order to improve the periorbital region, the tear trough deformity should be considered a separate anatomical subunit of the lower periorbital aesthetic unit. One of the unique aspects of the tear trough deformity is that while it may be age related, the dark appearing groove associated with the deformity is often present in young patients with no other signs of periorbital aging (Fig. 31.1). The “tear trough deformity” was reportedly first named by Flowers in 1969 when he “[noticed] how a shed tear often tracks the course of this groove…” Flowers also credited Loeb who earlier, in 1961, adopted the descriptive term “nasojugal groove” from the ophthalmology literature by Duke-Elder. During the decade that followed, the terms became synonymous and both Loeb and Flowers published elegant surgical techniques aimed at correction of the deformity. Since it became apparent that fat removal was not successful at correcting the tear trough deformity, techniques evolved which were specifically aimed at correction of the tear trough deformity. Early techniques by Loeb in 1981 included fat pad sliding and fat grafting, while Flowers used orbicularis muscle plication, fat translocation, and subgaleal grafts. Disappointment with resorption of autogenous grafts led Flowers to develop alloplastic tear trough implants by 1993.

Fig. 31.1 Surface contour deformity demonstrating the tear trough deformity.

In 1995, Hamra described the signs of the aged orbit as hollow, sunken and concave which were often made worse by traditional techniques of fat removal. The arcus marginalis release with preservation of orbital fat was introduced which combined release of the septum, elevation of the orbicularis, and use of all the orbital fat pads as vascularized flaps to add volume to the orbital rim. The technique of zygorbicular dissection could be performed during composite rhytidectomy or as an isolated procedure for periorbital rejuvenation. Barton in 2004 refined the septal reset technique described by Hamra in order to focus more specifically on correction of the tear trough triad which included herniation of orbital fat, tight attachment of the orbicularis, and malar retrusion. The importance of creating a youthful eyelid–cheek junction was gaining attention and alternative, perhaps less invasive, methods were developed. Golberg performed transconjunctival orbital fat repositioning into a subperiosteal pocket to correct the tear trough, and Kawamoto described the tear TROUF procedure which is an acronym for transconjunctival repositioning of orbital unipedicled fat into a more superficial submuscular pocket. While the potential advantage of a transconjunctival approach may be fewer complications, the disadvantage is that the anterior lamella is not directly treated.

In addition to surgical correction, the tear trough deformity has been treated by the addition of volume by periorbital injection of soft tissue fillers including autologous fat and hyaluronic acid. Coleman has utilized autologous fat injection in the periorbital region and emphasized the importance of using blunt needles to minimize the risk of blindness from embolization of the central retinal artery. Kane and Hirmand have reported good results using hyaluronic acid to treat the tear trough. While the less invasive aspect of fillers is an advantage, they may not be sufficient to optimally correct the deformity in all patients. The purpose of this chapter is to discuss both surgical and non-surgical approaches to blend the lid–cheek junction and to improve the tear trough deformity.

Physical evaluation

Fig. 31.2 The canthal tilt is demonstrated as the anatomical relationship of the medial and lateral canthus.

Anatomy

Flowers described the tear trough deformity as the triangular shaped defect between the angular head of the quadratus labii superioris muscle and the orbicularis muscle. There is often associated deficiency of the infraorbital rim which Rees described as bony deficit below the normal rim or suborbital hypoplasia. The presence of excess orbital fat often disguises the tear trough deformity and distracts the surgeon’s attention. Since removal of excess orbital fat does not correct the tear trough, simulation of fat removal with retropulsion of the fat superiomedial to the tear trough clearly defines the anatomy of the defect. The defect can be considered a depression bordered by orbital portion of the orbicularis oculi, the levator labii superioris, levator alaeque nasi muscles (Fig. 31.3). Since there is little subcutaneous tissue between the skin and the orbicularis muscle, the tear trough is comprised of thin skin at the junction of eyelid, nasal and cheek skin with attenuated subcutaneous tissue overlying the maxilla. The tear trough can therefore be considered a defect of the anterior lamella with underlying bony contributions. The formation of the tear trough deformity is often one of the first signs of aging around the eyes. The concavity in the nasojugal groove is often associated with apparent fat herniation above or it may present independently. There is individual variation in depth and morphology of the tear trough and periorbital hollows along the rim. In order to devise the optimal correction for the tear trough, understanding the anatomy of this area is critical.

Fig. 31.3 Anatomic landmarks in the tear trough/medial periorbital region as it correlated to the surface deformity.

The orbicularis oculi muscle has a direct attachment to the inferior orbital rim from the anterior lacrimal crest to the medial limbus or approximately 30% of the length of the rim. Lateral to this, the attachment to the bone is via the orbicularis retaining ligaments (ORL) which have variable length at different points along the inferior orbital rim. The length increases to a maximum centrally and then decreases laterally until the ORL merges with the lateral orbital thickening in the lateral canthal region. The levator labii superioris originates just below the orbicularis oculi muscle attachment to the medial orbital rim (Fig. 31.4). It is along the attachment of the orbicularis oculi muscle to the orbital rim that the tear trough deformity first manifests as a concavity that gets deeper with time. The tear trough deformity is at the inferior orbital rim most medially but very quickly falls below the rim, with the maximal distance from the rim occurring centrally. The hollowing can continue laterally in more advanced aging, presenting at or just below the orbital rim, where the retaining ligaments are thicker and less distensible.

Fig. 31.4 Anatomic dissections in the tear trough region showing the orbital rim (OR), orbicularis oculi muscle (OO), orbital fat (OF), suborbicularis oculi fat (SOOF), levator labii superioris (LLS) near its origin, through a window made in the SOOF.

(From: Zide BM. Surgical anatomy around the orbit. Lippincott, 2006, with permission.)

Clinically, the periorbital pattern of volume loss is categorized into three classes. Class I is limited to the tear trough or medial orbit. These patients sometimes show very mild flattening of the central area along the orbital rim in a reverse triangular pattern. Class II patients exhibit volume loss laterally as well as medially and they may have mild volume deficiency in the medial cheek and mild flattening of the central triangle. Class III patients exhibit a depression circumferentially along the orbital rim in a full and continuous pattern of hollowing medially to laterally (Fig. 31.5). This pattern is often associated with more advanced volume deficiency in the medial cheek, central reverse triangle, and malar eminence as well as demonstrating an oblique cheek crease highlighting the malar bags superiorly. The depth of the tear trough is used to estimate the volume required for correction with injections. Deeper and more extended patterns of volume loss (Classes II and III) can be associated with relative medial cheek/midface flattening, malar volume loss, as well as possible volume loss in the temporal region, brow and lower face.

Fig. 31.5 Classification of morphology of the periorbital volume loss patterns. Class I: limited to the tear trough or medial orbit (sometimes associated with very mild flattening of the central area). Class II: medial and lateral depression apparent (can be associated with mild volume deficiency in the medial cheek and mild flattening of the central triangle. Class III: full depression visible circumferentially at the orbital rim (often associated with more advanced volume deficiency in the medial cheek, central reverse triangle/midface and malar eminence, as well as the oblique cheek crease extension highlighting the malar festoons).

Technical steps

Surgical correction of the tear trough deformity

The goal of correction of the tear trough deformity therefore utilizes an anatomical approach by adding volume to the soft tissue deficiency. The fundamental techniques are performed at the time of lower blepharoplasty, and should be considered an adjunct to standard lower blepharoplasty. The technique should be performed on an individualized basis rather than as a routine part of lower blepharoplasty. In addition, correction of the tear trough deformity and blending the lid–cheek junction can be performed in a less invasive manner through the use of fillers. The principle of volume enhancement is achieved with both techniques. Patients who have isolated tear trough deformity without fat, skin or muscle excess who are otherwise not good candidates for lower blepharoplasty should be considered for treatment with injection of soft tissue fillers. Patients with more advanced signs of periorbital aging including fat excess and midfacial descent in addition to the tear trough deformity should undergo surgical correction of the tear trough deformity.

The tear trough procedure is performed utilizing an open transcutaneous lower blepharoplasty approach in order to address all of the anatomical changes in the periorbital region including the anterior and posterior lamella. While the procedure is aimed at correcting the anterior lamella, lateral canthopexy is a crucial aspect of the technique. Surgical correction of posterior lamellar tarsoligamentous laxity is required in order to prevent lower lid malposition thereby allowing the tear trough procedure to be safely performed. The technique can be performed under conscious sedation or general anesthesia. Corneal protectors are used and a lower blepharoplasty incision is made under the lash margin and within a crow’s foot line lateral to the canthus. A generous strip of pretarsal muscle is preserved by stair-stepping the transverse incisions separately below the lid margin ending inferior to the punctum. The skin muscle flap is elevated by placing a Blair retractor on the lid while dissecting with electrocautery in the avascular plane anterior to the septum to the level of the infraorbital rim.

The lid–cheek junction is addressed by volume redistribution of the orbital fat combined with muscular release of the tear trough, ligamentous release of the orbitomalar ligament, and vertical elevation of the orbicularis oculi (Fig. 31.6). The initial release of the orbitomalar ligament is performed with supraperiosteal dissection along the semicircle of the infraorbital rim from lateral canthus to the level of the infraorbital nerve. Care is taken to preserve the zygomaticofacial and infraorbital sensory nerves. Approximately 10 mm of inferior dissection is performed in order to release the orbitomalar ligament and elevate the SOOF with the skin muscle flap. Superior elevation of the SOOF and inferior transposition of the orbital fat across the rim create anatomical blending of the orbital and midfacial fat compartments. Rather than using the septum to accomplish this, subtotal septectomy is performed to reduce the risk of postoperative septal scarring and to allow the two separate fat compartments to merge. For more advanced midfacial aging, malar fat pad descent and malar bags, a more extensive subperiosteal midface lift may be performed.

Fig. 31.6 The orbitomalar ligament is shown on cross section separating the orbital and suborbicularis oculi fat (SOOF).

The central and lateral fat compartments are sutured with 6-0 Vicryl to the preserved periosteum below the rim to cover the infraorbital rim and add volume to the suborbital deficiency. Additional dissection of the tear trough is required in order to transpose the central and medial fat pads into the nasojugal groove. An insulated Desmarre retractor is used to expose the medial orbital rim to the level of the anterior nasolacrimal crest. Careful release of the origin of the orbital orbicularis oculi from the orbital rim is performed with low power electrocautery superficial to the periosteum. Dissection continues for 5 mm until the muscular triangle of the tear trough deformity is reached to create the pocket for fat transposition. The ligamentous attachments of the anterior lamella overlying the tear trough are released. Dissection should be limited in order to avoid injury to the buccal branch of the facial nerve which is medial to the tear trough at the level of the angular artery (Fig. 31.7). Stimulation of the levator labii or alaeque nasi with the electrocautery causes twitching of the upper lip and should be considered a sign of overdissection.

Fig. 31.7 The buccal branch of the facial nerve innervates the medial orbicularis muscle and dissection in the area of the tear trough should be cautious to avoid buccal branch injury.

Once the tear trough has been released, the nasal fat pad is transposed into the muscular triangle and sutured to the periosteum with 6-0 Vicryl (Fig. 31.8). Additional volume can be added by suturing a portion of the central fat pad taking care to avoid traction on the inferior oblique muscle. While ligamentous release and volume enhancement are key aesthetic principles of the procedure, tightening the anterior lamellae in a superolateral vector is the final step of the technique. In order to safely perform this step, the principles of separate points of bony fixation for the anterior and posterior lamellae respectively are followed. A lateral canthopexy is performed using a 4-0 double armed Mersilene suture placed through the tarsal plate and lateral retinaculum which is then anchored to the periosteum of the lateral orbital rim at the preoperative level of the lateral canthus which is most commonly at the level of the pupil (Fig. 31.9). Positioning of the lateral canthopexy suture is important in order to prevent complications and preserve preoperative eyelid shape. Following lateral canthopexy, the skin muscle flap is elevated as the orbicularis is sutured to the lateral orbital rim periosteum. Multiple points of orbicularis suspension with 4-0 Vicryl are performed in order to achieve the desired aesthetic result while minimizing the risk of lid retraction from anterior lamella scarring in the postoperative period. Conservative skin removal along the lid margin is also important in order to minimize the risk of complications and the skin is closed with 6-0 fast absorbing sutures.

Fig. 31.8 Surgical correction of the tear trough procedure is illustrated by transposition of orbital fat.

Fig. 31.9 Lateral canthopexy is an important part of lower blepharoplasty and correction of the tear trough in order to reduce the risk of lid malposition.

Non-surgical correction of the tear trough deformity

Surgery may not be the best option for young patients in the early stages of tear trough formation, or for a patient who had previous blepharoplasty with worsening of the periorbital hollowing. Non-surgical correction of the tear trough deformity, though an appealing alternative, was limited in the past due to a lack of appropriate fillers. Prior to the advent of injectable hyaluronic acid, autologous fat was the best filler for the periorbital region. Fat remains a useful tool for volume augmentation in patients with thick overlying skin and good elasticity with generalized orbital volume deficiency.

Fat transfer for correction of the tear trough deformity

Our preferred technique consists of transfer of very small amounts of autologous fat in multiple passes and over multiple sessions, if necessary, without significant overcorrection at each transfer. A preoperative map is marked in the intended areas which includes the estimated volume requirement. Light sedation is recommended for patient comfort both during harvest and injection; however, the procedure can be done entirely using local injection and regional facial nerve blocks. Use of extensive amount of local in the areas of fat transfer should be avoided as distortion will result making contour assessment less precise. Fat is harvested from the abdomen, hips or thighs using 10 ml syringes and a 2.4 mm Luer lock Mercedes cannula. The fat is centrifuged for approximately 3 minutes at 3000 rpm to separate the aspirate and the fat layer is isolated. Injection is performed using 1 ml Luer lock syringes and blunt 19 G cannulas in 0.05 to 0.1 ml aliquots in multiple passes. Average volumes injected are typically 1–2 ml per lower lid/tear trough and 2–3 ml in the midface. Extensive pre-procedure counseling is performed to the patient about the possible postoperative ecchymosis and edema. The need for multiple treatments is also discussed. Care should be taken not to overcorrect more than 5–10% with plans to repeat the fat transfer over the course of a year as needed. The most common areas treated are the tear trough and the lower lid/lower periorbital area and the midface and malar eminence. The disadvantages of fat injections include the need to harvest the fat, as well as the labor intensiveness of the preparation. Autologous fat has thick particulate consistency with flow characteristics which can increase the risk of lumpiness and long-lasting irregularities. Furthermore, prolonged edema and the need to overcorrect due to variable resorption are additional disadvantages. The advantage is a more long lasting correction.

Hyaluronic acid for correction of the tear trough deformity

Hyaluronic acid has the advantages of gel consistency and favorable flow characteristics, easy availability, and reversibility which make it preferable to fat for the tear trough. The longevity of the effect in this area is acceptable with the stability up to six months on average followed by a slow decrease during the second six months. While patients are informed that the correction lasts approximately 12 months, it is not uncommon to have lasting effect up to two years in some patients. The best candidates are Class I patients with good skin tone and minimal skin laxity with minimal tear troughs and periorbital hollowing. This procedure has excellent utility in post-surgical patients who have an uncorrected tear trough or overresected orbital fat. In addition to the tear trough, injection may be required in the central reverse triangle and the malar eminence. The areas to be treated are marked prior to the procedure to outline a road map for the injections.

The area of the concavity to be filled is marked with the patient in a sitting position at approximately 90 degrees. Upward gaze accentuates the deformity and delineates the borders of the tear trough. Bilateral infraorbital nerve block is performed with short acting bupivacaine or longer acting 1% lidocaine with epinephrine. A zygomaticofacial nerve block and direct infiltration of local anesthetic can be used to block the malar and lateral orbital areas.

The periorbital area is treated with cold packs before and after the procedure for five minutes. The face is cleansed with clear surgical prep solution and the procedure is performed with the patient in a sitting position.

Small volumes, approximately 0.01–0.05 ml, of hyaluronic acid are delivered using a sterile 30 G inch stainless steel blunt cannula introduced through a 25 G needle hole along the orbital rim as marked (Fig. 31.10). Alternatively, a 30 or 32 G needle can be utilized. The injections should be deep just superficial to the periosteum and deep, to the orbicularis oculi. Centrally, the orbitomalar ligaments are longer so the injection is performed in the deep subcutaneous plane. Hyaluronic acid is injected discontinuously in the deformity medial to lateral, while withdrawing the cannula. In order to minimize bruising, blunt release of the ligaments with the needle is not recommended. Typically 2–3 entry sites are used medially and centrally, and 1–2 entry sites are used laterally. Gentle massage is performed after the delivery, as needed, to disperse the filler in the intended location. Since there is little early resorption of hyaluronic acid, overcorrection is not performed. In specific instances, very superficial subdermal injection using a 32 G needle is performed to “lift” the overlying skin. This is usually a “spot’ application over a 1 or 2 mm surface area.

Fig. 31.10 Delivery technique with blunt cannula. A, Cannula inserted in the supraperiosteal plane in the medial aspect of the tear trough. B, Shows the medial half of the tear trough treated with filler and the lateral half or the central portion, which includes the triangular central apex, untreated with apparent concavity. This patient also exhibits volume loss laterally as well as in the medial cheek/midface just inferior to the tear trough area.

The most common volume injected to the tear trough is in the range of 0.2–0.5 ml on each side. The 30 G blunt cannulas were introduced to eliminate inadvertent intra-arterial injection. Additional advantages of the blunt cannula include less bruising, fewer entry sites, and use above the orbital rim near the globe for correction of post-blepharoplasty fat overresection.

Postoperative care

The postoperative care for the tear trough procedure is similar to routine care following lower blepharoplasty. Liberal use of icepacks for the first 24–48 hours and ophthalmic ointment and drops to prevent corneal dryness during the first postoperative week should be performed. In addition, in order to minimize bruising and swelling, postural elevation, avoidance of sodium, and perioperative arnica montana and bromelain are suggested. Sutures are removed at 5 days after surgery and the patient is allowed to resume limited activity with return to full activity by 2 weeks. Sunglasses and sunscreen are important to avoid periorbital hyperpigmentation and sun damage. Following injection to the tear trough, patients are instructed to use gentle digital pressure if areas of edema or irregularity persist after the first few days. Generalized massage is not recommended. Regular makeup, skin care can be resumed and camouflage makeup can be applied immediately. Cold packs in the hours following the procedure help reduce edema.

Complications

A ten-year review of lower blepharoplasty using this technique has determined that chemosis is the most common postoperative complication. Chemosis occurred in 12% of patients and was not significantly associated with the addition of the tear trough procedure. Chemosis is conjunctival edema which is caused by a combination of postoperative periorbital lymphatic obstruction and dryness of the conjunctiva. Chemosis was treated with a combination of anti-inflammatory and steroid eyedrops and ointments as well as patching the eye closed to prevent exposure. Severe chemosis required conjunctivotomy and vasoconstrictive eyedrops. All patients with chemosis resolved with conservative treatment unless lid malposition was present. Lid malposition requires correction in order for chemosis to resolve. Lid malposition ranges from scleral show to ectropion and may occur after transcutaneous or transconjunctival lower blepharoplasty. The incidence of scleral show was 8.7% and often resolved with conservative management including lid massage and taping for support during the perioperative period. The incidence of frank ectropion has been significantly reduced with the use of routine canthopexy and occurred in 0.8% of patients. Early ectropion during the first postoperative week indicates technical failure of the canthopexy suture and should be surgically revised immediately. Gradual ectropion which occurs during the first postoperative month is due to anterior or posterior lamellar scarring. Anterior lamellar scarring is present when the lower lid is mobile and can be superiorly elevated while posterior lamellar scarring causes lower lid fixation to the orbital rim. If lid position does not improve after 6–8 weeks of conservative treatment, surgical correction should be performed and posterior lamellar spacer graft considered. Persistent dark circles following surgery may be due to periorbital hyperpigmentation which does not improve with surgery or filler injections. Gradual lightening may be performed with hydroquinone as part of a skin care program.

The most common complication following injection to the tear trough is ecchymosis which occurs in up to 50% of patients and is usually limited to injection sites. Variable but subtle edema is not uncommon with resolution by 2–3 weeks. The most bothersome complication is visible surface irregularities or a blue color to the thin skin overlying the tear trough in some patients known as the Tyndall effect. Patients who are professionally photographed may have skin surface deformities which are only visible temporarily during flash photography and should be forewarned. Overall, the complication rates associated with non-surgical and surgical management of the tear trough procedure have been very acceptable. The aesthetic results which can be achieved represent a significant improvement compared to traditional methods of lower blepharoplasty with the clear advantage of blending the lower lid and the cheek thereby creating a more youthful and naturally shaped eyelid (Figs 31.11, 31.12).

Fig. 31.11 A–D, Results of surgical correction of the tear trough.

Fig. 31.12 A–D, Results of non-surgical correction of the tear trough deformity.