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