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The Tear Trough Deformity
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The Tear Trough Deformity


This presentation explains the various correction and caveats related to using dermal fillers. The intended audience is medical professionals. Dr. Scheiner is a Plastic Surgeon and the President of …

This presentation explains the various correction and caveats related to using dermal fillers. The intended audience is medical professionals. Dr. Scheiner is a Plastic Surgeon and the President of ASAMP (The American Society of Aesthetic Medical Professionals). ASAMP certifies medical professionals for cosmetic injection procedures (Botox; Dermal Fillers) and is accredited through the American Academy of Family Physicians (up to 14 CME credits).

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  • Secondary to age related volume loss as well as relaxation, atrophy & ptosis of the lower eyelid tissues. Also genetic varient in younger patients.Results in an obvious demarcation at junction of lower eyelid and cheek resulting in a sunken or hollowed out appearance. Nasojugal GROOVE.
  • Tear Trough formed at the arcus marginalis-the confluence of the orbital septum with the periostium of orbital rim
  • Light reflection from herniated fat casts a shadow under the eyes-Differentiate between this and hyperpigmented skin or visible underlying muscle color
  • Add volume to achieve the above
  • 20-80 y/o anyone with proper counceling and realistic expectations. May obtain full correction in young, shallow, thick skin. Limited correction in elderly with thin skin, deep groove, abundant herniated fat . M & F. No coumadin, asa, vitamins known to alter bleeding. Dark circles secondary to hyperpigmentation or shadow?Thin skin likely to result in visible product.
  • Young client with minimal depression, thick skin, and light discoloration
  • Poor candidate secondary to extensive herniated fat. Very difficult to overcome this degree of herniation. Best option surgical repair, however, occasional pt will understand limitations and consent to treatment.
  • 15 – 20 minutes. Downtime minimal if no bruising, if bruising may last 10 days. Correction up to 1 year or more with restylane-longer than used in N-L folds. May need 2-3 tx’s-better to be conservative than to risk lumps or discoloration
  • Injecting too superficial may result in the appearance of a blue discoloration of the skin as a result of the Tyndall effect-the scattering of light appearing as blue. Educate client before procedure of this risk-can use concealer and most happy with volume restoration as concealer effective
  • Restylane-L, Perlane-L, Juvederm Ultra XC all have lidocaine-will feel initial injections but as tx progresses lidocaine takes effect. Use gentle technique and speak during injection to help alleviate discomfort.
  • Use fillers with lidocaine prefer restylane as firmer
  • Operator choice and degree of deformity-shallow grooves easier to correct with several serial punctures delivering small aliquots of filler. Deeper grooves require multiple threads. Overall more demanding and less forgiving than N-L folds or Lips—as skin is thin and product may leave bumps or color changes
  • Thin skin lie on top of periostium. Thicker skin can be a bit more superficial. Product may be visible so needs to be deep-not intradermal as in nasolabial fold. Begin inferio-lateral and work superio medical laying down threads or serial punctures. Place finger on inferior orbital rim as you must be cognizant of orbital contents at all times. Massage after each addition of product as it is malleable. Typical volume is 0.2 to 0.5mls.
  • Red discoloration and swelling immediately secondary to trauma of injection resolves rapidly-ice for 24 hours. No asa containing products. No moving material themselves. f/u 10 days to evaluate for lumps and massage as needed
  • Typically charge per syringe for lips /N-L folds, however this is an advanced technique and typically charge more-825. check your own market-cold calls…


  • 1. The Tear Trough Deformity
    Correction & Caveats
    Using Dermal Fillers
    Marc S. Scheiner, M.D.
    Plastic Surgeon
  • 2. The Tear Trough
    Triangular Shaped Defect of the lower eyelid
  • 3.
  • 4. Presentation
    Fatigued Appearance
    Sunken Eyes
    Dark Circles under eyes
    Puffy Eyes
  • 5. Treatment Goals
    Soften, Refresh, Rejuvenate
    Restore Volume
    Improve dark circles
  • 6. Patient Selection
    Realistic Expectations
    Medication Review
    Careful Evaluation of “Dark Circles”
    Thin vs. Thick Skin
  • 7. Excellent Candidate
  • 8. Caution!
  • 9. Pre-Treatment Discussion
    Relatively Quick Procedure
    Length of Correction
    Multiple Treatments?
  • 10. Tyndall Effect
  • 11. Anesthesia
    Topical Lidocaine (EMLA)
    Filler with Lidocaine
  • 12. Products
    Hyaluronic Acid Fillers
    • Restylane®-L
    • 13. Juvederm® Ultra XC
    • 14. Perlane®-L
  • Technique
    Serial Puncture
    Multiple Threads
  • 15. Depth of Injection
    Lateral to Medial
  • 16. Complications
    Bleeding, Bruising, Swelling
    Tyndall Effect
    Overcorrection/Under correction
  • 17. Lumps & Bumps
    ~5% Incidence
    Most resolve quickly
    May require massage at follow-up
  • 18. Results
  • 19. Conclusion
    Additional Products