Should we stop injecting tear troughs with dermal filler?

Dr Tim Pearce is regularly asked about a video by Dr Gavin Chan from the Victorian Cosmetic Institute in Australia entitled – Why I stopped filling tear troughs.

Although Dr Chan’s video is a fantastic breakdown of an important topic; in this blog, Dr Tim will explain why, despite the case presented, he chooses to still inject tear troughs with dermal filler. If you treat this area, and worry about getting it wrong, then keep reading as we explore everything from puffiness and filler longevity to complications and things not to do when injecting the tear trough.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.

Why do we treat tear troughs to soften dark circles and shadows under the eye?

Before we dive into the issues surrounding tear trough fillers, it is worth reflecting on the value and benefit to patients from treating their tear troughs.

They say that the eyes are the ‘windows to the soul’, they are the centre point of communication and beauty. Thus, being able to provide your patients with a good result and soften the shadows under their eyes to improve what they believe they are communicating about their health, age, and emotional status can be extremely impactful. Darker shadows under the eyes are associated with tiredness, getting old, and being angry or grumpy, which can impede a person in their non-verbal communication with others, going on to affect their psychological state, their behaviour, and their ability to survive and thrive in society.

Dr Tim notes that there is no argument that the results are worth striving for, but the video by Dr Chan calls into question whether we are likely to get the results we are trying to achieve, and at what expense. For all the reasons that a great result is particularly valuable, a poor result, side effect, or complication is proportionally upsetting for the patient. Therefore, as aesthetic clinicians, we must consider this cosmetic intervention carefully.

The arguments for and against treating tear troughs with filler

Reviewing Dr Chan’s video, Dr Tim noted several core concepts put forward in opposition to treating the tear troughs.

What you see immediately after a tear trough treatment is not a true result.

There is no room for error with this treatment – with a dermis only 0.2mm in thickness, in an area that we look at the most, with products that grow unpredictably over time due to their hydrophilic nature, and a goal for perfection – it all makes for a blind tightrope walk. The problem is therefore one of injection precision and the predictability of products over time. Dr Tim notes that, like Dr Chan, he started treating tear troughs before the availability of less hydrophilic products, and thus early experiences were less rewarding as they used larger volumes (1-2ml), products swelled adversely, and often resulted in a need for dissolution. With the advent of better-quality products, Dr Tim believes a less is more (volume) approach can achieve the results desired.

Fillers last longer than we think they do.

Based on long-standing published research by Australian radiologist and aesthetic doctor, Dr Mobin Master, Dr Tim has also noticed that some patients get a much longer-lasting result from dermal filler products than others, in some cases years would go by and they would not need retreatment.

Watch Dr Tim Pearce’s interview with Dr Mobin Master from 2020, looking at how long dermal filler really lasts.

Dr Master has shown with MRI studies that filler product can remain up to twelve years after placement. This may sound perfect (and economical) for some patients, but in tear troughs, it presents a risk of creating a visible ‘bag’ requiring dissolution if product remains and/or migrates, causing unforeseen swelling long after it was expected to have been metabolised.

Filler placed behind the orbital septum.

In his video, Dr Chan reflects on a case of tear trough puffiness which was resistant to treatment (dissolving). Dr Master’s MRI studies established that the reason for this was because the filler had been placed behind the orbital septum – this is also covered in Dr Tim’s interview with Dr Master. The orbital septum is a very thin membrane that forms a barrier protecting the orbit from the external aspects of the face, particularly in relation to hyaluronidase application.

Considered rare, but much discussed, Dr Tim believes we need to further research and gather much more data on this complication before we truly understand what is happening, and how common post-septal filler placement is for patients receiving tear trough treatments. It is certainly something he is very conscious of when delivering his own tear trough and periorbital rejuvenation training with the team at SkinViva Academy where he guides his students so they do not inject into the orbit.

The tear trough shadow is caused by the tear trough ligament.

If this is always the case, the argument goes that adding volume is a flawed strategy.

Dr Bryan Mendelson, an aesthetic facial plastic surgeon from Melbourne, Australia was interviewed in Dr Chan’s video discussing the discovery of the tear trough ligament. Dr Tim agrees that in a very young person presenting with a tear trough shadow, treating the area as if it is due to volume loss will likely result in filler spreading either side of the ligament, as also concluded by Dr Chan.

However, Dr Tim believes that this is only in relation to one patient cohort – young patients where the tear trough ligament in the primary cause of the shadow, thus he does not see the presence of the ligament as a reason why we cannot expect to achieve a good result with tear trough filling.

In fact, he goes on to note that any of the signs of ageing that we treat are essentially the shadows and disruptions caused by the ligaments within the face – e.g., nasolabial folds, temple and cheek hollowing are all related to ligamentous attachments beneath that become visible with age, and we treat them routinely with good results, so why not tear troughs?

Dr Tim therefore believes that we can separate tear trough shadows into primary and secondary manifestations – in a young patient, the primary cause of shadowing can be a tight ligament, present since youth, and these are not the ideal patient for aesthetic clinicians because filler is a bad solution to their problem. Secondary tear trough shadows that develop with age are a much better candidate for filler treatment.

In these cases, the shadowing is caused by age-related disruptions in the relationships between several fat pads and the ligament. The ligament increasingly becomes a visible boundary between fat compartments that hypertrophy or atrophy with age at different rates.

There are multiple fat compartments around the eye that can contribute to the tear trough shadow – post septal (orbital) fat that often herniates from the orbit with age and creates shadowing, the sub orbicularis oculi fat (SOOF) that can atrophy with age and cause a shadow, and the medial cheek fat pad that sometimes atrophies, again causing shadowing.

All these patterns of light and shade are darkest where we find the tear trough ligament, but if they are age-related, the true, underlying cause is the altering balance of the fat pads (volume) and not the ligament.

The take home message must be that you should not attempt to remove the tear trough from individuals in the prime of life, unless there is a relatively depleted fat pad that you can replace (with filler); lifting the ligament will not work and surgical options will give much better results for such patients.

Dr Gavin Chan demonstrates a good test which uses gentle compression of the area beneath the tear trough ligament using a cotton bud that can show how raising the fat pad, as it meets the ligament, affects the shadow. Where the ligament is the primary cause of a shadow, you will see little improvement, and rarely a slight see-sawing of the fat compartments where there is a bulge on the other side but no improvement in the depth of the shadow.

Top tips for treating tear troughs with dermal filler

In conclusion, Dr Tim believes that with good patient selection and a very healthy fear of adding too much volume in the tear trough, good results can be enjoyed. With a good consultation, and thus appropriate patient selection, it should become rare to treat the tear trough in isolation, because with small adjustments in the cheek, both laterally and medially, it should result in only very small volumes being required near the actual tear trough.

A tight tear trough ligament will result in filler product going either side of it, and Dr Tim suspects that there are common variations in the tear trough ligament that can make for very different treatment options. He encourages you to start to observe your patients and notice if the tear trough is V-shaped or U-shaped – the meeting point of the orbicularis oculi retaining ligament and the zygomatic ligament at the tear trough often creates different challenges when treating this area, something that Dr Tim might explore in future videos on his Aesthetic Mastery Show.

Why not let him know on social media if you want him to do a deep dive into tear trough anatomy, treatments, and techniques – drop a comment to Dr Tim Pearce on Instagram.

In the meantime, you can check out some of his past blogs on tear troughs including –

• Does the fear of managing tear trough complications keep you awake?
• Is injecting filler into tear troughs via the mouth risky?

You can find Dr Gavin Chan on his You Tube channel for the Victorian Cosmetic Institute, and catch up with Dr Mobin Master and Dr Bryan Mendelson on Instagram.

Aesthetics Mastery Show

Dr Tim Pearce – Why I Stopped Filling Tear Troughs

Watch the full Aesthetics Mastery Show here.

Key points:

• 04:27 – Puffiness after tear troughs
• 05:13 – Don’t inject the orbit
• 07:09 – Have you been doing tear troughs wrong?

The show has active discussion from aesthetics professionals. Some of the latest comments include:

“Thank you Tim, I had watched Dr Chan’s video again and am more apprehensive about filling tear troughs now but your balanced comments have been a bit reassuring. It is worrying when very experienced injectors like Dr Chan advise against certain treatments. Thank you for making this video”

Pankaj Thakrar

“Thanks for citing and the references. At this stage, I see the worst of the complications. There are many happy patients without complications. Not ALL filler lasts for years and cause issues. Management of filler like a sculpture however is wise, with careful monitoring and dissolving as required.”

Dr Master

“Dr. Gavin Chan seemed to literally stopped doing all cosmetic procedures based on his latest videos. I agree with you that each patient needs to be assessed and treated individually.”

Ocean Medical Clinic Cosmetic Dermatology

Read more and add your own comments on our YouTube channel.

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Filler Complications eLearning Courses

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• Botulinum Toxin Complications Mastery
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Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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