Why I Still Treat Tear Troughs: A Response to Dr. Gavin Chan’s Viral Video

Dr. Gavin Chan’s video “Why I Stopped Filling Tear Troughs” has sparked more questions than perhaps any other video in aesthetic medicine. The breakdown is brilliant, the case compelling, and the concerns valid. After watching the arguments unfold, examining the research presented, and reflecting on my own experience treating thousands of tear troughs, I want to explain why I continue offering this treatment to carefully selected patients.

The title presents a black-and-white choice, but the reality holds substantial nuance worth unpacking from four different perspectives: Dr. Chan’s clinical experience, Dr. Mobin Master’s MRI research revealing how long fillers actually last, Mr. Bryan Mendelson’s anatomical discoveries about the tear trough ligament, and Dr. Ben Burt’s surgical insights.

Why This Treatment Matters

Before diving into technique debates, I always start by reflecting on the potential value this treatment offers patients. My experience shows that a good result in the tear trough area is extremely impactful, far more than many other facial treatments. Eyes are the window to the soul and serve as the center point of communication and beauty.

But why are these shadows so important to people? As a dad of two young boys, I’ve watched countless Disney films and use that time to appreciate how animators illustrate faces to create feelings. The young princess’s eyes are framed by catch lights, while the evil stepmom has tear trough shadows, which are part of the reason we instinctively feel differently when we see them.

Tiredness, grumpiness, and anger can be associated with these tiny shadows, which in turn can impede our patients in their non-verbal communication, affecting their psychological state and ultimately their ability to thrive in society. There’s no argument that the results are worth striving for, but this video calls into question whether we’re likely to get the results we actually want, and at what expense.

For all the reasons a great result is particularly valuable, a poor result, side effect, or complication is proportionately upsetting.

Eight Core Points Worth Understanding

Point One: What You See Initially Isn’t the True Result

Fine skin combined with hydrophilic products and a goal for perfection make for a blind tightrope walk. We have no room for error with a dermis of only 0.2 millimeters in thickness, using products that grow unpredictably over time.

Like Dr. Chan, I started treating tear troughs before we had less hydrophilic products. He talks about using one to two mills of products back in 2005, and I vividly recall trying to learn the skill with similar products, experiencing the disappointment of needing to reverse procedures.

This made me extremely cautious when treating tear troughs and much better at selecting the right patients. For me, the trepidation combined with awareness of the possible benefits became instrumental in how I approached this area. I started doing everything I could to reduce the volume in the tear trough while achieving the result. Looking back, new products arrived just in time because the technique I’d honed on bad products became a much more certain experience.

Point Two: Fillers Last Much Longer Than Labels Suggest

Dr. Mobin’s research shows that fillers appear to last much longer than they say on the packets. I noticed early that certain patients would get years out of products without needing re-treatment. Dr. Mobin has now shown this with MRI studies, with products visible even 12 years later.

Sounds great, but in tear troughs it’s a risk. There is so little margin for error that even a 5% increase in volume, or a shift of position, could create a visible bag over time requiring reversal.

Point Three: Don’t Inject Into the Orbit

Dr. Chan reflects on a case of tear trough puffiness resistant to treatment, and Dr. Master’s MRI studies established that filler had been placed behind the orbital septum. This very thin membrane forms a barrier protecting the orbit from the external face, particularly as far as hyaluronidase is concerned.

When I first learned about this, I was quite shocked because this wouldn’t be a frequent occurrence in my mind. I’ve heard of patients seeking MRIs after watching this video, only to find no evidence of filler. It’s a fascinating complication, but one we need much more data about.

From my perspective as an experienced injector, the lesson is simply: don’t inject into the orbit. Sounds obvious, but as a trainer with years of experience, I’ve stood over people many times and seen them become confused, starting to approach areas close to the orbit where they’ve lost their bearings with a cannula or needle.

Millimeter differences are often invisible to the inexperienced, and this is one of the key takeaways. My position is that one of the most interesting parts of this video is not on its own a reason to never treat the tear trough, in the same way as a vascular occlusion is not a reason to never treat lips. A conscientious injector, now conscious of the risks thanks to this work, will likely do things to avoid this complication.

Point Four: Understanding the Tear Trough Ligament

The video makes a fascinating point that the tear trough shadow is essentially caused by the tear trough ligament, so adding volume is inherently a flawed strategy. It was amazing to see Mr. Bryan Mendelson, the author of the paper, explaining how they discovered the tear trough ligament.

With this understanding, it’s clear that in a very young person with a tear trough shadow, treating the area as if its volume loss will likely result in filler spreading either side of the ligament. This point I absolutely agree with, but I believe it’s only for one cohort: young patients where the ligament is the primary cause of the shadow.

I don’t see the presence of the ligament as a reason we cannot expect to get a good result because many signs of aging we treat are shadows and disruptions caused by ligaments. The nasolabial fold, melolabial fold disruptions, temple and cheek are all related to ligamentous attachments beneath which become visible with age, and we treat them routinely with good results.

I believe we can separate tear trough shadows into primary and secondary categories. The learning I get from observing many young people with tear trough shadows is that patients seeking treatment at a young age have a tight ligament present from youth as the primary cause. These are not our ideal patients, and I agree that filler is probably a bad solution for a primary tear trough shadow.

But potentially, it’s an excellent solution for secondary tear trough shadows that develop with age. My mental model is that this is age-related disruption 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: postseptal fat which often herniates from the orbit with age, the sub-orbicularis oculi fat (SOOF) which may atrophy with age, and the medial cheek fat pad which sometimes atrophies. All of these patterns of light and shade are darkest where we find the ligament, but if they are age-related, the true underlying cause is the altering balance of fat pads, and not the ligament itself.

The test Dr. Gavin demonstrates is good. Gentle compression of the area beneath the tear trough ligament with a cotton bud (which is what I do in my clinic) can show how raising the fat pad as it meets the ligament affects the shadow. Where the ligament is the primary cause, you’ll see little improvement and rarely a slight seesawing of the fat compartments where there’s a bulge on the other side but no improvement in shadow depth.

My Treatment Philosophy: Patient Selection and Healthy Fear

Dr. Chan closes with a reminder that our first duty is to do no harm. In practice with any invasive procedure, this means justifying and balancing the risk for each individual patient, as every intervention includes some element of harm, even if it’s just a bruise.

What’s key is that both patient and clinician anticipate a result that outweighs the potential for harm. We must start telling patients routinely that filler can last many years, which means the potential to diffuse and change in its properties is one of the variables we must accept and be prepared to navigate.

My position is 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 patient selection, it should become rare to only treat the tear trough in isolation.

With small adjustments in the cheek (both lateral and medial), the lateral lid-cheek junction, and good patient selection, this should result in only small volumes being required anywhere near the true tear trough. When you are near the ligament, be aware of the concept Dr. Gavin describes: a tight ligament will result in filler going either side of the ligament.

I also suspect there are important and common variations in the tear trough ligament which make for very different treatment options. Start to notice in your patients whether 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 quite different challenges.

I would like to thank Dr. Gavin Chan and the other contributors for an excellent video that got everyone talking. This discussion pushes all of us toward better patient outcomes and safer practices.

Watch the full Aesthetics Mastery Show

Dr Tim Reacts: Why I Stopped Filling Tear Troughs

Cosmetic Physician, Dr Gavin Chan from ‪@drgavinchan‬ went viral with a thought provoking video explaining why he no longer fills tear troughs. It’s the number one video Dr Tim gets asked about, so he’s made a video responding to Dr Chan’s concerns, and explaining why he still chooses to treat tear troughs.

You can also subscribe to our YouTube channel for really useful regular tips and advice.  

FREE Complications Webinar

Want to overcome your fear of complications and confidently master anatomy?

Join us for one of Dr Tim's FREE upcoming webinars. .

Check dates here and save your spot

Complications Webinar