What are “Tear Troughs”

The term tear troughs are loosely being applied to a variety of under eye concerns which can include dark circles, a true tear trough deformity or a pseudo-trough secondary to prolapsed fat bags.

Accurate Diagnosis is Essential

When addressing the under eye area the most critical factor is an accurate diagnosis as this must guide the treatment plan. Too often both patients and injectors believe that “just a bit of filler” will or can correct all their concerns. And this is why so many patients are left disappointed or in some cases, worse off than before their treatment.

Who is a good candidate for Tear Trough Treatment?

Not all patients are good candidates for tear trough filler and this depends on a variety of factors including:

  • Overlying Skin Quality
  • Underlying bone support
  • The presence of prolapsed fat bags
  • Soft tissue support ( a thin layer of fat immediately under the skin)
  • An individual’s unique lymphatic drainage system
  • A patients propensity to allergies and or underlying medical conditions
  • Medications
  • Genetics
  • Lifestyle factors

Overlying skin

it is important to look at several factors where the skin is concerned.


The skin in our under eye area is the thinnest skin in our body and we can in fact “see” into it for a mm or so, making it possible to see the underlying veins and vasculature.

Not all dark circles are caused by a shadow due to hollowness.  An easy way to determine if filler will improve the “coloring” of the under eye is to slightly stretch the skin between two fingers- if the color improves then filler will most likely improve the “darkness”. However, if there is no improvement it is most likely due to other factors. The two main factors are hyperpigmentation and/ or vascular effects.

Hyperpigmentation can be due to congenital dark circles where the darkness affects both the nasal root as well as the upper lids. This condition often has a genetic predisposition and presents itself during the teenage years. Congenital dark circles look worse in certain lighting conditions and are notoriously difficult to treat, filler in no way helps improve this type of discoloration but if there is an anatomical trough it can improve the overall aesthetic of the under eye. Other causes of hyperpigmentation that can affect the under eye include: PIH/ freckles/ Nevi of OTA/ actinic keratosis etc.

Vascularity can manifest as a blue or red coloring. A blue discoloration can be either due to large veins that we can see through the skin or as a diffuse blue color which represents pooling of venous blood in the underlying muscle. The venous return in our under eye area is sluggish compared to the cheek for instance. Red or pinkish discoloration close to the corner of our eyes is capillary perfusion that we can see because the skin is so thin. This is more common in people with very fair skin.

 Skin quality

Skin quality is often determined by age, genetics and external factors like sun damage and smoking. Here a “snap test” gives us a good idea of the extent of laxity. Gently pull the skin away from the lid and then when we let go we can look at how quickly the skin “snaps” back to its original position and shape. Often the skin goes back very slowly and this is a bit of a warning sign that someone might not be a very good candidate for filler.



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