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Books/Facial Aesthetics: The Anatomy of Natural Results/Eye Area: Tear Trough and Periorbital Rejuvenation
Chapter 0611 min read

Eye Area: Tear Trough and Periorbital Rejuvenation

The eye area is the most delicate and impressive part of the face. This section explains the anatomical causes and treatment options for under-eye dark circles, hollows, and bags.

Main ideas in this chapter

  • Under-eye dark circles are usually shadows created by anatomical depth — not pigmentation.
  • Tear trough filler is a delicate application; if done incorrectly, the Tyndall effect (blue color) occurs.
  • Under-eye bags are usually a surgical indication; filler can conceal bags but does not treat them.

Three sources of undereye shadow

Undereye darkness is a mixture of three different things: (1) anatomical shadow — the depth of the tear trough absorbs light; (2) vascular pigmentation — the reflection of the underlying vessels' color to the surface due to thin skin; (3) true pigmentation — melanin accumulation. In most patients, these three coexist, and treatment is directed at all three.

Tear trough ligament

In the undereye area, the tear trough ligament is a fibrous band known as the orbicularis retaining ligament. This ligament connects the skin to the bone, creating a slight groove even in a young face. With aging, the overlying malar fat pad slides, the underlying bone recedes, and the groove turns into a prominent hollow.

Attention:Tear trough filler is a hybrid area: the skin is thin, the vascular structure is dense, and the anatomy is complex. The wrong product in the wrong hands can create serious risks on the face — Tyndall effect (blue appearance), nodule formation, edema, sometimes vascular damage. This area should be treated by very experienced physicians; preferably with low hydrophilic (less swelling) HA-based products.

Combined approach instead of classic filler

The tear trough is treated in some patients with filler alone, and in some with a combined approach (malar filler + low volume tear trough + mesotherapy/PRP for skin texture). Assessment according to the patient — there is no single formula. If pigmentation is dominant, it should be treated first; if the anatomical hollow is dominant, malar support is given first, then if necessary, the tear trough is filled very carefully.

Undereye bags and surgical decision

"Undereye bags" occur when the orbital fat pad herniates outwards from the front; this is a surgical indication. Transconjunctival blepharoplasty — reducing or repositioning the fat pad from the inner lid without an external incision — is the most common periorbital surgery. Filler sometimes "hides" this bag — but does not treat it; for a correct diagnosis, an opinion from a physician experienced in periorbital issues should be sought.

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Forehead and Eyebrow Line Design: The Frame of the Face

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Cheekbone and Midface: Volume Architecture