What is tear trough deformity (under eye hollows) and how to treat it

Written by Dr Naveen Somia MBBS, PhD, FRACS - REG: MED0001189889

Tear troughs or under eye hollows are well defined, dark and deep hollows that are located between the lower eyelid, nose and upper cheek. In youth, no significant separation is typically noticeable between the eyelid and the cheek. However, with the passage of time, resulting from the shrinkage of the bone and the downward slide of the skin and cheek fat pad, the separation is noticeable. This prompts patients to seek a solution as these hollows highlight the ageing process.

Most people begin to notice the dark circles under eyes by their late thirties and early forties, however certain individuals who have a family history, notice them in their 20s. The early development of the tear troughs or dark circles has to do with the 'flat' cheek bone or a 'negative vector orbit' where the cheek bone flattens prematurely and no longer supports the lower eyelid.  In this article I’ll discuss strategies to address the tear trough deformity, and correct  significant under eye hollowing.

How are tear troughs/under eye hollows caused?

The under eye area tends to crinkle and billow in small bags and because the skin is so thin, it begins to show the dark blood vessels and muscles below. There is a tough ligament that connects the skin to the bone. As the bone shrinks with age, this ligament tugs and pulls the skin deeper making the tear trough groove deeper, darker and hence more noticeable especially in certain lights that highlight the shadowing. These tear troughs appear deeper when eyelid fat above the trough is bulging more prominently. This can result in tear trough lines, hollows, dark circles, crinkles and tiny bags.

Treatment option #1: Dermal Fillers

There are several approaches to addressing hollowed tear troughs. The most common one is to use dermal fillers to replace volume, raise and smooth the area. By restoring volume to the area where volume (fat and collagen) has been lost, hollowing can be filled and darkness, crinkles and bagginess can be reduced significantly . The results are immediate and generally last 12 – 18 months. Fillers must be used sparingly in the eye area because the tissues are thin and there is a risk of irregularities and visible product. Some patients have mild to moderate swelling after the procedure. There is a small risk of skin necrosis and blindness that has been reported with the use of dermal fillers.

Treatment option #2: Fat transfer

Some plastic surgeons recommend fat transfer whereby fat is harvested from the hip, thigh or abdomen via liposuction, processed and then injected into the area using a very fine cannula.  Fat transfer procedures can be under local anaesthesia but only in a registered and licensed facility for cosmetic surgey. The fat fills the tear trough in the upper check and directly under the eye. Since it is your own fat, there is reduced risk of rejection or reaction from the body. The longevity of the fat in the new area varies between individuals.

Treatment option #3: Surgery

Another option to address tear troughs is surgery. A lower eyelid blepharoplasty (lower eyelid surgery) is more invasive than the other approaches and involves a longer recovery but it can offer a long-term correction of the problem. The procedure is performed with an external incision just below the lash line or underneath the lower lid. There will be some swelling and bruising but both incision locations generally heal quickly. Fat in the area under the eye, or even from the upper cheek, can be repositioned to fill in the hollow, helping to eliminate dark discolouration and allowing for a more undetectable transition between the lower lid and upper cheek.  

Safety of cosmetic eyelid blepharoplasty surgery

With modern techniques and recent technological advancements, eyelid surgery has become safe, effective and capable of delivering results that you always wanted with minimal pain, discomfort and downtime. 

New Cosmetic surgery safety guidelines effective July 1, 2023.

AHPRA has introduced guidelines to improve safety and patient outcomes in cosmetic surgery following the extensive media coverage on poor patient outcomes . 

A medical referral from your GP before seeing your Plastic Surgeon , mandatory 2 consultations with your Plastic Surgeon , a cooling off period before surgery, standardised psychological testing and numerous other safety initiatives are in effect.

For additional information on eyelid blepharoplasty surgery to assist you in your decision,  download my free eBook

For an detailed analysis of eyelid surgery, download the Comprehensive Guide to Eyelid Blepharoplasty Surgery

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Disclaimer:  The patient information provided is general in nature and is not formal medical advice. All surgery carries risks. Individual results vary and different people experience different outcomes. Please seek a 2nd opinion from qualified Plastic Surgeon. All surgical procedures are performed by Specialist Plastic Surgeon, Dr Naveen Somia (MBBS, PhD, FRACS, MED0001189889). For full information on Dr Somia's qualifications and information about procedural risk and recovery, please visit the about and resources pages on this website.  In accordance with AHPRA's Cosmetic Surgery Guidelines, from the 1st July 2023, all surgical procedures require a referral from your GP and all patients are subject to standardised psychological screening .

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