Tear trough rejuvenation is a non-surgical aesthetic treatment for patients with lower eyelid dark circles or dark hollows (also referred to as ‘tear troughs’ or ‘tear trough defects’).

In the lower eyelid a weakening of the orbital septum, and in the cheek area (the ‘mid-face’) a loss of soft tissue volume, tend to accentuate the appearance of the lower bony orbital margin which lies between the lower eyelid and the cheek. This also leads to the appearance of lower eyelid fat pockets (‘eye bags’) and together these can lead to a dark shadow or hollow beneath the eyes (a ‘tear trough defect’). The can cause a tired appearance.

A patient with typical lower lid tear trough defects causing dark circles and a tired appearance

The patient following conservative tear trough Restylane injections

Miss Pilson performing tear trough injections at Face & Eye

Not all patients who complain of lower eyelid dark circles or lower eyelid dark hollows are suitable for surgical improvement, usually in the form of cosmetic eyelid surgery (a lower eyelid blepharoplasty, eyelid lift or eye bag removal). The use of Restylane injections offers some patients a less invasive alternative treatment than cosmetic eyelid surgery for their problem as shown in the photographs below. Some patients also benefit from Restylane Volyme or Juvéderm Voluma injections which help to restore a youthful shape to the face by filling the inner and outer part of the upper cheeks.

A young patient with lower lid tear trough defects causing dark circles and a tired appearance

The patient following conservative tear trough Restylane injections

Although the use of Restylane as a soft tissue filler in other areas of the face is very well established and associated with high patient satisfaction, its use for the management of ‘tear troughs” (or hollow eyelids or lower eyelid dark circles) and, with Restylane Volyme or Juvéderm Voluma, the management of a loss of soft tissue volume in the mid-face, has proved to be a very good application for many patients. Patients have been undergoing such treatment very successfully at Face & Eye for over 13 years. The effects of the injections last approximately 12 months before repeat injections are required. For many patients the effects can last longer. Following a further injection after approximately 12 months, the effects have been seen to last a lot longer for the majority of patients.

Another patient with typical lower lid tear trough defects causing dark circles and a tired appearance

The patient following conservative tear trough Restylane injections

Some patients benefit from a combination of cosmetic eyelid surgery (blepharoplasty) and tear trough Restylane injections to the outer lid-cheek junction and/or cheek dermal filler injections e.g. using Restylane Volume or Juvéderm Voluma, undertaken following a recovery from the surgery. Your oculoplastic surgeon will be able to advise about the best option for you.

A patient with lower lid bags

The patient following a bilateral ‘scarless’ lower lid blepharoplasty

The patient following a small amount of Restylane injected into the areas of hollowing at the outer lid-cheek junction

Many patients send in photographs demonstrating their concerns and we can provide an initial opinion about a patient’s suitability for this non-surgical treatment.

A patient with hollowing of the inner aspect of the upper eyelid

The appearance following the injection of Restylane 

The treatment is undertaken as an outpatient procedure that can offer immediate cosmetic results, and a short recovery period. Dermal fillers can be injected as a trial without removing the option of a lower eyelid blepharoplasty at a later stage. The treatment is associated with mild discomfort. The injections also contain lidocaine, a local anaesthetic, which helps to minimise any discomfort. Bruising and swelling usually take a few days to subside.

Tear trough rejuvenation is now undertaken using a specially designed blunt-tipped cannula  (the Pix’Lcannula or TSK cannula).

The Pix’L Micro Cannula and TSK Cannula

The introduction of the Pix’L and TSK ranges of micro cannulas for use with Restylane and other hyaluronic acid dermal fillers for facial rejuvenation treatments offers the advantages of less pain, a safer approach with fewer complications and a much faster recovery period when compared with a standard needle injection technique. Whereas a needle may pierce delicate structures (such as blood vessels) a cannula has a blunt tip that will push these structures to one side, much reducing the risk of injury to them as it is advanced.

A cannula is designed to deliver a thin smooth thread of hyaluronic acid filler. This also reduces the chance of a lumpy appearance because the delivery is more precise and controlled.

This is of particular benefit in specialist treatments around the eye such as tear trough rejuvenation. The cannulas have been designed to deliver precise threads of hyaluronic acid dermal filler in this area where the skin and subcutaneous tissues are thin. The risks of lumpiness, bleeding and bruising, bluish discolouration, and injection into a blood vessel in the tear trough area are much reduced.

Advantages of the cannula:

• Reduced pain – the cannula does not readily puncture tissues like a sharp needle. Instead it glides smoothly along the tissue planes with a much reduced risk of injury to adjacent structures. There is less pain and swelling as a result.

• Less tissue trauma – the smooth outline and blunt tip of the cannula make injury to  tissues much less likely. This reduces the risk of blood vessel injury and bruising and swelling.

• Reduced risk of potential complications – the cannula delivers a precisely controlled fine thread of HA filler and so reduces the risk of a lumpy appearance compared to a needle.
 Moreover a cannula virtually eliminates the risk of inadvertently injecting the filler into a blood vessel. Although extremely rare, this can result in very serious complications such as loss of vision. A cannula therefore offers a major potential safety advantage over a standard needle technique.

• Reduced downtime – you are less likely to have any significant bruising or swelling after treatment with a cannula and so can often resume your daily routine activity immediately after treatment.

In order to minimise the risk of bruising it is essential to discontinue the use of Aspirin, Anadin or any anti-inflammatory medicines e.g. Indomethacin, Ibuprofen, Diclofenac, Voltarol, for 2 weeks before treatment, provided it is medically safe to do so (if you have been prescribed such medications please discuss this with your GP or physician if in doubt about this).

Excessive bruising can lead to staining of the Restylane gel in the lower eyelids and a blue discolouration of the skin although this occurs very infrequently. Occasional contour irregularities can occur following the injections. These are managed with massage after applying Auriderm cream.

On the very rare occasion that a patient is unhappy with the results, the hyaluronic acid filler can be dissolved away with the use of a small injection of Hyalase (an enzyme commonly used in local anaesthetic solutions given around the eye in patients undergoing eye operations). This is a major advantage of such fillers over permanent or semi-permanent fillers.

You will visit the clinic to have a pre-treatment consultation. This usually lasts about 20 minutes. (Some patients prefer to schedule the treatment on a separate occasion – if you prefer to undergo the treatment on the same day you will need to make this clear when you book the appointment with your surgeon). You will also need to provide information before attending (see below).

You will be asked to complete a healthcare questionnaire, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery, and any previous non-surgical aesthetic treatments e.g. Botox injections, dermal fillers injections, the use of IPL or laser treatments. We need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. We need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke. You may have your blood pressure checked by the nurses at the clinic.

It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.

If you are unsure of the names of any medications, bring them with you.

You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to the treatment. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.

If you can, try to stop smoking at least six to eight weeks prior to the treatment. Smoking has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision).

Photographs of your face and eyelids will be taken before your treatment so that the results of your treatment can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.

The risks and potential complications of the treatment should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.

After the injections it is advisable to avoid rubbing the eyes, lifting weights or straining for a few days. Vigorous gym work should be avoided for a few days.

Make up should be avoided for 48 hours. You must not touch the small injection sites.

It is helpful to apply Auriderm cream to the tear trough areas and to undertake gentle side to side massage twice a day for a week. This can be purchased from the Face & Eye Clinic.

You are advised to sleep with the head raised approximately 30 degrees to help to minimize any eyelid swelling.

Contact lenses can still be worn following this type of surgery.