Tear Trough Rejuvenation
Under Eye Dark Circles & Hollows
Tear trough fillers


The Tear Trough Deformity

The tear trough is the groove at the junction between where the lower eyelid and the cheek. As we age, one of the changes which is commonly noticed and commented on is the appearance and gradual worsening of dark circles under the eyelids. This occurs due to the thinning of the overlying skin and soft tissue over the bony orbital rim. A band of tethering fibrous tissue called the orbitomalar ligament binds the skin underneath the lower eyelid to the underlying bony rim of the eye socket. In youth, due to the surrounding plump fat, thicker overlying skin and soft tissue surrounding this structure, this ligament is usually invisible. However, with age atrophy of the adjacent tissues and thinning of the skin occurs, leading to increased visibility of this deep attachment between the skin and orbital rim-the so called tear trough deformity.

Treatment Options
Various treatment options for the disguising the tear trough deformity exist but all of them are based around two principles.
Either to:
  • default_titlePlump up the tissue around the ligament (leaving the ligament intact) e.g. using filler or fat injections or to
  • default_titleDisrupt the ligament altogether i.e. using surgery (lower eyelid blepharoplasty/lower eyelid bag removal)
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Both treatment principles have their advantages and disadvantages and the suitability of each treatment option varies from patient to patient. For example, some patients benefit from a combination of both surgery and filler injections. Mr Cheung offers multiple treatment options and will be able to advise on the best option for each individual patient.

Injectable filler (Restylane & Perlane) for tear trough rejuvenation
Tear Trough Filler Treatment
An increasingly popular treatment is the use of injectable implant fillers, especially in patients in their late 30's to 40's, to essentially fill out the trough. Commonly in this age group, the loss of volume at the junction between the upper cheek and lower eyelid, i.e. a worsening tear trough deformity, is the only obvious sign of ageing. Therefore simple replacement of this lost volume without the need for surgery can lead to dramatic improvement. In the past, various injectable implants e.g. the patients own harvested fat cells have been used with varying patient acceptability and success. Over the past decade though, injectable fillers such as Restylane & Perlane, which are based on hyalauronic acid- a natural tissue component produced by the body, have been used with excellent safety and effectiveness.
The aim of the treatment is to place the filler deep below the skin and soft tissue around orbitomalar ligament, thereby lifting up the these tissues, making the tear trough appear shallower. In most patients there is an almost immediate improvement with a reduction in the depth and width of the tear trough itself. Dark circles which are often due to shadowing within the trough itself similarly improve. In some patients though, there may remain some residual dark circles due to actual longstanding skin pigmentation built up over many years. In these patients they often notice an enhanced effect from using makeup to mask these lines.

Non Permanent
As with all safe hyalauronic acid based fillers, there is very slow absorption of the injected material over time and these injections can quite safely be repeated if necessary. As one's face slowly changes with time, cosmetic doctors have now recognised that non-permanent treatments are advantageous since they allow them to maintain harmony rest of the patients face. A permanent implanted material such as silicone given to a patient in their 30's may not look as good or harmonious if it still present when the patient is 80. For this reason, patients and their surgeons are seeking non-permanent absorbable injectable implants since they allow for retreatments in the future customised for that patient.

Reversible
Another major advantage of these hyalauronic acid based fillers is that they can quickly reversed if the patient so desires. In the rare situation where the patient is not content with the treatment, a small injection of Hyalase (hyalauronidase) into the injected implant, an enzyme drug commonly used during cataract surgery for over 20 years, can be used to quickly dissolve the implant.

No Surgery Required
On the whole, the treatments are very well tolerated, being virtually painless with only a small amount of skin numbing local anaesthetic cream necessary applied to the skin just prior to injection. Patients can feel some mild pressure during the procedure itself. The procedure is usually performed within the outpatient clinic and takes about 5 minutes per side. The recovery time is very quick and although patients do notice some mild swelling over the first postoperative week, most of this would have disappeared within 10 days. The material is still mouldable under the skin over the forthcoming weeks to months and this characteristic is very often useful as patients can often self mould the implant to their own liking e.g. to smooth out any tiny lumps. Mr Cheung uses a combination of standard injection using needles and also subdermal fanning techniques using Pix’l microcannulae depending on the area to be treated. The use of a microcannula has greatly improved the safety, comfort and reliability of treatment recently.

Minor bruising is uncommon with this procedure and usually disappears over 10 days. Most bruising is superficial and light and is easily concealed with makeup.

A first course of treatment consists of an outpatient clinic visit for treatment, then a follow up clinic review two weeks later to reassess and top up if necessary.
Patients may undergo a repeat course of top up retreatment if desired to replace any filler which has slowly dissolved over time, sometimes 12-18 months later.

Risks
As with any procedure there is a risk that things can go wrong:
-
Theoretical risk of vision loss. As with ANY injectable around the face there is a very rare risk of vision loss. This can theoretically occur due to the interconnection between the blood supply to the face and the posterior circulation of the eye. Any practitioner administering fillers to the face be they hyaluronic fillers or fat injections e.g. to the forehead, therefore has a responsibility to inform the patient of this risk and try his utmost to minimise this risk. In depth knowledge of the anatomy around the eye and using blunt cannula techniques helps to minimise this risk.
- Visibility. Patients with very thin skin risk the filler looking blue under certain lights. This can be minimised by using less viscous fillers and deeper placement.
- Migration. Very rarely fillers can migrate. This is more likely to occur if the filler has been injected into deposits under high pressure. This is less likely to occur with a diffuse subdermal microcannula technique.
-
Infection. This can very rarely occur despite the strict aseptic injection practices but can usually be treated very easily with antibiotics




Case Gallery

  • Stacks Image 5831

    Tear trough deformity in a 30 year old lady. She complained that she looked tired.

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    Notice that she has some hollowing under her eyes (tear trough deformity) and a mild bulging of a fat bag

  • Stacks Image 5820

    She complained that she had looked tired even in her teens and that this had worsened as she got older.

  • Stacks Image 5833

    Immediately following injection of Restylane. Only a tiny volume was necessary on each side

  • Stacks Image 5835

    Notice the single injection points when using a microcannula technique

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    There was minimal bruising and the patient can return to work the following day

  • Stacks Image 5839

    Two weeks Restylane injection for tear trough deformity.

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    All the bruising has disappeared. The Restylane filler not only fills up the under eye hollowing but also helps disguise the mild bulging from the small fat bag

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    Before treatment again

  • Stacks Image 5845

    After treatment again.


  • Stacks Image 5867

    This lady in her early 40s complained of looking tired.

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    She had moderate under eye hollowing/ tear trough deformities with minimal fat bulging her HER RIGHT and moderate fat bulging on HER LEFT.

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    She was keen to avoid surgical debulking of her fat pads as this was her first cosmetic treatment. Mr Cheung advised her that although tear trough fillers may help matters, there would still likely be minimal bulging of particularly prominent fat bags.

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    Immediately following injection of Restylane for the tear trough deformities. Notice the single injection point when using a microcannula technique

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    Immediately following injection of Restylane for the tear trough deformities. Notice the single injection point when using a microcannula technique

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    Two weeks following injection. Notice the result looks very natural. All the swelling has dissipated. She has still has a slightly prominent fat bag on HER LEFT but it has completely been camouflaged on HER RIGHT

  • Stacks Image 5885

    Two weeks following injection. Notice the result looks very natural. All the swelling has dissipated. She has still has a slightly prominent fat bag on HER LEFT but it has completely been camouflaged on HER RIGHT

  • Stacks Image 5887

    Two weeks following injection. Notice the result looks very natural. All the swelling has dissipated. She has still has a slightly prominent fat bag on HER LEFT but it has completely been camouflaged on HER RIGHT

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    Before treatment again.

  • Stacks Image 5892

    After treatment again


  • Tear trough deformity in a lady in her late 30s

    Tear trough deformity in a lady in her late 30s. She complained that she looked tired.

  • 20 minutes after injection of Restylane Perlane to the tear trough to recreate mimic the soft tissue lost. Notice the increased youthful looking fullness. Besides the mild bruising caused by the injection, there are very few indicators that she has undergone any treatment at all. This lady went straight back to work the following day. Notice the small amount of bruising and swelling. This fades and often becomes inconspicuous within a week

    20 minutes after injection of Restylane Perlane to the tear trough to recreate mimic the soft tissue lost. Notice the increased youthful looking fullness. Besides the mild bruising caused by the injection, there are very few indicators that she has undergone any treatment at all. This lady went straight back to work the following day. Notice the small amount of bruising and swelling. This fades and often becomes inconspicuous within a week




  • Tear trough deformity in a lady in her late 20s. This lady complained that her eyes looked tired.

    Tear trough deformity in a lady in her late 20s. This lady complained that her eyes looked tired.

  • Tear trough deformity in a lady in her late 20s. This lady complained that her eyes looked tired.

    Tear trough deformity in a lady in her late 20s. This lady complained that her eyes looked tired.

  • 2 weeks after injection of Restylane in to the tear trough. Notice the increased fullness to the tear trough. The filler helps camouflage the bulge of the lower lid caused by prolapsing fat pads. One can see why this procedure is sometimes termed a ‘non-surgical blepharoplasty’

    2 weeks after injection of Restylane in to the tear trough. Notice the increased fullness to the tear trough. The filler helps camouflage the bulge of the lower lid caused by prolapsing fat pads. One can see why this procedure is sometimes termed a ‘non-surgical blepharoplasty’

  • 2 weeks after injection of Restylane in to the tear trough. Notice the increased fullness to the tear trough. The filler helps camouflage the bulge of the lower lid caused by prolapsing fat pads. One can see why this procedure is sometimes termed a ‘non-surgical blepharoplasty’

    2 weeks after injection of Restylane in to the tear trough. Notice the increased fullness to the tear trough. The filler helps camouflage the bulge of the lower lid caused by prolapsing fat pads. One can see why this procedure is sometimes termed a ‘non-surgical blepharoplasty’



Prices
The typical cost for a course of tear trough rejuvenation with injectable fillers by Mr Cheung is around £775.

  • The standard cost of a cosmetic consultation appointment to see Mr Cheung first is £100.
  • Mr Cheung performs tear trough filler treatment at BMI The Edgbaston Hospital, Birmingham
  • Due to recently introduced hospital and pharmaceutical industry regulations, Mr Cheung is unfortunately no longer able to offer a fixed price inclusive package for tear trough filler treatment. The total fee for treatment will comprise of two separate charges - Mr Cheung’s surgeon fee and the hospital’s fee to supply the actual filler to the patient.
  • Mr Cheung charges £550 to administer a course of tear trough filler for both new and returning patients. This will include the actual injection of the filler and any necessary review appointments.
  • The BMI Edgbaston hospital will separately invoice the patient for however much filler is used. As of December 2014, prices are: Restylane 0.5ml £75, Restylane 1ml vial £120 and Perlane 1ml £125.
  • Most patients require about 1ml of filler. However for patients who have excessively deep troughs, larger volumes of filler may be necessary.
  • Perlane is Mr Cheung’s current filler product of choice for most patients. For patients with very thin skin, the less viscous Restylane is used instead.
  • On average, Perlane lasts 12-24 months whereas Restylane lasts 9-18 months.