What the research shows
The groove has a fixed cause. Skin and fat thin with age, and the muscle under the groove is attached directly to bone, so it does not descend with the cheek (Haddock 2009). Cadaver dissection found a true ligament, the tear trough ligament, tethering the skin to the bone along the groove (Wong 2012). Fat bulging above the groove makes it look deeper (Haddock 2009).
Hyaluronic acid filler is the usual nonsurgical treatment. Pooled studies found high satisfaction; swelling and bruising were common, and lumps and a bluish tint under thin skin were uncommon (Liu 2024). The effect lasted about eight to twelve months, and most injectors place the filler deep, on the bone (Trinh 2022). Patients followed five years or more after their first filler had lasting mild swelling, bluish color or unevenness in a sizable minority, though most cases needed no treatment (Mustak 2018). A vein runs inside the muscle along the groove, which is another reason to inject deep (Calomeni 2022). Bleeding behind the eye after filler has been reported and was treated without vision loss (Wilde 2024).
Age decides who benefits from filler. In a large multicenter group, filler worked best at ages 30 to 40, helped up to 50, and the authors no longer recommend it as the main treatment after that (Diaspro 2022).
Surgery corrects the groove through the lower eyelid. The surgeon releases the attachment along the groove, keeps the bulging eyelid fat and moves it down into the hollow (Barton 2004). Releasing the tear trough ligament corrected the groove over years without lowering the eyelid, and it also lifted the lid-cheek junction when smiling (Wong 2019). For deeper grooves, moving the eyelid's own fat gave more improvement than injecting fat from elsewhere (Chiu 2017). Problems after fat grafting or repositioning, such as unevenness, bruising or a return to surgery, affected about 1 in 9, and about 1 in 40 needed another operation (Xu 2024).
Where surgeons disagree
- Which surgical method. Nearly all surgeons agree the ligament must be released and volume added, but they differ on whether to move fat through the inside of the lid or through a skin incision, and where to place it (Atiyeh 2023).
- Needle or blunt cannula for filler. A review found no difference in results, satisfaction or side effects, so neither can be called better (Rao 2022).
What is new
- Surgeons now operate to remove filler that has spread or swollen in the tear trough, combining dissolving enzyme, removal and fat repositioning, and most patients were satisfied (Kang 2024).
- Ultrasound mapping of the vein in the groove now guides where filler goes (Calomeni 2022).
What is still unknown
- The best surgical method: a review could not name one technique that suits every face and avoids a puffy look (Atiyeh 2023).
- Long-term effects of years of filler: most filler studies are short and descriptive (Rao 2022, Mustak 2018).
Key papers
- Barton 2004: keeping eyelid fat and moving it into the groove.
- Haddock 2009: the groove comes from thinning tissue fixed to bone.
- Wong 2012: found the tear trough ligament.
- Mustak 2018: what under-eye filler looks like five years on.
- Wong 2019: releasing the ligament corrects the groove for years.
- Diaspro 2022: filler works best before 50.
- Liu 2024: pooled satisfaction and side effects of under-eye filler.
- Xu 2024: pooled complications of fat grafting and repositioning.