Tear trough and lid-cheek junction surgery

What it is

The tear trough is the groove that runs down and out from the inner corner of the eye, and the lid-cheek junction is its continuation toward the side of the face (PMID 18047604, PMID 19337101). Under the tear trough, the eyelid muscle attaches straight to bone through a true bone-to-skin ligament, the tear trough ligament; farther out, it attaches through the orbicularis retaining ligament along the rim of the eye socket (PMID 22634656, PMID 19337101). Where those ligaments insert into the skin is where the grooves form (PMID 35139056).

The groove deepens with age because three things happen together. The skin and fat over the rim thin, the fat of the eye bag bulges above the fixed ligament and exaggerates the step (PMID 19337101), and the cheek tissue below descends: in a 3D photography study, simply lying down filled the groove by about as much as a typical filler treatment (PMID 31974554). Treatment follows from that: release the tether, then add volume where the groove is (PMID 36456652).

Where it came from

• Loeb described the groove in 1961 as the nasojugal groove, and Flowers named it the tear trough in 1969 (PMID 20124855).
• In 1995 Hamra released the attachment of the eye-socket septum at the rim and advanced the eye-bag fat over the rim instead of removing it, the arcus marginalis release (PMID 7624408). He added the septal reset, advancing the septum itself over the rim, in 2004 (PMID 15253208).
• In 2000 Goldberg moved the inner and central fat pads through an incision inside the lid into a pocket under the bone lining of the cheek (PMID 10697189).
• Mendelson mapped the space below the lower lid and the ligaments that bound it in 2002 (PMID 12172155), and in 2012 Wong identified the tear trough ligament itself (PMID 22634656). In 2017 Wong and Mendelson, working in Singapore and Melbourne, combined ligament release with fat redistribution through an incision inside the lid (PMID 28746272).
• Sadick defined the tear trough and a rating scale for its depth in 2007 (PMID 18047604).

Who it suits

• Moderate to deep grooves, with or without eye bags. Surgery is the most predictable and durable option (PMID 42150047).
• Little excess fat. Fat repositioning still worked in patients with little bulging fat, and in patients who had fat removed at an earlier eyelid operation, as long as a fat pad could be felt (PMID 37220233).
• Mild grooves with good skin and a firm lid. Hyaluronic acid filler is an option (PMID 42150047); its effect lasts about 8 to 12 months (PMID 34192769).
• Facelift and midface-lift patients. The groove can be treated in the same operation (PMID 7624408, PMID 40341978).
• People unhappy with filler. Filler-related swelling and lumps can be dissolved and the groove then corrected with surgery (PMID 38727846, PMID 30298348).

How it is done

• Through the inside of the lid. Most surgeons release the tear trough ligament and add volume; most move the fat into a pocket on or under the bone lining of the cheek and hold it with stitches, inside or out (PMID 36456652). An incision inside the lid suits patients with little excess skin (PMID 39590588).
• Moving fat on its blood supply (transposition). The inner and central fat pads are slid over the rim into the groove (PMID 10697189, PMID 37220233). Fixing the fat inside rather than through the skin avoids an outside stitch, with no hematoma, ectropion or numbness in one series (PMID 37010464).
• Septal reset. The septum is advanced over the rim and gives a firmer surface than moved fat alone (PMID 15253208).
• Free fat grafts. Small pieces of the removed eye-bag fat are placed in the groove (PMID 38720103, PMID 41150997), or processed fat is injected at the lid-cheek junction (PMID 29878987). A cannula can release the ligament and inject fat without an open operation (PMID 35857083).
• How much to release. Releasing the tear trough ligament is standard (PMID 36456652). Releasing the orbicularis retaining ligament farther out added no visible benefit in one comparison and brought longer swelling and more ectropion (PMID 28445185).

Results and how long they last

• Surgery removes the groove in most patients. Fat repositioning after ligament release eliminated the groove in more than 8 in 10 patients, with similar results in first and repeat eyelid surgery (PMID 37220233). Ligament reset gave better groove scores and higher satisfaction than standard eye-bag surgery at 6 months (PMID 36513526).
• Moved fat or free fat grafts give similar results. A fat pad moved on its blood supply and minced free fat grafts had similar complications, satisfaction and reoperation, with no residual groove in either group (PMID 37463504). Repositioning did better than fat injection for deeper grooves (PMID 28008460).
• Results hold. In Wong and Mendelson's consecutive series, followed for nearly 2 years on average, no patient developed scleral show and satisfaction was high (PMID 41150997). A large Asian series reported high satisfaction and few revisions (PMID 38353810). Moved fat still added measurable volume to the groove and upper cheek on 3D photographs a year later (PMID 26847158).
• Fat injection fades a little. After cannula release with fat injection, about 9 in 10 patients were satisfied at 1 month and about 8 in 10 at 2 years (PMID 35857083).
• Surgery against filler. Fat repositioning lasts longer and carries surgical risk; filler needs repeat treatment (PMID 39590588). In pooled filler studies about 9 in 10 people were satisfied (PMID 37684413).

Risks and how surgeons lower them

• Overall. In pooled data on fat grafting and repositioning, about 1 in 9 patients had a complication, most often undercorrection, an uneven contour, swelling or bruising, and about 1 in 40 needed another operation (PMID 39158343).
• Undercorrection. About 1 in 8 patients in a large repositioning series (PMID 37220233).
• Fat necrosis and lumps. Fat necrosis followed about 1 in 30 extended transconjunctival operations, and about 1 in 100 needed revision (PMID 41150997). Skin wrinkling, undercorrection and firmness were the commonest problems after fat grafting (PMID 39658665).
• Lower lid pulled down (ectropion). Rare in large series, about 1 in 170 in one (PMID 38353810). Releasing the orbicularis retaining ligament raised the risk (PMID 28445185).
• Eye movement. Up-and-down and side-to-side eye movement was reduced at 3 months after fat repositioning and back to normal by 6 months (PMID 34260464).
• Other. Bleeding under the lining of the eye, lid numbness and dry eye occurred and resolved on their own (PMID 37220233).
• With filler. Swelling and bruising each follow about 1 in 5 filler treatments, lumps about 1 in 20 and a blue tint under the skin about 1 in 100 (PMID 37684413); late swelling and lumps can appear more than a year later (PMID 34666405).

Recovery

• An outside stitch holding the moved fat comes out after 3 to 5 days, and the texture and contour settle over 1 to 2 months (PMID 10697189).
• Temporary swelling and lumpiness are the commonest early problems after ligament release with fat injection (PMID 35857083).
• Swelling and swelling of the eye lining (chemosis) last longer when the orbicularis retaining ligament is released (PMID 28445185).
• Changes in eye movement after fat repositioning had resolved by 6 months (PMID 34260464).
• After earlier filler, some patients had long-lasting swelling after eyelid surgery, and most of it resolved by 6 months (PMID 30298348).

With a facelift

• Hamra released the rim attachment and kept the eye-bag fat in every composite facelift (PMID 7624408), and later added the septal reset to it (PMID 15253208).
• A midface lift through a skin-muscle flap of the lower lid filled the tear trough whether the eye-bag fat was left alone, moved or removed (PMID 36719989).
• Fat grafted to the tear trough through an endoscope during a midface lift removed the groove and held at 12 months (PMID 40341978).
• Endoscopic brow and midface lifts in patients with difficult lower lids, deep tear troughs among them, caused no lower lid retraction; added filling and skin resurfacing were the commonest revisions (PMID 22929253).

Questions to ask a surgeon

• Is my groove deep enough for surgery, or would filler serve? (PMID 42150047)
• Will you move my eye-bag fat, graft it, or both? (PMID 37463504)
• Which ligaments will you release? (PMID 28445185)
• How do you protect the position of my lower lid? (PMID 38353810)
• I have had filler here: should it be dissolved before surgery? (PMID 30298348)
• How often do your patients need a second operation for lumps or undercorrection? (PMID 39158343)

Open questions

• Cause of the groove: cadaver work points to thinning tissue over fixed ligaments (PMID 19337101), and 3D photographs point to descent of the cheek (PMID 31974554).
• Moved fat or grafted fat: repositioning beat injection for deeper grooves in one comparison (PMID 28008460), and moved and minced fat were equal in another (PMID 37463504).
• Ligament release: one comparison found more morbidity without visible gain from releasing the orbicularis retaining ligament (PMID 28445185), while series releasing the tear trough ligament report low complication rates (PMID 41150997).
• Fat injection loses some of its effect over 2 years (PMID 35857083).
• No single technique has been shown best across patients (PMID 36456652).

Terms

• Tear trough: the groove at the inner lower lid, next to the nose (PMID 18047604).
• Lid-cheek junction: the outer continuation of the groove where lid meets cheek (PMID 19337101).
• Tear trough ligament: the bone-to-skin ligament that creates the tear trough (PMID 22634656).
• Orbicularis retaining ligament: the ligament along the rim of the eye socket under the lid-cheek junction (PMID 35139056).
• Arcus marginalis: the septum's attachment at the rim, released to move fat (PMID 7624408).
• Fat transposition (repositioning): moving eye-bag fat on its blood supply over the rim (PMID 10697189).
• Septal reset: advancing the orbital septum over the rim (PMID 15253208).
• Minced (free) fat graft: small pieces of the removed eye-bag fat placed in the groove (PMID 38720103).
• Stromal vascular fraction (SVF): a processed fat fraction rich in non-fat cells used for grafting (PMID 39658665).
• Tear trough rating scale: a graded score of groove severity (PMID 18047604).
• Hyaluronidase: enzyme that dissolves hyaluronic acid filler (PMID 30298348).

Papers