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Understanding the Tear Trough Cosmetic Problem

Dr Barry Eppley

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The tear trough facial deformity is an area of frequent confusion. Some patients think they have this problem and don't know what to call it, while others think they have it and it is really another type of facial problem. Because the cheek and eyelid areas are adjacent to each and bone from area can impact the shape of the other, it is important to clearly define what the tear trough deformity is. . . and isn't. Treatment methods will, of course, differ based on the anatomy of the problem which is why clarification is more than just a semantic issue.

Tear troughs are refer to a sunken in or hollowed out area below the eye. One must determine what anatomic area is sunken in, whether it be at the eyelid, orbital rim, or out in the cheek area. Sometimes it can even be all three together.

Hollowness below the eyelid (put your finger in the area, if you feel bone then you are on the lower rim of the eye socket) is most typically caused by sagging of the cheek tissues, known as midface descent, or inadequate development of the bone of the upper cheek, known as midface hypoplasia. The patient's age is usually a key element in determining the cause of this ‘bone’ problem. A younger patient most likely has cheek/orbital rim bone underdevelopment, an older patient more likely has midface descent. Some older patients, however, may have both.

Hollowness above the bone (if you push and feel no bone or slide over the rim of the bone), then the defect is in the eyelid area. This is not a bone problem but a reflection of the amount of fat that surrounds the eye, otherwise known as orbital volume.

Neither of the aforementioned eyelid/orbital rim/cheek issues is a true tear trough deformity. When hollowness in the area between the rim of eye socket bone and the side of the nose exists, this is a true tear trough deformity. One can envision or see how tears would roll down this ‘facial gutter’. Medically speaking, the tear trough is the nasojugal fold. a normal anatomic indentation for most people. But if it becomes aesthetically too deep, usually with aging, it is referred to as a tear trough depression. Such a depression near the eye contributes to a visible sign of aging.

It is easy to see how many confuse tear troughs, cheek/orbital rim hypoplasia, and decreased orbital volume. All affect the eye area but the treatments for each are quite different.

Dr Barry Eppley is a board-certified plastic surgeon in private practice in Indianapolis, Indiana at Clarian Health Systems. ( ) He writes a daily blog on plastic surgery, spa therapies, and medical skin care at


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