Tear trough and lid-cheek junction surgery

What it treats

• Loeb named the concavity the "nasojugal groove" in 1961 and Flowers named it the "tear trough" in 1969; under-eye dark circles are an early sign of periorbital aging (PMID 20124855).
• Definition: the depression of the medial lower lid just lateral to the anterior lacrimal crest, bounded below by the orbital rim; the tear trough rating scale showed little variation between observers (PMID 18047604).
• Twelve cadaver dissections: under the tear trough the orbicularis muscle attaches directly to bone; under the lid-cheek junction it attaches through the orbicularis retaining ligament (PMID 19337101).
• The same study found skin and fat atrophy the most likely cause, found descent unlikely because the structures are fixed to bone, and found that bulging orbital fat accentuates the groove (PMID 19337101).
• Forty-eight hemifaces: a true osteocutaneous tear trough ligament runs from the medial canthal tendon to about the medial pupil line, then continues laterally as the orbicularis retaining ligament (PMID 22634656).
• The prezygomatic space below the lid is bounded above by the orbicularis retaining ligament and below by the zygomatic ligaments; facial nerve branches to the orbicularis run in its walls, not across it (PMID 12172155).
• Micro-CT of 12 cadavers: the orbicularis retaining ligament is a main septum on the rim plus many fibrous septa; their skin insertions match the tear trough and the lid-cheek groove (PMID 35139056).
• 3D photography of 53 women: lying down filled the tear trough by a mean 0.22 mL; the authors attributed midface aging in this cohort mainly to tissue descent (PMID 31974554).

How it is done

Fat transposition

• Arcus marginalis release: the septum is released at the rim and the lid fat is advanced over the rim under the orbicularis, 152 cases (PMID 7624408).
• Transconjunctival fat repositioning: medial and central fat pedicles are moved into a subperiosteal pocket and held with an external suture, 24 patients (PMID 10697189).
• Septal reset: the orbital septum is advanced over the rim, giving a firmer undersurface than fat transposition alone (PMID 15253208).
• Literature review, 50 papers: almost all authors release the tear trough ligament and add volume; most move fat into a subperiosteal or preperiosteal pocket; internal and external fixation are both used (PMID 36456652).

Ligament release

• Extended transconjunctival blepharoplasty, 54 patients: the orbicularis origins and tear trough ligament are released medially and the orbicularis retaining ligament laterally, and excised fat is grafted under the released ligament; revision 2%; no chemosis, retraction or ectropion at a mean 10 months (PMID 28746272).
• Internal fixation of the fat pedicle to the midcheek through the premaxillary and prezygomatic spaces, 22 patients aged 22-39: no hematoma, ectropion or numbness at a mean 11.8 months (PMID 37010464).
• Tear trough ligament reset against conventional eye bag surgery, 60 patients: better tear trough rating scores (4.82 against 5.92) and higher satisfaction (25 of 30 against 18 of 30) at 6 months (PMID 36513526).

Fat grafting

• Fractionated fat injected at the lid-cheek junction during lower blepharoplasty: complications no different from regular fat; no fat nodules (PMID 29878987).
• Minced orbital fat grafts during transconjunctival blepharoplasty, 98 patients: mean tear trough grade fell from 3.11 to 0.87; 78.5% rated the result excellent or good (PMID 38720103).
• Cannula release of the tear trough ligament with fat injection, 152 patients: satisfaction 93.4% at 1 month and 82.4% at 24 months; investigator-rated improvement 94.1% and 71.8% (PMID 35857083).

Results and evidence

Surgery

• Fat repositioning after ligament release, 232 patients: the groove was eliminated in more than 85%; patients describing a moderately or extremely severe groove fell from 86.3% to 34.0% (PMID 37220233).
• Results in 34 patients who had fat removed at an earlier blepharoplasty were comparable to primary cases; the authors require a palpable fat pad (PMID 37220233).
• Supraperiosteal fat repositioning with midface lift, 1,152 Asian patients (2,304 eyes), mean follow-up 10 months: revision for residual lateral fat 0.7%; 78% extremely satisfied and 19.1% satisfied (PMID 38353810).
• Extended transconjunctival technique, 200 consecutive patients, mean 22 months: no scleral show; fat necrosis 3.5%; revision 1.0% (PMID 41150997).
• 3D volume after fat repositioning, 10 patients, mean 12 months: mean gain 0.64 mL in the tear trough and upper cheek (PMID 26847158).
• Fat repositioning with septal reset (51 patients) against fat injection (50): no improvement in 4 of 102 against 7 of 100 eyes; repositioning gave greater improvement in grade II and III grooves (PMID 28008460).
• Pedicle fat flap (73) against minced free fat graft (69): no significant difference in complications, satisfaction or reoperation; no residual tear trough deformity in either group (PMID 37463504).
• Fat grafting meta-analysis, 20 studies, 2,372 patients: pooled satisfaction 94.9% for standard fat grafts; complications 10.1% for standard grafts and 1.5% for stromal vascular fraction (PMID 39658665).

Filler compared (the nonsurgical alternative)

• Hyaluronic acid meta-analysis, 31 reports, 2,556 patients: satisfaction 91.0%; swelling 19.2%, bruising 18.4%, lumps 5.3%, blue discoloration (Tyndall effect) 0.9% (PMID 37684413).
• Filler review, 23 articles: effect lasted 8-12 months (PMID 34192769).
• Delayed filler complications, 52 cases: mean onset 16.8 months; swelling 42.3%, lumps or nodules 25.0% (PMID 34666405).
• Filler-related deformity corrected with hyaluronidase, filler excision, ligament release and fat transposition, 22 patients: 90.9% satisfied (PMID 38727846).
• Hyaluronidase before lower blepharoplasty, 23 patients with filler problems: 82.6% had an acceptable outcome without complications; mild malar edema persisted in some (PMID 30298348).
• Narrative review of 20 studies: fat repositioning lasts longer but carries surgical risk; hyaluronic acid filler needs periodic maintenance (PMID 39590588).

Risks and complications

• Fat grafting and repositioning, meta-analysis of 33 studies, 4,671 patients: total complications 11.2%; undercorrection or contour irregularity 6.2%; hematoma, swelling or bruising 6.2%; reoperation 2.4% (PMID 39158343).
• Orbicularis retaining ligament release, 53 patients: no added aesthetic benefit; longer swelling and chemosis and a higher likelihood of ectropion (PMID 28445185).
• Undercorrection in 30 of 232 patients; transient conjunctival bleeding in 12, lid numbness in 2 and dry eye in 6, all resolved (PMID 37220233).
• Eye movement, 18 eyelids: vertical and horizontal movement worsened at 3 months after fat repositioning and returned to baseline by 6 months (PMID 34260464).
• Lower lid ectropion treated with lateral tarsal strip in 7 (0.6%) of the 1,152-patient series; no facial numbness, paralysis, new double vision or granuloma (PMID 38353810).
• Most common complications after fat grafting: skin wrinkles, undercorrection and induration (PMID 39658665).

Recovery

• The external fixation suture for repositioned fat is removed after 3-5 days; fat texture and contour settle over 1-2 months (PMID 10697189).
• Temporary swelling and lumpiness were the most common problems after ligament release with fat injection (PMID 35857083).
• Swelling and chemosis last longer when the orbicularis retaining ligament is released (PMID 28445185).
• Eye movement changes seen at 3 months after fat repositioning had resolved by 6 months (PMID 34260464).
• After earlier filler, 4 of 23 patients had prolonged edema after blepharoplasty; 3 resolved by 6 months (PMID 30298348).

Combined procedures

• Hamra performed arcus marginalis release with fat preservation in all composite rhytidectomies (PMID 7624408), and added the septal reset to the composite rhytidectomy (PMID 15253208).
• Midface lift through a skin-muscle flap, 130 patients: tear trough volume rose whether orbital fat was left, moved or removed (PMID 36719989).
• Endoscopic fat grafting to the tear trough during midface lift, 32 patients: groove eliminated in all; grafts stable at 12 months (PMID 40341978).
• Endoscopic brow and midface lift, 300 patients including deep tear troughs: no postoperative lower lid retraction; volume filling and skin resurfacing were the most common revisions (PMID 22929253).
• The volume restored by repositioning facial fat is comparable to the volume typically injected (PMID 31974554).

Current questions

• Cause of the groove: cadaver work points to atrophy with fixed ligaments (PMID 19337101); 3D positional data point to descent (PMID 31974554).
• Transposition or grafting: repositioning beat injection for deeper grooves in one comparison (PMID 28008460); pedicle flaps and minced grafts were equal in another (PMID 37463504).
• Ligament release: one comparative series found more morbidity without aesthetic gain (PMID 28445185); series releasing the tear trough ligament report low complication rates (PMID 41150997).
• Durability of fat injection: satisfaction fell from 93.4% to 82.4% over 24 months (PMID 35857083).
• Evidence quality: no single technique can be named 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 lateral 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 orbital rim 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 orbital fat on its pedicle 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