The Tear Trough and Lower Lid Folds: Etiology and Implications for Treatment.

The lower eyelid tear trough deformity is a common cosmetic concern presenting to the oculoplastic surgeon. In contrast to the smooth convexity of the transition between the lower eyelid and upper cheek seen in children and young adults, older patients can develop a double convex lid-cheek profile due to deepening of the nasojugal fold (“the tear trough”) (Fig. 1). This is typically due to age-related laxity of the supporting tissues of the face, although the process can also be accelerated by conditions associated with periocular inflammation and orbital fat expansion such as thyroid eye disease.1 The uneven contour often contributes to the appearance of dark circles by creating shadow irregularities, resulting in patients seeking a reduction of “eye bags” or “dark circles” which contribute to a tired and aged appearance. The tear trough is a challenging area to treat due to the complexity of the underlying anatomy and its variation between patients, as well as the range of surgical and nonsurgical approaches available.2–7 Furthermore, intervention in this area carries several potential risks, which the clinician must first know how to minimize, and how to treat should they occur. Here, we aim to review the anatomy of the tear trough region, aided by reference to cadaveric anatomic studies in the literature, and to relate these findings to rejuvenation methods, providing an anatomic approach clinical aesthetic lower eyelid treatments.