Tear Trough Procedure

Rethinking Lower Eyelid Rejuvenation 

Haideh Hirmand MD
Aesthetic Plastic Surgery

The Tear Trough  

The eyes are the center piece of the face and most commonly bear the first signs of aging in the face. Most notice the perpetually “tired” look before anything else. Traditionally, the aging eye meant “bags” and “puffiness” that needed surgery. In truth, despite the appearance of “bags”, the very first change is often hollowness or indentation that happens along an area known as the tear trough. In some, this loss of volume extends out all the way around the lower eyelid and in time this happens in most.  A complex anatomy of muscle and ligamentous attachments to bone exist in this dynamic area where the indentation occurs.

Better understanding of the aging process dictates that we should fill the area of volume loss instead of surgically removing tissue. Hyaluronic Acid fillers such as Restylane (safe, made of natural sugar molecules that are already in our body, with a gel consistency) are perfect for layering in the tear trough and around the eye to give the lower lid a naturally rejuvenated look.

How is it done?

Small droplets of Restylane are placed very deep along the tear trough and around the eye rim and massaged and sculpted into place.

What is unique about this technique?

Dr. Hirmand injects Restylane deep (not in the dermis) with blunt needles, custom designed by her, as opposed to sharp needles. This evolution in technique makes it safer by minimizing the risk of injecting into a blood vessel or causing bleeding around the eye. It allows precise gliding of the blunt needle through the tissue for delivery of the filler. The blunt needle is inserted through a minute and invisible needle hole. It has resulted in less overall bruising and swelling and better results.

The other unique aspect is that this procedure correctsmore than just the tear trough. The sculpting is planned and mapped based on your individual pattern of volume loss not only around the eyes by also in the adjacent areas of the cheeks and midface. The tear trough is only one part of the picture and the whole (mid)face is lifted and regains its volume and youthful contour.

Who is the best candidate?

Individuals with thicker skin and minimum to moderate indentation. Even those who have had previous surgery can benefit from this procedure.

What are the risks and downtime?

Bruising is the most common and is usually seen only at the entry sites of the blunt needle.  Generalized bruising is rare but can occur and takes a week to ten days to resolve.  The extent of swelling is variable but it is most pronounced during the first week.  We suggest a regimen of Arnica and

Bromelin starting the day prior to the procedure and ask that all medications or supplements which can promote bleeding be stopped two weeks prior.  Irregularities can be seen in patients with extremely thin skin or very deep tear troughs. The use of smaller blunt needle has decreased their occurrence.


Is the procedure painful?

No. A nerve block and use of local anesthetic makes the procedure practically painless.


How long will the effect last?

The results last 6-12 months: the effect appears stable in most patients for the first six months and the loss is gradual after this.  A good average re-application time to keep in mind is around one year although many patients have good effect well after one year. 


What if I don’t like the results?

There is an antidote: an enzyme that once injected will selectively and immediately melt the hyaluronic acid away!


* Fillers injected in the Tear Trough are used off label.

Microbeading of the Eyelids

A note on Microbeading of the lower lid…

The lower eyelid (and upper eyelid) age in tandem with the tear trough by losing volume but thus far adding volume to the eyelids has been challenging. Regular maintenance injections in the tear troughs, cheeks and midface often exacerbate the hollowed appearance of the eyelids. The final frontier for correction of volume loss is the lower and upper lids. The MicroBeading procedure developed for the lower lid is not only new, but a more advanced and intricate extension of the tear trough procedure. 

Technique: Smaller caliber blunt micro-needles are used to introduce miniscule droplets of filler homogenously in a fanning pattern,  under the skin and muscle, to lift the “hollowed out” eyelids and bring them back to life. Adding volume to the lower eyelid above the tear trough and often into the upper eyelid is intricate and requires precise execution.  A fraction of a millimeter makes a significant aesthetic change in the eyes and face.

This novel technique is not mainstream, but offers a powerful tool to treat the “sunken eye look” and contradict excessive hollowness of from aging and thinning of the tissues, the deep set appearance exacerbated by maintenance of the cheeks and tear troughs, and even hollowness after eye surgery caused by aggressive reduction of fat.

The  MicroBeading technique can also be used for volume correction in the upper lid and brow in the right candidate.

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