The Anatomy of The Tear Trough-Why This is a Difficult Treatment Challenge

There are numerous instances of unhappy patients after tear trough filler injections. There seems to be a sound anatomical explanation for this. Injection of a filler deep to the muscle (as is the popular recommendation) is veritably impossible as the “overlying” muscle is firmly attached to the underlying bone in this target area (see below). In other words there is no tissue plane to accommodate the injected filler “deep to the muscle”.  “Non Esiste” as the Italians may say. This does not mean that improvement by injection is impossible but it does confirm why so many tear trough injections result in complications and misery. Essentially the intended injection placement has nowhere to go other than into the muscle itself or “out the side” so to speak. The injected product ends up in the muscle, over the muscle into the subcutaeous fat plane, into the inferior orbital fat or inferior to the muscle in a fat pad know as SOOF. This will be a source of debate and conjecture among cosmetic injectors for some time to come. However anatomy is a fact rather than theory. I recently attended Australasian Society of Aesthetic Plastic SurgeryAn Anatomical Basis for Non-surgical Rejuvenation seminar at Macquarie University ( )  where facial human anatomy dissections were performed. I was keen to examine the controversial anatomy of the tear trough and lid-cheek junction. Essentially the following extract from a 2009 scientific paper is consistent with what I saw demonstrated in the anatomy dissections:  

“In the suborbicularis plane, the tear trough and the lid/cheek junction differ. Along the tear trough, the palpebral portion of the orbicularis oculi muscle is rigidly attached to the bone, with no dissectible anatomical plane deep to the muscle. It was not technically possible to dissect above the periosteum and below the muscular attachment. Along the lid/cheek junction, however, the orbicularis muscle has a ligamentous attachment to the bone by means of the orbicularis retaining

ligament. Unlike the tear trough region, there is a plane deep to the muscle into which material can
be injected or surgical dissection performed.”

The tear trough and lid/cheek junction: anatomy and implications for surgical correction
Haddock NT, Saadeh PB, Boutros S, Thorne CH  2009 Apr;123(4):1332