Anatomy and Nonsurgical Correction of the Tear Trough ...journals.lww.com/plasreconsurg/Documents/Updates_in_Aesthetic... · COSMETIC Anatomy and Nonsurgical Correction of the Tear

COSMETIC

Anatomy and Nonsurgical Correction of theTear Trough Deformity

Haideh Hirmand, M.D.

New York, N.Y.Summary: The development of dark circles under the eyes is one of the earlysigns of periorbital aging, lending a fatigued and aged appearance to the face.Loeb, in 1961, used the term “nasojugal groove” to describe the concavity at theborder of the eyelid and the cheek medially. Flowers, in 1969, first named thisgroove the “tear trough.” In the present article, the author presents a detaileddescription of the anatomy and nonsurgical correction of this deformity. Non-surgical correction of the tear trough deformity with hyaluronic acid is effectiveand safe and is associated with high patient satisfaction. The procedure offersboth an adjunct to surgery and an alternative to it in some patients. It alsoprovides an opportunity for global midfacial volume correction. Careful patientselection and attention to technique will minimize side effects. (Plast. Reconstr.Surg. 125: 699, 2010.)

The development of dark circles under theeyes is one of the early signs of periorbitalaging, lending a fatigued and aged appear-

ance to the face. Loeb, in 1961, used the term“nasojugal groove” to describe the concavity at theborder of the eyelid and the cheek medially. Flow-ers, in 1969, first named this groove the “teartrough.” Loeb and Flowers both published surgi-cal techniques aimed at correction of the teartrough deformity.1–3

Multiple surgical techniques have since beendescribed to correct the tear trough deformity.4–16

Most blepharoplasty techniques do not fully cor-rect the tear trough deformity, and some can ac-centuate it. Surgery may not be well justified oraccepted in the young patient, or in a patient whohas undergone a blepharoplasty with residual orworsening concavity in the tear trough.

Nonsurgical correction of the tear trough de-formity has traditionally been performed usingautologous fat. Although fat is a good filler, itslimitations are labor intensiveness, particulateconsistency, unfavorable flow characteristics,risk of lumpiness and long-lasting irregularities,possibility of volume distortion with weight

changes, and prolonged edema. Fat can be use-ful in patients with significant orbital and mid-face volume loss, especially in conjunction withsurgery. However, hyaluronic acid has the ad-vantage of gel consistency, favorable flow char-acteristics, and reversibility, with less potentialmorbidity. Its nonpermanence is a plus.17–23

Other fillers such as calcium hydroxylapatiteare used in the periorbital area; however, they donot offer similar versatility in this unforgiving re-gion. Similarly, L-poly(lactic acid) injections havebeen performed; however, this method suffersfrom a lack of precision and a higher risk of com-plications.

ANATOMYThe “tear trough” refers to the medial one-

third of the periorbital hollow, and in early aging,it may be the only area of concavity visible (Fig. 1).The tear trough is not exclusively the product ofage. A mild trough is seen in youth in many in-dividuals. It is the deepening of this groove thatleads to true indentation and significantly impactsfacial appearance. To devise the optimal correc-tion for the tear trough, understanding the anat-omy of this area is critical.

The indentation that defines the tear troughdeformity is at the junction of thin eyelid skinabove and the thicker and different nasal and

From Plastic Surgery, Cornell-Weill Medical College/NewYork Presbyterian Hospital.Received for publication May 23, 2008; accepted July 22,2009.Reprinted and reformatted from the original article publishedwith the February 2010 issue (Plast Reconstr Surg. 2010;125:699–708).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318265b0d6

Disclosure: The author has no financial interest todeclare in relation to the content of this article.

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cheek skin below, with attenuated subcutaneoustissue overlying the maxillary bone. The skin in thearea of the concavity is indeed of different quality,texture, and color compared with either area. Insome individuals, there is a distinct melanocytichyperpigmentation in the skin of the tear trough.In some instances, this skin takes on an almosttransparent appearance.

The tear trough is at the inferior orbital rimmost medially but very quickly falls inferior to therim, with the maximal distance from the rim oc-curring centrally. Volume loss can be present lat-erally in more advanced aging, at or just below theorbital rim, where the retaining ligaments arethicker and less distensible.

The concavity in the groove is often associatedwith orbital fat herniation superiorly in the lowerlid fat compartments, accentuating its appear-ance. The presence of herniating lower lid fatdistracts from the deficiency in the trough, whichis an independent problem. There is individualvariation in depth and morphology of periorbitalvolume loss. Anatomical illustrations in cadaversreveal that the location of the indentation is alongthe fibers of the orbicularis oculi in the medialthird at the orbital rim (Fig. 2).

The orbicularis oculi muscle has a direct at-tachment to the inferior orbital rim from the an-terior lacrimal crest to the medial limbus or ap-proximately 30 percent of the orbital rim length.Lateral to this, the attachment to the bone is bymeans of the orbicularis retaining ligaments,which have variable length at different pointsalong the inferior orbital rim. The length in-creases to a maximum centrally and then de-creases laterally until the orbicularis retaining lig-aments merge with the lateral orbital thickening

in the lateral canthal region. The levator labiisuperioris originates just below the orbicularis oc-uli muscle attachment to the medial orbitalrim24–27 (Fig. 3).

It is in this medial area, along the attachmentof the orbicularis oculi muscle to the orbital rim,that the tear trough deformity first manifests as adepression that becomes deeper with time. Thereis scant subcutaneous tissue between the skin andthe orbicularis muscle in this area; therefore, the

Fig. 3. Anatomical dissections in the tear trough region showingthe orbital rim, sub– orbicularis oculi muscle, orbital fat, sub– or-bicularis oculi fat, and levator labii superioris near its origin,through a window made in the suborbicularis oculi fat. (FromZide BM. Surgical Anatomy Around the Orbit: The System ofZones. Philadelphia: Lippincott Williams & Wilkins; 2006. Usedwith permission).

Fig. 1. Patient with the tear trough deformity.Fig. 2. Anatomical illustration on a preserved cadaver showingthe depression in the orbicularis oculi in the medial lower orbitwhere the tear trough deformity forms. 3, Orbicularis oculi; 9, le-vator labii superioris alaeque nasi; 10, levator labii superioris(From McMinn HRM, Hutchings RT. Color Atlas of Human Anat-omy. Chicago: Year Book Medical; 1985. Permission pending).

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tear trough is composed of thin skin adherent tothe orbicularis muscle that is attached to the or-bital rim (Fig. 4).

The cause of the tear trough deformity is mostlikely multifactorial. Volume loss seems to pre-dominate. However, orbital fat herniation,(if pres-ent), skin laxity, and possible ptosis of tissues be-low secondary to volumetric changes or otherreasons could all play a role. The tear trough is infact a dynamic area. It would stand to reason, giventhe fixed attachment of the muscle to the rim andcontraction of muscles, notably the orbicularis oc-uli, that the tear trough would show the conse-quences of volume loss earlier and more dramat-ically than the rest of the face.

Volume loss at the orbital rim is of course notan isolated aging event. In truth, it is part of avolumetric involution that occurs globally in theface.28 Clinically, the periorbital pattern of volumeloss can be categorized into three classes (Fig. 5):

Class I patients have volume loss limited mediallyto the tear trough. These patients can also havemild flattening extending to the central cheek.

Class II patients exhibit volume loss in the lateralorbital area in addition to the medial orbit andthey may have moderate volume deficiency inthe medial cheek and flattening of the centralupper cheek.

Class III patients present with a full depressioncircumferentially along the orbital rim medi-ally to laterally. This pattern is often associatedwith more advanced volume deficiency in themedial cheek, central cheek, and malar emi-nence. Class II and III patients often demon-strate a depression along an oblique cheekcrease, between the two fat compartments ofthe cheek, highlighting the malar bags superi-orly, and volume loss in the temporal region,upper eyelid, brow, and lower face.

Patients of any class may present with excess or-bital fat or significant skin laxity. The presenceof either of these variables identifies a patientwho would benefit from surgery or surgery fol-lowed by filling of the tear trough for optimalresults. These patients are not good candidatesfor nonsurgical correction alone.

INDICATIONS AND PATIENTSELECTION

Patient selection is critical to obtaining goodresults. The best candidates are patients with goodskin tone and minimal skin laxity, with mild tomoderately deep tear troughs. This procedure hasexcellent utility in postsurgical patients who haveuncorrected troughs or overresected orbital fat.

Patients with very thin or transparent skin,those with significant skin laxity, and those withextremely deep tear toughs are poor candidates.These patients could still obtain improved appear-ance with the procedure; however, they need to becounseled as to the higher risk of visibility, irreg-ularity, and overall less-than-perfect results. Manyof these patients still elect to proceed and rarelyseek reversal even if the results are not perfect.

Patients who would clearly benefit from sur-gery are those with orbital fat herniation and sig-nificant skin laxity. These patients are unlikely toobtain good results from injecting the tear troughalone and should be advised of this. It is helpfulto simulate the effect of filling, in the less-than-ideal candidate, by pushing on the soft tissues justunder the tear trough with the patient observingin the mirror while their reaction is assessed. Thisprocedure is an effective adjunct to lower lid bleph-aroplasty and can be recommended as part of therejuvenation plan at the time of consultation.

Fig. 4. Illustration depicting anatomical landmarks in the tear trough region as it correlates to the surface deformity.

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TECHNIQUE

Preparation and AnesthesiaThe tear trough is marked using a fine-

tip marker with the patient sitting at approxi-mately 90 degrees. Upward gaze accentuatesthe deformity medially and centrally and delin-

eates the borders of the tear trough. Upwardoutward gaze outlines the deficit laterally onthe contralateral side. A comprehensive road-map of not only the tear trough deformity butalso of all adjacent areas that need volume aug-mentation is marked and reviewed with the pa-tient (Fig. 6).

Fig. 5. Classification of the patterns of periorbital volume loss: (above)class I, limited to the tear trough or medial orbit (sometimes associatedwith very mild flattening of the central cheek); (center) class II, medial andlateral depression apparent (can be associated with mild volume defi-ciency in the medial cheek and mild flattening of the central triangle; and(below) class III, full depression visible circumferentially at the orbital rim(often associated with more advanced volume deficiency in the medialcheek, central reverse triangle/midface and malar eminence, and theoblique midcheek crease highlighting the malar bags).


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Infraorbital nerve block is administered with asmall volume of 0.5% to 1% lidocaine with epi-nephrine. Direct infiltration of local anestheticcan be used to block the malar area and the lateralorbit. Care should be taken not to distort thevolume status of the midface and the tear troughby using large volumes of anesthetic solution.

Cold packs are used before and after the pro-cedure. Patients are advised to avoid antiplateletagents for 10 days before the procedure. The pro-cedure is performed under semisterile conditionsusing clear surgical preparation solution, sterilegauze, and meticulously clean technique.

Personal TechniqueI prefer using a sterile 30-gauge, ½-inch, stain-

less steel blunt cannula (custom made by Popper& Sons, Inc., New Hyde Park, N.Y.) introducedthrough a 25-gauge needle hole for injection inthe tear trough (Fig. 7). A small volume, approx-imately 0.01 to 0.05 cc, of hyaluronic acid, is in-jected in a retrograde fashion with each injection.The injections are deep to or within the orbicu-laris muscle and just superficial to the periosteumof the orbital rim in the most medial aspect. Cen-trally, the orbitomalar ligaments are longer andthe injection is performed at multiple levels asneeded. Hyaluronic acid is injected discontinuouslyin the deformity medial to lateral (Fig. 8). It isimportant to avoid injecting a large continuouscolumn of filler along the tear trough because anoval bulge or a “sausage” appearance can resultthat is accentuated with animation. Alternatively,more entry sites can be made with depot injectionsto avoid long continuous retrograde injections.

The tear trough is at or below the infraorbitalrim in 100 percent of cases; thus, injections above theorbital rim are not necessary in the absence of vol-ume deficiency within the confines of the orbit. Typ-ically, two to three entry sites are used medially andcentrally, and one to two entry sites are used laterally.Gentle digital massage, or massage with a cotton-tipped swab, is performed to disperse the filler in theintended location. Overcorrection is not recom-mended. The most common total volume injectedinto the periorbital area is 0.2 to 0.5 cc on each side.

Fig. 6. The treatment plan is marked as a roadmap, based on thepattern of volume loss, at the time of the procedure.

Fig. 7. Blunt needles/cannulas used in the procedure; the 30-gauge cannula is recommended. Alternatively, a 30- or 32-gaugeneedle can be used.

Fig. 8. The injection technique. The cannula is inserted deepsuborbicularly, in the supraperiosteal plane, in the medial aspectof the tear trough. Discontinuous deposition of filler is performed.Filler is massaged in place and visual evaluation is performed.Multiple passes are made as needed for full correction.


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The key to aesthetic correction of the teartrough is to think beyond the tear trough. Depend-ing on the depth and extent of volume loss, fur-ther injections are indicated to correct the centraland lateral aspect around the orbital rim and alladjacent areas. Typically, there is a flattened areacentrally in the shape of a reverse triangle that

should be filled. The medial cheek, if left deflated,will contribute to an unnatural appearance, espe-cially with facial expression. The oblique malardepression line that often develops in later stageshighlighting the malar bags is corrected, as is thesubmalar area. Augmentation of the malar emi-nence may be needed. It is important, though

Fig. 9. (Above) A 37-year-old man immediately after injection (1.5 cc total; 0.75 cc on each side for circumferential treatment).(Center) A 39-year-old woman before and 6 months after injection (0.8 cc total; 0.45 cc on the right and 0.35 cc on the left). (Below)A 43-year-old woman before and 7 months after injection (1 cc total; 0.5 cc on each side).


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often neglected, that patients be evaluated in an-imation throughout the procedure to identify andcorrect bulging or dimpling that can occur withmotion (Figs. 9 through 11).

Though not as essential, conservative injectionof the subbrow eyelid, medial upper lid A-framedeformity, and the brow, when indicated, can cre-ate harmonious and soft periorbital enhance-ment. In fact, periorbital volume augmentation isideally performed in conjunction with volume cor-rection in the whole face to preserve harmony andaesthetic proportions of facial features.

In specific instances, very superficial subder-mal injection using a 32-gauge needle is per-formed to “lift” the overlying skin. This is usuallya “spot’ application over a 1- or 2-mm surface area.

I initially designed the blunt cannulas to elimi-nate the risk of inadvertent intravascular injection;however, it is now my method of choice in the tear

trough for independent reasons. The blunt needleglides easily through the tissue once past the orbic-ularis oculi with minimal pressure. Medially, it is easyto feel for the periosteum with the tip of the cannulaand to direct it superior to the periosteum. Thus, themost medial part of the tear trough is accessiblesafely and precisely. Additional advantages includefewer entry sites and safe use above the orbital rimnear the globe for correction of postblepharoplastyoverresection of fat or generalized volume defi-ciency in the area above the orbital rim.

I have been using Restylane (Medicis Aesthetics,Inc., Scottsdale, Ariz.) since its approval in 2003, asan off-label application, and more recently Juved-erm (Allergan, Inc., Santa Barbara, Calif.). Theredoes not seem to be any major advantage to usingthe more robust preparations of either formulation.In addition, Juvederm, which is more hydrophilic,can result in prolonged edema around the eyes in

Fig. 10. A 38-year-old woman with significant midface volume loss, before and early after injection at 2 weeks. There is somevisibility and edema medially that resolved over time about which patients need to be counseled (1 cc total; 0.45 cc on the rightand 0.55 cc on the left).

Fig. 11. A 41-year-old woman before and 6 months after injections (2.0 cc total: 1 cc on each side).


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certain patients, whereas Restylane may be moreprone to exhibiting the Tyndall effect in some. Pres-ently, I recommend Restylane preferentially for thetear trough. For patients with thin transparent skinor those prone to significant ecchymosis, lower con-centration hyaluronic acids, such as Prevelle Silk(Mentor Corp., Santa Barbara, Calif.), should beconsidered.

Postprocedure CareAfter injection, patients are instructed to use

gentle digital pressure if areas of edema or irregu-larity persist after the first few days. Generalized mas-sage is not recommended. Regular makeup and skincare can be resumed and camouflage makeup canbe applied immediately. Cold packs in the hoursfollowing the procedure help reduce edema.

TECHNICAL PITFALLS ANDSOLUTIONS

The most commonly encountered pitfall isovercorrection, which results in an unnaturalbulge. A baggy appearance can also result frominjections that are too superficial. Hyaluronidasecan be used in both instances to salvage the cor-rection. The Vitrase (ISTA Pharmaceuticals, Ir-vine, Calif.) preparation can be used starting inthe range of 25 to 50 units per site and titrated asneeded. The patient should be advised that mul-tiple sessions and revision with the filler may berequired. Much like the nasolabial folds, it is notnecessary to completely obliterate the trough inmost individuals because a slight trough is presentin many young people. “Less is more” applies wellin this case, and softening of the hollow oftensuffices. A 1:1 correction at the time of the pro-cedure is recommended.

Another commonly encountered scenario isinadequate correction. It is critical that the peri-orbital pattern of volume loss is fully evaluated anda comprehensive strategy for injection planned. Acorrected tear trough in the absence of repletionof volume loss at the lateral orbit or of the midfaceresults in an overall unaesthetic appearance at restand especially with animation. Further evaluationand correction effectively corrects this issue.

Poor candidates, as identified previously, arelikely not to obtain the best results and may not besatisfied with this procedure. The goal is to identifythese patients at the outset. If a patient who is asurgical candidate is injected with suboptimal re-sults, reversal is indicated. Often, injections cancomplement surgery in these patients to optimizetheir results.

Occasionally, unevenness or undercorrectionis seen on follow-up. This is easily corrected withadditional application. Patients should be advisedof this possibility before the procedure.

RESULTSWe have evaluated the efficacy and longevity

by estimating the percentage correction after theprocedure and at 1 month, 6 months, and 1 year.The initial group of patients were followed closelyand the results were reported in 2005.17 Review ofthe last 100 consecutive patients has confirmed itsefficacy with a high level of patient satisfaction(unpublished data). Longevity of the effect in thisarea has proven unexpectedly long. Most patientscan expect to have good effect on average for 1year. Younger patients, or repeat patients, can ex-pect acceptable correction well over 1 year andsome up to 2 years. The effects wear off slowly overtime, and reapplication or touch-ups are based onsubjective parameters.

The longevity could be related to less motionin this area and possibly a stimulation of collagenproduction as has been reported. Applying hyal-uronic acid filler changes the aging process in theareas treated beyond the expected longevity of theproduct. It is not uncommon to see patients whorequire volume in areas not originally treated be-fore they need reapplication in the treated teartrough. Patients should be counseled as to theneed for such maintenance.

Botulinum toxin in the lateral orbicularisoculi or in the medial third along the orbital rimis a useful adjunct for preventing distortion ofthe filler by muscular action and for increasinglongevity.

COMPLICATIONSThe most common complications are ecchy-

mosis and edema. Ecchymosis can occur at theinjection sites and takes 1 week to 10 days to re-solve. Variable but subtle edema is not uncommonbecause of the hydrophilic nature of this filler, andresolution may take 2 to 3 weeks.

The most significant complication is visibleirregularities, which are more prevalent in pa-tients with thin or lax skin. These irregularities aremanaged effectively with massage over severalweeks. Irregularities that are caused by superficialinjections are difficult to resolve and can persistwell over 2 years. They require hyaluronidasetreatment.

Visibility is another possible complication.Deep injections decrease its risk; however, in rarepatients, tissue characteristics exist that make


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them prone to visibility regardless of technique.This may be attributable to persistent and delayededema that can occur days after injection. Smalldoses of hyaluronidase can improve this infre-quent complication. Visibility may be associatedwith a gray or blue color, a refractive phenomenonknown as the Tyndall effect. Patients who are pho-tographed professionally may show skin surfacedeformities that are only visible temporarily dur-ing flash photography and should be forewarned.

A theoretical yet significant complication isintravascular injection leading to visual compro-mise. Rare cases of blindness, stroke, and skinnecrosis after injections with needles in the facehave been reported in the periorbital area (gla-bella, forehead, temple, crow’s feet), nose, cheeks,nasolabial folds, and lower lip.29 Injected materialsreported include fat, Cymetra (LifeCell Corp.,Branchburg, N.J.), collagen, silicone, and steroids.There are reports of tissue injury with presumedintravascular injection of hyaluronic acid; how-ever, to date, there have been no reports of blind-ness after such injections.30,31

It is not clear what consistency or viscositycould increase the risk of vascular occlusion. It isalso difficult to ascertain the true risk of such a rareevent.

The blood supply to the eyelid and orbit isthrough both the internal and external carotidarteries connected by means of a vascular network.The central retinal artery is one of the proximalbranches of the ophthalmic artery (a branch of theinternal carotid artery), whereas many of the distalbranches of the ophthalmic artery supply parts ofthe face, such as the dorsal nasal, angular, su-praorbital, and supratrochlear arteries.

Retrograde and then antegrade movement ofa filler within vessels by means of the internalcarotid artery and the ophthalmic artery can the-oretically account for occlusion of the central ret-inal artery. To minimize risk of intravascular in-jection, whether a sharp or blunt needle is used,filler should only be injected under low pressure,in a discontinuous and retrograde manner.

Overall, the complication rates associated withinjection of the tear trough with hyaluronic acidhave been acceptable. The aesthetic results thatcan be achieved represent a significant improve-ment compared with traditional methods, creat-ing a more effective rejuvenation of the lower lidand midface.

CONCLUSIONSNonsurgical correction of the tear trough de-

formity with hyaluronic acid is effective and safe

and is associated with high patient satisfaction.The procedure offers both an adjunct to surgeryand an alternative to it in some patients. It alsoprovides an opportunity for global midfacial vol-ume correction. Careful patient selection and at-tention to technique will minimize side effects.

Haideh Hirmand, M.D.Plastic Surgery

Cornell-Weill Medical College/New York PresbyterianHospital

105 East 73rd StreetNew York, N.Y. 10021

REFERENCES1. Loeb R. Fat pad sliding and fat grafting for leveling lid

depressions. Clin Plast Surg. 1981;8:757–776.2. Flowers RF. Tear trough implants for correction of tear

trough deformity. Clin Plast Surg. 1993;20:403–415.3. Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast

Surg. 1993;20:393–400; discussion 401.4. Hamra S. Arcus marginalis release and orbital fat preserva-

tion in midface rejuvenation. Plast Reconstr Surg. 1995;96:354–362.

5. Hamra ST. The role of orbital fat preservation in facial aes-thetic surgery: A new concept. Clin Plast Surg. 1996;23:17–28.

6. Hester TR, Codner MA, McCord CD. The “centrofacial ap-proach” for correction of facial aging using the transblepha-roplasty subperiosteal cheek lift. Aesthet Surg Q. 1996;16:51–58.

7. McCord CD Jr, Codner MA, Hester TR. Redraping the in-ferior orbicularis arc. Plast Reconstr Surg. 1998;102:2471–2479.

8. Goldberg RA. Transconjunctival orbital fat repositioning:Transposition of orbital fat pedicles into the subperiostealpocket. Plast Reconstr Surg. 2000;105:743–748; discussion749–751.

9. Coleman S. Periorbital rejuvenation. Aesthet Surg J. 2001;21:337–343.

10. Little JW. Applications of the classic dermal fat graft in pri-mary and secondary facial rejuvenation. Plast Reconstr Surg.2002;109:788–804.

11. Kawamoto HK, Bradley JP. The tear “TROUF” procedure:Transconjunctival repositioning of orbital unipedicled fat.Plast Reconstr Surg. 2003;112:1903–1907; discussion 1908–1909.

12. Atiyeh BS, Hayek SN. Combined arcus marginalis release,preseptal orbicularis muscle sling, and SOOF plication formidfacial rejuvenation. Aesthetic Plast Surg. 2004;28:197–202.

13. Barton FE Jr, Ha R, Awada M. Fat extrusion and septal resetin patients with tear trough triad: A critical appraisal. PlastReconstr Surg. 2004;113:2115–2121; discussion 2122–2123.

14. Sullivan PK, Kim R. Treatment of the lower eyelid tear troughand lid cheek junction abnormality using a transconjunctivalretroseptal approach with fat transposition and internal con-tinuous suture fixation. Paper presented at the AestheticMeeting 2004, the Annual Meeting of the American Societyfor Aesthetic Plastic Surgery; April 17, 2004; Vancouver, Brit-ish Columbia, Canada.

15. Jelks G. Paper presented at: Aesthetic Meeting 2005, theAnnual Meeting of the American Society for Aesthetic PlasticSurgery; April 28-May 4, 2005; New Orleans, La.


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16. McCord CD. Paper presented at the Aesthetic Meeting 2005,the Annual Meeting of the American Society for AestheticPlastic Surgery; April 28-May 4, 2005; New Orleans, La.

17. Hirmand H. The tear trough and hyaluronic acid: Is it ahappy union? Paper presented at the Aesthetic Meeting2005, the Annual Meeting of the American Society for Aes-thetic Plastic Surgery; April 28-May 4, 2005; New Orleans, La.

18. Goldberg RA. The three periorbital hollows: A paradigmfor periorbital rejuvenation. Plast Reconstr Surg. 2005;116:1796–1804.

19. Kane MC. Treatment of tear trough deformity and lower lidbowing with injectable hyaluronic acid. Aesthetic Plast Surg.2005;29:363–367.

20. Airan LE, Born TM. Nonsurgical lower eyelid lift. Plast Re-constr Surg. 2005;116:1785–1792.

21. Hirsch RJ, Carruthers JD, Carruthers A. Infraorbital hollow treat-ment by dermal fillers. Dermatol Surg. 2007;33:1116– 1119.

22. Klein AW. Technique issues in non-surgical filling of theperi-orbital hollows. Aesthet Surg J. 2007;27:294–295.

23. Lambros VS. Hyaluronic acid injections for correction of thetear trough deformity. Plast Reconstr Surg. 2007;120(6Suppl.):74S–80S.

24. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy ofthe ligamentous attachments of the lower lid and lateral canthus.Plast Reconstr Surg. 2002;110:873–884; discussion 897–911.

25. Lucarelli MJ, Khwarg SI, Lemke BN, Kezel JS, Dortzbarch RK.The anatomy of midfacial ptosis. Ophthal Plast Reconstr Surg.2000;16:7–22.

26. Sullivan PK. The anatomic basis for the tear trough andcrescent deformity at the lower eyelid-cheek junction. Paperpresented at the American Society of Plastic Surgeons An-nual Meeting; October 28, 2003; San Diego, Calif.

27. Zide BM. Surgical Anatomy around the Orbit: The System of Zones.Philadelphia: Lippincott Williams & Wilkins; 2006.

28. Lambros VS. The dynamics of facial aging. Paper presentedat the 35th Annual Meeting of the American Society forAesthetic Plastic Surgery 2002; April 27-May 3, 2002; LasVegas, Nev.

29. Coleman S. Avoidance of arterial occlusion from injection ofsoft tissue fillers. Aesthet Surg J. 2002;22:555–557.

30. Bellman B. Complication following suspected intra-arterialinjection of Restylane. Aesthet Surg J. 2006;26:304–305.

31. Lowe NJ. Arterial embolization caused by injection of hyal-uronic acid (Restylane). Br J Dermatol. 2003;148:379; authorreply 379–380.


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