Treatment of nasojugal crease or tear trough deformity.

Aaron Stone MD - Plastic Surgery: Nasojugal crease, tear trough deformity, nasojugal groove, bags under eyes, under eye hollowness

Aaron Stone MD - Plastic
Surgery
2080 Century Park East #1110, Los Angeles, CA 90067
310-843-9021 www.aaronstonemd.com
www.aaronstonemd-plasticsurgery.blogspot.com
http://twitter.com/aaronstonemd

A board certified cosmetic and reconstructive plastic surgeon
performing plastic surgery of the eyes, face, ears, nose, breast,
abdomen, thighs in Los Angeles, California.

Monday, April 26, 2010
Nasojugal crease, tear trough deformity,
nasojugal groove, bags under eyes, under eye
hollowness
In the young individual the transition between lower eyelid and cheek is imperceptible. The
dividing line between these areas in older individuals is the nasojugal crease also called the
nasojugal groove (term first used in 1961) or tear trough (term first used in 1969). It is an early
sign of aging around the eyes, lending a fatigued and aged appearance to the face. As part of the
aging process ligaments that fix facial skin to the underlying facial bones thin and lengthen or
stretch, facial bones recede back and facial fat shrinks. This results in the drooping of facial skin
and appearance of laugh lines, jowls, nasojugal creases, eyelid bags etc.. The skin within the
nasojugal groove or crease becomes thinner and/or darker in color than the slightly lower nose or
cheek skin. It can also seem deeper or be more visible if there is protrusion of fat into the lower
eyelid. The aging process starts near the nose as the tear trough and progresses outwardly
towards the same side ear becoming what is called the palpebromalar groove.

http://aaronstonemd-plasticsurgery.blogspot.com/2010/04/nasojugal-crease-tear-trough-deformity.html (1 of 13)6/17/2010 11:56:24 AM


Tear Trough and Palpebromalar Groove Boundaries

Examples of Tear Troughs in Younger Patients Without Protruding Eyelid Fat



In the aging eye a loose orbital septum membrane and/or receding bone under the eye allow
eyelid fat to bulge outward making the tear trough more noticeable.

Aging Patient with Protruding Lower Eyelid Fat Making the Tear Trough and Palpebromalar
Creases More Visible

Plastic surgeons treat the nasojugal crease or tear trough in a number of ways. Drooping tissue
can be lifted up with the aid of sutures, material (fat or synthetic fillers) can be injected or



placed right into the crease line to efface it or implants can be placed to replace the absorbed
receded bone. It is difficult to treat the area because the soft tissue between the edge of bone
and outer skin surface is so thin and the skin is very thin as well. Because most of this soft tissue
is in fact muscle with little fat or skin there is a tendency for anything injected into this area
(restylane, fat, sculptra etc.) to form visible lumps and/or be visible through the thin skin. Muscle
movement also tends to make the injected material coalesce into lumps. The width of area you
can safely inject into is very thin and if you inject right on the bone or just under the skin you
will have a problem with most fillers. Some surgeons therefore advocate placing an implant made
of silicone, medpor or goretex right on the edge of bone under the eye with the thought of
augmenting to replace lost receded bone.

For over 50 years plastic
surgeons removed the eyelid fat through a skin incision (as in this Afro-American patient) or an
incision on the inner surface of the eyelid when performing lower eyelid blepharoplasty. This
approach hollowed out the eyes and accentuated the appearance of the tear trough. Although it
got rid of the protruding eyelid fat it did not restore the youthful invisible transition between
lower eyelid and cheek.
TREATMENT BY INJECTION

37 Year Old Right After Injection of Hyaluronate Filler

Injection works best for patients with thick, smooth skin, and a well-defined tear trough, without
excessively protruding lower eyelid fat. Patients with extremely wrinkled skin and less of an
actual indentation to fill do less well with injections. The larger the overhanging eyelid fat, the
less improvement you will get from filler injection alone. The older and more crepe-like the skin,
the less well the injection works.

In the tear trough, hyaluronic acid like restylane or juvederm lasts far longer than it does in the
lips and nasolabial folds. One to 1½ years is not uncommon. Only small amounts 0.2 to 0.4cc are
injected at a time and into or beneath the muscle. Then massage is used to even it out and



prevent lumps but over massage can displace the filler. Some doctors prefer using a blunt tipped
needle to avoid piercing any blood vessels under the skin. If you need skin removed as well its
better to have it removed and then recover before doing the injection. Filler injection is not a
substitute for surgery in those who would benefit from surgery i.e. have protruding eyelid fat or
excess lower eyelid skin.

TREATMENT WITH IMPLANTS

Implant and outline of implants used with notch for sensory nerve to cheek

Before and After Placement of Infraorbital Implants
This seems excessive given the results that are currently achievable by injection as depicted
above.



I prefer to use implants only
if the vector of a perpendicular from the cornea drops down in front of the cheek tissue, a
negative vector. In such cases the use of an implant can convert the patient to a positive vector
and significantly add to the end result. The presence of a negative vector in and of itself also
makes the tear trough more visible over time.



This patient had a negative vector that
was improved with the use of an implant.

TREATMENT WITH FAT GRAFTS OR MANIPULATION OF EYELID FAT
This is my preferred approach because it gives virtually permanent results with less risk and a
natural look but it cannot be performed on every patient.



Cutting the orbital septum membrane allows eyelid fat to be used to fill the groove with or
without removal of excess skin (first described in 1981)



In this patient I removed
excess eyelid skin via an incision just under the eyelashes, cut the orbital septum membrane and
sutured the eyelid fat to the deep cheek fat. Only a small amount of eyelid fat was trimmed away
or removed.

This younger patient had no
excess eyelid skin so I only cut the orbital septum membrane and then sutured the eyelid fat to
the deep cheek fat. I did not remove any fat from the eyelid.

In older patients with hollowed out eyes that are undergoing a facelift I prefer to take some
superficial cheek fat (SMAS) and place that is a graft over the edge of the bone. That gives much
the same result as the filler injection shown above with almost no risk of lumps or unevenness
and the added advantage of being permanent.

The most difficult patients to treat are those with protruding eyelid fat that moves in and out of
the eyeball socket as the eye is moved around. If you just suture the eyelid fat to the deep cheek
fat the continual backward forward movement of the fat will separate it from the cheek fat and
over time lead to a recurrence of the problem.

Blepharoplasty



Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

eye bags, eye puffiness, eye trough, eyelid bags, Nasojugal crease, nasojugal groove, tear trough deformity, under
eye furrow, under eye hollowness


Treatment of nasojugal crease or tear trough deformity.

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Treatment of nasojugal crease or tear trough deformity.