The tear trough is one of the most anatomically complex and aesthetically sensitive regions of the face. Even small errors in depth, product choice, or injection plane can lead to complications such as oedema, contour irregularities, Tyndall effect, or vascular compromise. As demand for non-surgical periorbital rejuvenation increases, injectors must have a precise understanding of the layered anatomy, ligamentous structures, and vascular pathways that define this region.
Rather than being a simple “hollow,” the tear trough deformity is now recognised as a multifactorial condition involving skeletal support loss, fat compartment descent, ligament tethering, and skin thinning. Haddock et al. (2009) demonstrated through cadaveric dissection that the appearance of the tear trough and lid-cheek junction is determined by the relationship between the orbicularis muscle, the malar fat pad, and the underlying deep fat compartments — and that these relationships differ between the subcutaneous and submuscular planes.
This blog synthesises anatomical evidence to provide injectors with a clear, clinically relevant understanding of tear trough anatomy and safe injection principles.
The tear trough is defined by a concavity extending inferomedially from the medial canthus. Its appearance is influenced by:
Ageing exacerbates these changes, leading to deeper hollows, shadowing, and a fatigued appearance. Hirmand (2010) classified tear trough severity into three grades based on degree of hollowing, skin laxity, and orbital fat prominence, providing a practical framework for treatment selection.
The thinnest skin on the face, prone to Tyndall effect, oedema, and visible irregularities.
Minimal in the medial tear trough, contributing to the hollowed appearance.
A key structural element: thin medially, thicker laterally, with dynamic movement that influences filler behaviour. Haddock et al. (2009) described how the junction between the palpebral and orbital portions of the orbicularis aligns with the visible tear trough groove.
Distinct deep fat pads have been identified:
These compartments provide safer, more stable planes for filler placement.
The maxilla forms the deep foundation. Maxillary retrusion is a major contributor to tear trough depth.
The ORL is the primary anatomical structure responsible for the tear trough groove. Ghavami et al. (2008) demonstrated through 16 cadaveric dissections that the ORL is a true circumferential periorbital ligament, arising from the orbital rim and inserting into both the orbicularis muscle and the overlying skin. It acts as a tether, creating a visible demarcation between the lower eyelid and cheek.
Ageing causes ligament laxity, fat descent, and increased shadowing. Bernardini et al. (2021) showed that strategic filler placement directly inferior to the ORL can reorient the ligament and significantly improve the lid-cheek junction in a study of 163 patients assessed by eleven blinded raters.
Implication for injectors: The ORL creates a transition zone where superficial injections are high-risk. Deep injections below the ORL are safer and more predictable.
The tear trough is a high-risk vascular region due to the proximity of:
Emerges from the infraorbital foramen, travels superficially as it ascends, and is highly variable in course. Jitaree et al. (2018) mapped the arterial anatomy of the tear trough in 30 cadaveric hemifaces, demonstrating that arteries from the infraorbital, angular, and dorsal nasal vessels all converge near the tear trough injection zone. Their findings confirmed a high risk of arterial injury in this region and emphasised the importance of deep, supraperiosteal injection to minimise vascular compromise.
High-risk zones:
Safer zones:
Ideal for maxillary retrusion, deep hollows, and structural correction.
Technique:
Useful for blending the lid-cheek junction, supporting the ORL, and reducing shadowing.
Superficial injections risk Tyndall effect, persistent oedema, contour irregularities, and vascular compromise.
Cannula (25G or larger) reduces vascular injury risk but does not eliminate it. Needle offers precision but increases risk in inexperienced hands.
Choose fillers with low hydrophilicity, low swelling ratio, and low G′. Avoid overcorrection.
• The tear trough deformity is multifactorial, involving bone, fat, ligaments, and skin (Haddock et al., 2009).
• The ORL is the key anatomical structure creating the tear trough groove (Ghavami et al., 2008).
• Strategic filler placement relative to the ORL can reorient the ligament and improve the lid-cheek junction (Bernardini et al., 2021).
• Deep fat compartments (SOOF, deep medial cheek fat) provide safer injection planes.
• The infraorbital artery and foramen represent major high-risk zones; multiple arteries converge near the tear trough (Jitaree et al., 2018).
• Deep, conservative, low hydrophilicity filler placement reduces complications.
• Superficial injections should be avoided due to high risk of oedema and Tyndall effect.
| Master Periorbital Anatomy and Inject with Confidence The tear trough is one of the highest-risk areas in facial aesthetics — and one of the most rewarding to treat well. At Acquisition Aesthetics, vascular anatomy, ligamentous structures, fat compartment mapping, and complication management are taught at every level of our curriculum, so you have the knowledge to treat this region safely. From Foundation to Level 7, our courses are designed for clinicians who want to treat with precision and confidence. ➤ Explore Our Courses and Book Your Place acquisitionaesthetics.co.uk/courses |
Bernardini FP, Casabona G, Alfertshofer MG, et al. Soft tissue filler augmentation of the orbicularis retaining ligament to improve the lid-cheek junction. J Cosmet Dermatol. 2021;20(11):3446–3453. PubMed
Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich RJ. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008;121(3):994–1001. PubMed
Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and lid/cheek junction: anatomy and implications for surgical correction. Plast Reconstr Surg. 2009;123(4):1332–1340. PubMed
Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg. 2010;125(2):699–708. PubMed
Jitaree B, Phumyoo T, Uruwan S, Sawatwong W, McCormick L, Tansatit T. The feasibility determination of risky severe complications of arterial vasculature regarding the filler injection sites at the tear trough. Plast Reconstr Surg. 2018;142(5):1153–1163. PubMed
