Deep tear trough: assessing the hollow under-eye

"Doctor, my under-eye is hollow, it looks like I have a hole under my eye." It is one of the most frequent concerns in the HOF office and one of the easiest to get wrong, because it describes three different things with one word: the trough, the bag and the color. The most common mistake in this area is treating color with volume, or treating the bag with volume, and creating a picture worse than the original.

This page uses the trough as the decision point. The question is: what is producing the shadow, and what is the smallest suitable intervention? Possible answers include volume with hyaluronic acid, a biostimulator, treatment of the midface, skin care or referral. For the broader view of under-eye circle types, see under-eye circles: types and assessment.

What the tear trough is

The tear trough is the depression that starts at the inner corner of the eye and runs down toward the cheek. It appears where the orbicularis oculi muscle has a firm attachment to the bone, so the skin and covering tissue stay fixed while the surroundings lose volume and descend over time. The result is a sharp line of shadow.

It continues laterally into the palpebromalar groove and, below, into the mid-cheek groove. The distinction matters because the tear trough, the palpebromalar line and the mid-cheek groove are different areas and call for different reasoning. The nasojugal groove is a related term, used variably among authors, and checking what each one means avoids noise in conversations with colleagues.

The four pictures that get confused

The exam is done standing, seated and with the head slightly tilted, with light from above and from the front. The shadow of the trough changes with the angle of light, and that helps distinguish depression from color. Under diffuse light, an under-eye circle that is only shadow tends to lighten, and one from pigment remains.

Volume with hyaluronic acid: when and with what expectation

Hyaluronic acid is the best-known option for softening the trough. The logic is to fill the depression to reduce the shadow. The area has thin skin, little margin for irregularity and lies beside important vessels, among them the angular artery, so the margin for error is small and the procedure belongs to a qualified professional with experience and preparation for complications.

Two ideas guide planning: small, gradual volumes, and tolerance for touch-ups rather than trying to correct everything at once. An excess in this area is visible and hard to undo without hyaluronidase. In addition, filler under thin skin can give a bluish tone, the Tyndall effect, which the patient may mistake for the under-eye getting worse.

Bag, skin and other factors

If the patient has a protruding fat bag, the trough below it looks deeper by contrast. Filling the trough without addressing the bag can create a continuous, heavy mass. Reading the eyelid fat bag and the orbital septum is central, and the case may call for assessment by an eyelid surgeon. See also bags under the eyes and malar bags: assessment.

When the skin is very thin and the color is dark, the conversation changes. The gain from filler may be modest, and the patient needs to know that beforehand. In some cases, the most honest approach is to care for skin quality, treat cheekbone support and leave the trough as it is. On thin skin, see thin skin under the eyes.

Biostimulator in the area

The collagen biostimulator appears as an alternative in some profiles, especially when the skin needs thickness and quality and the patient accepts a gradual result. It is a selected indication, depending on the product, technique and experience of the professional, and it carries its own risks, such as nodules. It is not a shortcut for someone afraid of filler, and it should not be presented as safer without qualification.

The midface as part of the answer

A deep trough often goes with a cheekbone that has little support. If the bone and fat of the midface descend, the tear trough becomes proportionally more evident, and treating only the trough compensates without correcting the cause. In some patients, improving cheekbone support softens the look of the trough without touching it. The combined reading is in tear trough and nasolabial fold: combining them in the plan and in sunken eyes and low cheekbone.

How to organize the plan

1. Classify the picture: depression, bag, skin and color, swelling.
2. Assess the midface and decide whether it comes first.
3. If there is a significant bag, consider specialist assessment before any volume.
4. If volume is indicated, plan it in a small amount with a follow-up scheduled.
5. Record standardized photos, under the same light, before and after each stage.

Safety and hyaluronidase

Possible complications include persistent swelling, bruising, Tyndall effect, nodules, asymmetry and, rarely, vascular occlusion with visual risk. Review vascular occlusion and keep the emergency protocol up to date, including the contact of the reference ophthalmologist. In patients with a history of eyelid surgery, the risk of irregularity and adhesions increases, and the approach should be more cautious.

How to use Harmy in this conversation

The projection uses the frontal photo and changes only the marked area. The Tear Trough point represents the area of the tear trough and lets you show the patient the effect of a small volume on the shadow. The app does not simulate the bag, pigment or swelling variation, and that must be said.

For the conversation with the patient, explaining the under-eye circle to the patient offers supporting phrases, and eye bags and filler answers the most common question.

Questions to test the reasoning

What to record in the patient record

Note the classification of the picture, the photos under different lights, the skin thickness, the presence of a bag, the conversation about limits and the specific consent for the area. Record that the patient was informed about the Tyndall effect, persistent swelling and vascular risk. For the photo standard, see standardized clinical photography.

Summary for the decision

A deep tear trough is a symptom with several possible origins. Before any decision, separate depression, bag and color, assess midface support and the degree of skin thickness. Volume and biostimulator appear as options for selected profiles, with conservative amounts and a touch-up plan. Referring or leaving it as it is is also a legitimate decision. All at the discretion of the qualified professional, in line with the rules of their professional council in Brazil, and without promising results.