Injecting the Tear Troughs

Sheila Barbarino, MD, FAAO, FAACSS, FACS, says she’s learned a few things over the years about injecting the tear trough area from colleagues, the literature, and her own patient experiences.

In her presentation, “Periocular Fillers: Right or Wrong—What I Do in My Practice,” at the recent virtual meeting of the American Academy of Facial Plastic and Reconstructive Surgeons (AAFPRS), Dr. Barbarino says addressing the hills and the valleys of the face can be challenging, but there is a way to bridge the gap between the midface and the periocular area with careful planning.

“The goal is to have no identifiable transition spot between the upper face—periocular area—to the mid face,” she says.

The Assessment Phase

Dr. Barbarino examines the periocular area from several angles during assessment, having the patient animate and move her chin up and down. She also examines the midface to see if the tear troughs first require underlying structural support to achieve desired outcomes.

“When you assess a patient in a static position, you're never going to make them happy because the face is such a dynamic area,” says Dr. Barbarino. “When they talk, there are differences and little nuances… you really have to watch them animate, and just pulling the tissue and elevating the tissue really makes the biggest difference.”

Dr. Barbarino strongly recommends examining the midface before addressing the periocular area. The face is generally discussed in three distinct areas—upper, mid, and lower—in medical school, residency, and fellowship, she says, but you need to consider them collectively to create overall facial harmony.

“If you pull up the side of the face and you see periocular improvement, then you know that you have some laxity—that you need to give support around the eye area. If you address the eye area without any sort of midface filling, what's going to happen is you're going to have that midface zygomatic cutaneous ligament cutting across,” which could result in something that looks like a big fat sausage, she says.

In some patients, addressing the midface even eliminates the need to fill the tear troughs.

“I can actually bring up their midface enough so that I don't even have to ever address their actual tear trough,” and that’s a win-win for the patient, says Dr. Barbarino.

Furthermore, “I refuse to fill any tear troughs, and just do the tear troughs, if they need their midface to be lifted. I set myself up for success,” she emphasizes.

NEXT: Approach to Periocular Fillers