Understanding Male Tear Troughs

Consultant oculoplastic surgeon Miss Elizabeth Hawkes and speciality registrar in ophthalmology Dr Priya Udani provide an introduction to treating male tear troughs

The post-pandemic aesthetic boom has led to an increase in attendances of patients looking for facial enhancements. 1 Cosmetic procedures are increasing in popularity, with men accounting for 13% of surgical and 8% of all non-surgical procedures.2 The American Society of Plastic Surgeons (ASPS) 2020 statistics showed that blepharoplasty was the second most popular surgical procedure in men and non-surgical procedures included botulinum toxin.2 In a culture of mask wearing, eyes have become a bigger focus and an imperative form of facial expression. Hence there is no surprise that eye rejuvenation using both surgical and non-surgical techniques is gaining in popularity. An increasingly common ocular complaint presenting to clinics include that of sunken, dark, tired eyes which are secondary to tear trough deformities. There are many treatment options including toxin, filler, chemical peels, energy-based devices and surgical options. In this article we will discuss the male anatomy of tear troughs, which will aid in appropriate evaluation and selection of suitable treatment.

Anatomy of the tear trough

Surface anatomy The term ‘tear trough’ corresponds to the periorbital hollow inferior to the medial lower lid that extends obliquely away from the medial canthus to the level of the mid-pupillary line (Figure 1).3 The sulcus that this forms is at the site where the thin eyelid skin meets thicker medial cheek and nasal skin that is the tear trough deformity.4 The eyelid skin is thinner and there is little subcutaneous fat, and in some patients this area can be pigmented in comparison to nasal and cheek skin.4 Pigmentation can exaggerate the appearance of the depth of the tear trough, hence it is an important factor to consider during a consultation. The reason being that once the tear trough deformity is filled, if the skin remains pigmented hence the ‘dark circles’ remain, which would hinder patient satisfaction of the aesthetic result.

Anatomical development of tear trough deformity Rhytids can exaggerate the appearance of the sulcus. Orbital fat prolapses and herniation secondary to weakening of the orbital septum can accentuate the appearance of the tear trough, resulting in a cigar shaped central fat compartment, deepening the tear trough.3,4 Advancing age leads to bone reabsorption with volume loss of the inferior orbital rim. The mid-face contributes to the appearance of the tear trough, the volumetric loss of central and medial cheek fat as well as increased prominence of the malar eminence deepens the trough deformity. There is also development of generalised laxity of supporting ligaments in the midface, which results in the gravitational decent of the suborbicularis fat pad (SOOF) causing a descent of the mid-face and subsequently the periorbital region, again exaggerating the tear trough.3,4

Lying silkworm

Eyebag Female vs male tear trough

Tear trough In order to treat the male face, it is important to consider the outcome that you are trying to achieve. Studies have shown that facial maturity is an attractive feature in males, hence men can be perceived as becoming more desirable as they age.5,6 Even though the basic anatomical structures are the same in both sexes there is significant variability, which results in a masculine and feminine face. Masculine facial features include a prominent supraorbital ridge, resulting in deep set eyes, a prominent glabellar and frontonasal suture, flatter eyebrows which sits at the level of the supraorbital rim, chiselled cheek bones and jaw.7 Feminine features are softer with a flat supraorbital ridge, smooth convexity of the forehead, arched eyebrows extending over the supraorbital rim and an upward tilt of the lateral canthus.7 The periocular changes noted with advancing age stem from the loss of bone from the orbital rim; in females there is receding noted at the inferior orbital rim, laterally, conversely the entire orbital rim recedes in males.8 As the masculine face has bulkier facial muscle, ageing results in loss of subcutaneous fat and tissue, hence deeper set lines are visible at an earlier stage in life.7 Ethnicity also plays a role in the appearance of tear troughs; hyperpigmentation is a common complaint in ageing Asian and darker Fitzpatrick skin tones, which accentuates the appearance of the tear trough deformity.7 Considering the change in facial anatomy with time and noting what surface anatomical changes you can observe, treatment options for tear trough deformities can be considered.9

Dermal filler To obtain good results from filler, patient selection is imperative. Those who benefit the most from tear trough fillers are patients with good skin tone, minimal laxity and moderate tear troughs with no orbital fat prolapse (Class I patients).9 Patients with laxity of the skin and orbital fat herniation benefit from surgical intervention (Class III patients).9 In the cohort straddling these two groups, results obtained with dermal filler alone may be less than desirable (Class II patients). In some cases, dermal fillers can be used as part of a rejuvenation plan in a surgical patient.10 When treating the tear trough area, it is important to assess the volume loss in the mid-face first. By using a highly cohesive filler via subperiosteal bolus injection in the cheek, the lift would reduce the volume of filler required in the tear trough.11 In male patients it is not advisable to inject large volumes of filler in the cheek, unless desired, as the plumpness of the mid-face would feminise features.12

Class I: Volume loss limited medially to the tear trough. May have mild flattening extending to the central cheek area. No bulging orbital fat.

Class II: Volume loss in the lateral orbital area and the medial orbit, may have moderate volume deficiency and flattening of the middle and upper cheek. Mild to moderate orbital fat bulging.

Class III: Full depression circumferentially along the orbital rim, from medial to lateral. Severe orbital fat bulging.

Table 1: Tear trough deformity classification4,12

Product selection is important in the tear trough area as the skin is thin and lymphatic drainage is poor, hence highly cross-linked fillers are more hydrophilic and cause swelling in the tear trough area resulting in an unsightly oval bulge.10 There is also a risk of the Tyndall effect with these fillers so it is advisable to run a cannula deep to the muscle to prevent lumpy boluses which may result in a ‘sausage’ appearance in the tear trough.11 Due to the hydrophilic effect of the filler, it is sensible to undertreat and then build as some swelling is expected.9-11

Botulinum toxin An adjunct to tear trough fillers for Class I and II patients is the use of toxin. As the periocular skin changes in males and lines become more prominent a combination treatment of toxin and fillers results in a better cumulative effect.13 If a slight heaviness of the upper lid is noted, the toxin would raise the eyebrows and open the eyes.13 Due to the increased bulk of facial muscle in men it may appear advisable to inject more units. However, it is important to understand particularly for lateral canthal lines, that these lines are deemed attractive and therefore more advisable to soften rather than eliminate lines.7 The recommended dose of botulinum toxin (Botox) around the eyes is 2.5-5 units per injection at three superficial injection points. For wrinkles under the eye, it is possible to inject a lower dose of 1.25-2.5 units, inferior to the mid-pupillary line.13

Surgical lower eyelid blepharoplasty For patients with prominent orbital fat prolapse, dermatochalasis and eyelid laxity, surgical treatment may be the most appropriate approach in our experience. Due to the age-related changes of the masculine face regarding receding of the entire orbital rim and loss of subcutaneous fat and tissue,7 surgical treatment is a more common procedure compared to females.2 A lower lid blepharoplasty will address the above. The technique used transconjunctival or transcutaneous approach is dependent on the presentation and anatomical changes of the patient and beyond the scope of this article.14 Simply, a transconjunctival fat repositioning or resection is reserved for younger patients with orbital fat prolapse and good lid tone. Patients with orbital fat prolapse, eyelid laxity and excess skin usually require a transcutaneous approach which would tighten the skin and muscle as well as reposition the fat to smooth the tear trough deformity. 14,15

Chemical peels Chemical peels can be used as an adjunctive treatment to treat fine lines and dark circles. Dark circles can be exaggerated by the presence of a tear trough deformity; however it can be independent of this. Peels can be used to cause controlled skin damage resulting in rejuvenation and reduced pigmentation of the skin post-healing. Chemical peels in the periocular region must be approached with caution as the thickness of the skin can be as little as 0.2mm.14,15 Male patients require a greater number of treatments to gain desired result as their skin has a more sebaceous quality.16

Energy-based devices Lasers are used for ablations and resurfacing of the epidermal and dermal layers of the skin via selective thermolysis. The light energy which is emitted by the laser is absorbed by melanin and water, which then go on to emit thermal energy resulting in deep tissue tightening by denaturing collagen and subsequently stimulating production of new collagen.17,18 In a study of 259 patients with facial rhytids where individual responses were evaluated independently by two blinded assessors at one, two, four, eight, 12 and 24 weeks post-operatively, on average CO2 lasers have showed a 90% reduction in rhytids and are suitable for treatment of fine lines around the mouth and eyes.17 The Er:YAG laser causes re-epithelialisation of the epidermal layers and the effect is more rapid and the recovery is faster to CO2 lasers. This laser has more precision than CO2 lasers, therefore is suitable for periocular treatment and also causes less thermal damage, although it reduces the amount of skin tightening that can be achieved.18 Radiofrequency devices work differently to ablative lasers as their thermal energy penetrates deep into the dermis and subcutaneous fat causing neocollagenesis, which results in skin tightening.19

The combination approach

There are multiple treatment modalities available for tear trough deformity. It is imperative to assess the anatomical changes to determine a suitable treatment modality. Male facial anatomy is vastly different from a female, hence this needs to be taken into consideration. There is not a one size fits all when treating this area and a combination approach is usually required, such as chemical peels for hyperpigmentation and tear trough filler to address a Class I deformity. For a Class II deformity you may also require botulinum toxin, energy-based treatments to aid neocollagenesis and dermal fillers. Finally, with Class III, a surgical lower eyelid blepharoplasty combined with a chemical peel to aid treatment of hyperpigmentation might be required.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon. She is lead oculoplastic surgeon at the Cadogan Clinic in Chelsea and specialises in blepharoplasty surgery and advanced facial aesthetics. Miss Hawkes is a full member of the British Oculoplastic Surgical Society and the European Society of Ophthalmic Plastic and Reconstructive Surgeons. She is also an examiner & fellow of the Royal College of Ophthalmologists. Qual: FRCOphth, MBBS, BSc

Dr Priya Udani is a senior registrar in ophthalmology with a special interest in oculoplastics within the NHS. She has an MBBS and a BSc in Human Biology from King’s College London. Qual: MBBS, BSc

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