Nasojugal Line | Tear Trough
In young people the transition between lower eyelid and cheek is imperceptible, the area corresponds to the youthful invisible transition between lower eyelid and cheek (we know at CAstleknock Cosmetic Clinic Dublin!). 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 colour 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 Tear Trough Line.
At Castleknock Cosmetic Clinic Dublin, Dr Hazem Kahlout treat the nasojugal groove or tear trough in a number of ways. Drooping tissue can be lifted up with the aid of sutures performed during a mini lift procedure. However material like autologous fat or synthetic dermal fillers can be injected or placed right into the crease line to correct it. Finally 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 non specialised dermal fillers (regular restylane, juvaderm or teosyal) injected into this area 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. Dr Hazem Kahlout therefore advocates placing strong colloidal fillers like Sub-Q, Ultimate or Radiesse right on the edge of bone under the eye with the thought of augmenting to replace lost or receded bone.
Treatment with Dermal Fillers
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 Perlane or Teosyal Deep Lines lasts far longer than it does in the lips and nasolabial folds. One to 1½ years is not uncommon. Variable amounts 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. Dr Hazem Kahlout prefers using a soft blunt tipped needle knows as cannula to avoid piercing any blood vessels under the skin.
Treatment with Colloidal Fillers
This seems excessive given the results that are currently achievable by injection as depicted above.
Dr Hazem Kahlout prefers to use colloidal fillers only if a negative vector is present, that’s to say if a perpendicular from the cornea drops down in front of the cheek tissue, a negative vector. In such cases the use of colloidal filler like Restylane Sub-Q or Teosyal Ultimate or Radiesse 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.
Treatment with Fat Graft
In some patients this is the preferred approach. Fat Graft gives virtually permanent results with less risk and a natural look but it cannot be performed on every patient. However changing facial features over time could render the fat grafted to be peculiar looking.
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 with almost no risk of lumps or unevenness and the added advantage of being permanent.
Cost of tear trough correction is highly dependant on the level of intervention required as well as the amount of dermal filler used. For moderate strength dermal fillers, the cost is €450 per 1 ml used. Some patients require 1ml while others will need 2mls or more. For high colloidal dermal fillers the cost is around €1200 whole fat harvesting and transfer procedures will cost in the regioin of €4500.
Dermal Filler | Juvaderm, Perlane| €450
High Colloidal Lift dermal filler Procedure | €1200
Fat harvesting & Grafting Procedure | €3000