The tear trough – why so difficult?

What 'dark circles' can be: (1) a true tear trough – a hollow between lower lid and cheek from volume loss and ligaments. (2) Thin skin through which muscle and vessels shimmer bluish. (3) Pigmentation of the skin (inherited, after allergies, rubbing). (4) Eye bags – bulging fat that casts a shadow beneath. (5) Tiredness, allergies, dehydration. Only the first cause is a case for hyaluronic acid.

Why the area is difficult: the skin is the thinnest of the face; the gel lies directly beneath it and becomes visible if placed too superficially or in excess (bluish tinge – Tyndall effect – or ridges). Lymph drainage is slow, so the area tends to swell, sometimes only weeks later and for months. And the gel lasts especially long here – a mistake stays visible for a long time unless dissolved.

Who is suitable: younger to middle-aged patients with thin skin, a clear trough and little eye bag, without a tendency to swelling. Anyone with puffy eyes in the morning, eye bags or very slack skin is usually not a candidate – here filler often makes things worse.

How it is treated: small amounts (0.3–0.5 ml per side) of a very soft, low-water-binding filler, deep on the bone, with a cannula. Often the cheek is supported first, which already softens the trough. Better to under-correct and add after four weeks. The result: less shadow, not 'gone'.

Alternatives: for pigment: sun protection, vitamin C, retinoid, allergy therapy. For thin skin: skin boosters or polynucleotides to thicken the skin. For eye bags: surgical lower-lid blepharoplasty – no injection. For tiredness: sleep, cooling, antihistamines.

And if it goes wrong: hyaluronidase dissolves the gel – even years later. That is why only hyaluronic acid is used here, never permanent fillers.