The tear trough deformity is most commonly found in older individuals, is a sign of more advanced facial aging and is seen as a depression running beneath the cheek bone or Zygoma out toward the side of the face. The key event in the production of the tear trough deformity is the sagging or downward displacement of the cheek into the lower portion of the face, a condition referred to as the herniation of the cheek fat pad.

A youthful appearance of the face is characterized by a full youthful cheek, a plump cheek appearance with the fat and skin of the cheek high attached to the cheek bone. Remember the “chubby cheeks” of childhood. As facial aging occurs and the facial tissues become lax and descend in the face, the cheek fat pad, also called the malar fat pad, descends into the midface, leaving a hollow beneath the cheek bone which is the tear trough deformity, because tears roll out to the side of the face rather than straight down the cheeks as they did in childhood. The arcus marginalis ligament and other fascial attachments of the cheek on the cheek bone do tether the skin to the higher cheek bone and contribute to the tear trough deformity, but the descent of facial skin and the malar fat pad are the predominant event causing the tear trough deformity. The true tear trough deformity occurs in the 5th or 6th decade in most patients I see-this is very different from my experience with patients complaining of dark circles under the eyes.