The "valley of tears" gives the gaze a tired, sad, or aged appearance. This anatomical area, also called the tear trough, is particularly delicate because it lies at the intersection of multiple muscular, fatty, and bony structures. Its progressive alteration is a frequent concern, particularly in Geneva, where discerning patients seek targeted, effective solutions that respect facial harmony. Understanding the precise causes of the appearance of the valley of tears is essential to offer appropriate treatments and achieve natural, lasting results.
With age, the progressive loss of deep facial fat compartments is one of the primary causes of the appearance of the valley of tears. More specifically, malar fat — located at the cheekbones — decreases and shifts, leading to a loss of suborbital support. This fat loss is often accompanied by ptosis (sagging) of the tissues, accentuating the hollow between the orbit and the cheek. Volume loss is not limited to superficial tissues: deep areas are also affected, altering the overall architecture of the face.
Bone aging also contributes to the formation of the valley of tears. 3D imaging studies have shown that the malar bone (cheekbone) gradually resorbs with age, particularly in its medial portion. This resorption reduces structural support for the soft tissues, causing them to sag downward and accentuating the suborbital hollows. This phenomenon, often subtle but progressive, contributes over time to the perception of a tired gaze.
The infraorbital region is a particularly complex anatomical area, where several tissue layers with distinct functions and characteristics overlap: the epidermis, dermis, orbicularis muscle, superficial and deep fat pads, supporting ligaments, as well as the zygomatic bone and orbital rim. This multilayered, fine, and dense organization is designed to allow both high mobility and expressiveness of the gaze.
Over time, the different tissue layers lose their functional cohesion. The network of fibrous septa anchoring superficial fat to deep fat becomes looser, causing migration and loss of fat volume. At the same time, the skin thins, making underlying anatomical discontinuities more visible. This micro-anatomical restructuring creates a clear demarcation between the periocular area and the cheek, accentuating the hollow that forms the valley of tears.
This insidious and progressive process explains why the valley of tears can appear from the age of thirty, even in the absence of pathology or fatigue. It also highlights the importance of considering each tissue layer in the aesthetic analysis of the midface.
The orbicularis oculi muscle, a ring-shaped muscle surrounding the eyelid, plays an essential role in eyelid closure and the expressiveness of the gaze. Its contraction is constantly engaged, either reflexively (blinking) or voluntarily (facial expressions). In some patients, this muscle activity is excessive.
Hyperactivity of the orbicularis muscle exerts chronic traction on the underlying tissues. Over time, this mechanical action contributes to the wear of ligamentous attachments and compression of superficial fat, promoting its atrophy. The orbicularis muscle, through repeated contraction, also creates a “pleated” effect on the skin, accentuating the appearance of the tear trough.
This functional factor is particularly important because it is often present from a young age, contributing to the early appearance of the valley of tears in young patients. It also explains why some patients, despite good skin quality, exhibit a prematurely hollowed gaze.
The lymphatic system plays a key role in eliminating cellular waste and maintaining fluid balance within tissues. The infraorbital area, however, is characterized by a poorly developed lymphatic network and relatively slow vascularization. This anatomical peculiarity makes it sensitive to stasis phenomena, particularly in cases of fatigue, stress, or prolonged lying down.
When lymphatic drainage is insufficient, edema can form — often subtle, but enough to accentuate the natural shadows of the eye contour. This congestion gives the gaze a tired and heavy appearance, while visually emphasizing the hollow of the tear trough. Although secondary, this cause acts as an aggravating factor, making the valley of tears more noticeable, especially upon waking or in patients prone to water retention.
Vascular congestion can also play a role in the perception of the infraorbital hollow. Venous stasis, particularly in the suborbital plexuses, can darken the area, highlighting the depth of the groove by contrast. This is often a transient mechanism, but it can become chronic if the causes are not identified and addressed.
Hormones play a crucial role in tissue regeneration, collagen production, and water retention in cutaneous and subcutaneous tissues. Among them, estrogens have a direct effect on skin hydration, dermal thickness, and the density of supporting fibers. In women, the abrupt drop in estrogen during menopause leads to a rapid deterioration of skin tone and tissue firmness, including in the infraorbital region.
More generally, hormonal aging — whether related to age or certain endocrine pathologies — causes a reduction in hyaluronic acid synthesis, loss of dermal elasticity, and decreased vascularization. These factors reduce the natural turgor of tissues, making underlying structures more visible. In men, the gradual decline of androgens can also lead to decreased bone and muscle density, contributing to laxity of facial support.
This hormonal factor is often underestimated, yet it represents a major systemic cause in the acceleration of facial aging. It must be considered in the overall facial assessment, particularly in premenopausal women or patients showing signs of endocrine disturbances.
Skin aging and the appearance of aging signs such as the valley of tears are strongly influenced by the living environment. Among the most harmful extrinsic factors are chronic exposure to ultraviolet rays, urban pollution, tobacco, and blue light emitted by digital screens. These often silent aggressions induce cellular oxidative stress, gradually damaging collagen fibers, weakening cell membranes, and reducing elastin production.
The skin around the eyes, naturally thinner than the rest of the face, is particularly vulnerable to these attacks. It undergoes accelerated aging, resulting in dermal density loss and accentuation of hollows, such as the valley of tears. Furthermore, atmospheric pollution has been identified as a factor that aggravates periocular pigmentation, visually enhancing the contrast between the hollow and adjacent areas.
In Geneva, where pollution levels are moderate but real, these factors must be considered in aesthetic assessment, particularly in patients exposed daily to an urban environment. Preventing these aggressions is an integral part of a comprehensive and reasoned approach to periocular aging.
Article written by Dr Romano Valeria
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