The tear trough corresponds to a natural depression extending from the inner corner of the eye to the upper part of the cheek, along an anatomical axis supported by the ligamentous and bony structures of the midface. This area, particularly exposed to variations in volume and skin tension, plays a central role in the expression of the gaze. Over time, the junction between the lower eyelid and the cheekbone deepens: the supporting tissues — under-eye fat, malar prominence, and ligamentous structures — gradually sag.
This hollowing, initially subtle, tends to become more pronounced with age, sometimes as early as the thirties depending on individual predispositions. It creates a break in the smooth contours of the face, casting a permanent shadow that enhances a tired or melancholic appearance of the eyes, regardless of health or actual rest. The tear trough thus represents one of the first noticeable signs of midface aging and is a common reason for consultation, especially among patients seeking to restore a fresher, more rested expression without altering their identity.
Non-surgical treatment of the tear trough is primarily based on hyaluronic acid injection, a biocompatible and resorbable filler. The therapeutic approach varies according to the degree of sagging, tissue quality, patient anatomy, and the depth of the hollow.
The choice of hyaluronic acid type is fundamental: it should be a low-hydrophilic gel, flexible enough to integrate harmoniously in an area with thin and mobile skin, yet cohesive enough to maintain volume over time. In certain situations, particularly when there is malar fat volume loss, it is essential to begin treatment with a deep structural restoration. This work is performed as close as possible to the bone plane to re-establish solid anatomical support, a necessary prerequisite before considering more superficial tear trough filling. This two-step approach restores the natural projection of the cheekbone, improves the anchoring of overlying tissues, and ensures a harmonious transition between the lower eyelid and the cheek. Without this deep support, any superficial injection risks inappropriate volume augmentation, compromising naturalness and longevity of the result.
The injection can be performed using a blunt-tip cannula for an atraumatic procedure, or a fine needle, depending on the indications and the physician’s experience. Each protocol is personalized to ensure a natural result, without excessive correction.
One of the main advantages of tear trough treatment with hyaluronic acid lies in its logistical simplicity: the procedure is quick, generally performed in under 30 minutes during a consultation. It requires neither general anesthesia nor hospitalization.
Before the injection, a precise facial analysis is conducted, taking into account volumes, asymmetries, gaze dynamics, and skin condition. This rigorous morphological evaluation determines the injection points, necessary quantities, and the most suitable products.
The treatment is immediately followed by a return to normal social activities. Although redness, mild swelling, or bruising may occur, these side effects are transient and disappear within a few days.
One of the most common concerns expressed by patients is pain. In reality, tear trough treatment is minimally painful when performed by an experienced physician with full technical mastery.
The use of fine needles or blunt-tip cannulas significantly limits discomfort. Moreover, most hyaluronic acids used contain a local anesthetic (lidocaine), which gradually acts during the injection.
If necessary, a topical anesthetic cream can be applied before the treatment. This precaution further reduces the sensation of pricking or pressure during the passage of the cannula under the skin. The sensation is most often described as mild discomfort or moderate pressure, rarely as sharp pain.
It is essential to emphasize that technical skill, precision in the injection plane, and a detailed knowledge of midface anatomy help secure the treatment and minimize discomfort.
One of the first points to emphasize is that tear trough treatment is, in the vast majority of cases, well tolerated in terms of sensitivity, even among the most sensitive patients. During consultation, most describe the procedure as slightly uncomfortable, without reporting real pain. The sensations experienced are more akin to localized pressure or slight tension in the under-eye area, rather than sharp or persistent pain.
Compared to other areas of the face, tear trough treatment is generally better tolerated in terms of sensitivity. Unlike regions that are more richly vascularized or innervated, such as the lips or mandibular angle, this area has more discreet innervation and lower superficial vascular density. This allows for a more comfortable procedure for the patient, with a reduced risk of sharp pain during the injection, especially when performed with an appropriate cannula and along safe anatomical planes.
Patient comfort largely depends on the choice of injection equipment — in particular, the blunt-tip cannula, which is the preferred tool for tear trough treatment. Unlike a traditional needle, the cannula does not cut through the tissues but gently separates them, significantly reducing trauma, bruising, and pain sensations.
The injection is usually performed from a single entry point, often located on the cheekbone, allowing treatment of the entire tear trough while avoiding multiple punctures. This injection protocol, specifically designed to respect the anatomy of the eye contour, ensures excellent tolerance, even in this particularly delicate area. The precision of the technical gesture, combined with the physician’s experience, allows for controlled and gradual distribution of the product, promoting its smooth integration into the tissues. This mastery significantly reduces discomfort and minimizes the risk of bruising or inflammatory reaction, contributing to a quick recovery and high patient satisfaction.
The treatment of the tear trough requires precise knowledge of periocular anatomy, due to the complexity of this region. The skin there is extremely thin, measuring on average 0.33 mm, lacking any significant superficial fatty support, and traversed by numerous sensory nerve endings, notably from the infraorbital nerve. These characteristics could suggest an increased sensitivity to medical procedures. Yet, in practice, this area responds very favorably to injections, provided they are performed according to a rigorous and anatomically respectful protocol.
The tolerance of the treatment largely depends on proper management of the injection plane. When a product is injected accurately at the deep plane, generally supported on the periosteum, the trajectory lies outside the main neurovascular axes. This anatomical arrangement significantly reduces the risk of unwanted nerve stimulation or vascular injury, making the procedure safer and better tolerated. The use of a blunt-tip cannula instead of a needle also contributes to procedural safety. It allows tissues to be traversed atraumatically and reduces the risk of hematoma while limiting nociceptive stimulation. Combined with a slow, progressive injection and a suitable choice of product (low-hydrophilicity, moderately cross-linked hyaluronic acid), this technique ensures excellent tissue integration and a comfortable experience for the patient.
Thus, although the infraorbital region presents notable anatomical complexity, it can be treated with minimal discomfort, provided that the indication is established rigorously, the injection plane is followed precisely, and the procedure is carried out by a physician with a thorough mastery of periocular anatomy.
Pain management begins well before the injection itself. Careful preparation, including, if necessary, the application of a topical anesthetic cream, helps desensitize the area and optimize comfort from the very start of treatment. This step is offered to the most sensitive patients or those undergoing their first aesthetic injection.
Moreover, most hyaluronic acids injected already contain lidocaine, a local anesthetic integrated into the gel, which gradually acts during the injection to reduce unpleasant sensations.
Finally, the care environment plays a crucial role: a calm, welcoming, and well-equipped medical office, combined with clear and compassionate communication from the physician, helps ease apprehension and ensures the procedure is a controlled and reassuring experience.
Once the injection is performed, the immediate after-effects are generally very well tolerated. There may be a slight feeling of tightness or pressure at the injection site, but it is not true pain. This sensation disappears spontaneously within a few hours or days, without the need for analgesics in most cases.
In some cases, small bruises or slight localized swelling may appear, especially in patients with thin skin or capillary fragility. These signs, mild and temporary, are not accompanied by significant pain and can be reduced by applying cold or suitable soothing creams.
It is rare for tear trough treatment to require social downtime, and patients can generally resume their activities immediately after leaving the clinic, without major discomfort or lasting pain.
Although pain is rarely reported after a properly performed treatment, it is essential to remain vigilant for certain atypical signs. Sudden, intense, asymmetric, or persistent pain in the injected area may indicate a complication, such as vascular compression, a deep hematoma, or an inflammatory nodule.
These situations are exceptional when the treatment is performed by an experienced physician with thorough knowledge of periocular anatomy. Nevertheless, patients should be informed about the appropriate course of action in case of doubt.
The physician must always remain available after the treatment to reassess the injected area and intervene if correction or additional treatment is necessary.
Pain in aesthetic medical procedures is also a matter of perception. Some patients arrive with significant apprehension, related to past experiences, individual sensitivity, or simply anticipation. It is therefore essential not to overlook the psychological aspect in patient care.
Clear information, explanations of the treatment steps, and a trusting relationship with the physician are all key tools to alleviate anxiety. This reassuring approach is especially crucial because pain perception is amplified in cases of stress or emotional tension.
Providing a professional, compassionate, and transparent environment helps transform fear into a controlled and positive experience.
Article written by Dr Romano Valeria
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