The valley of tears corresponds to a natural depression that extends 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 — suborbital fat, malar contour, ligamentous structures — gradually sag.
This hollow, 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 softness of the facial contours, casting a permanent shadow that accentuates a tired or melancholic appearance of the eyes, regardless of health status or actual rest. The valley of tears is thus among the first perceptible signs of midface aging and is a frequent reason for consultation, particularly for patients wishing to restore a fresher, more rested expression without altering their identity.
Non-surgical treatment of the valley of tears mainly relies on hyaluronic acid injections, a biocompatible and resorbable filler. The therapeutic approach varies according to the degree of sagging, tissue quality, patient anatomy, and depth of the hollow.
The choice of hyaluronic acid type is fundamental: it must be a low-hydrophilic gel, flexible enough to integrate harmoniously into an area with thin and mobile skin, yet cohesive enough to maintain volume over time. In certain situations, particularly when malar fat volume loss is observed, it is essential to start treatment with deep structural restoration. This work is performed as close as possible to the bone plane to re-establish solid anatomical support, a crucial prerequisite before considering more superficial filling of the valley of tears. This two-step approach restores the natural projection of the cheekbone, improves the anchoring of the overlying tissues, and ensures a harmonious transition between the lower eyelid and the cheek. Without this deep support, any superficial injection risks creating inappropriate volume, compromising the naturalness and durability of the result.
Injections can be performed using a blunt-tipped cannula for an atraumatic procedure or a fine needle, depending on indications and the physician’s experience. Each protocol is personalized to guarantee a natural result without overcorrection.
One of the main advantages of treating the valley of tears with hyaluronic acid lies in its logistical simplicity: the procedure is quick, generally completed in less than 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 allows determination of the injection points, the necessary quantities, and the most suitable products.
The treatment is immediately followed by a return to social activities. Although redness, slight swelling, or bruising may occur, these side effects are temporary and disappear within a few days.
One of the most frequently expressed concerns by patients is pain. In reality, treatment of the valley of tears is minimally painful when performed by an experienced physician with perfect technical mastery.
The use of fine needles or blunt-tipped cannulas greatly limits discomfort. Additionally, most hyaluronic acids used contain a local anesthetic (lidocaine), which gradually takes effect during the injection.
If necessary, a topical anesthetic cream can be applied before treatment. This precaution further reduces the sensation of pricking or pressure when the cannula passes under the skin. The sensation is most often described as slight discomfort or moderate pressure, rarely as sharp pain.
It is essential to emphasize that technical skill, precise injection planning, and a thorough knowledge of midface anatomy ensure a safe procedure and minimize discomfort.
One of the first points to highlight is that treatment of the valley of tears is, in the vast majority of cases, well tolerated in terms of sensitivity, even in the most sensitive patients. During consultation, most describe the procedure as slightly uncomfortable, without reporting real pain. The sensations felt are more akin to localized pressure or slight tension in the suborbital region, rather than sharp or persistent pain.
Compared to other areas of the face, treatment of the valley of tears is generally better tolerated in terms of sensitivity. Unlike more richly vascularized or innervated regions, such as the lips or mandibular angle, this area has more discreet innervation and lower superficial vascular density. This allows a more comfortable procedure for the patient, with a reduced risk of sharp pain during injection, particularly when performed with an appropriate cannula and following safe anatomical planes.
Patient comfort relies largely on the choice of injection equipment, particularly the blunt-tipped cannula, which is preferentially used for treating the valley of tears. Unlike a conventional needle, the cannula does not cut the tissues but gently displaces them, significantly limiting trauma, bruising, and painful sensations.
The injection is generally performed from a single entry point, often located on the cheekbone, allowing treatment of the entire valley of tears while avoiding multiple punctures. This injection protocol, carefully designed to respect the anatomy of the eye contour, ensures excellent tolerance, even in this particularly delicate area. The precision of the technique, combined with the physician’s experience, allows controlled and gradual distribution of the product, promoting its integration into the tissues. This mastery significantly reduces discomfort and also minimizes the risk of bruising or inflammatory reactions, contributing to rapid recovery and high patient satisfaction.
Treatment of the valley of tears requires precise knowledge of periocular anatomy due to the complexity of this region. The skin is extremely thin, averaging 0.33 mm, lacks significant superficial fat support, and is traversed by numerous sensory nerve endings, notably from the infraorbital nerve. These characteristics could suggest increased sensitivity to the medical procedure. Yet, in practice, this area responds very favorably to injections, provided they are performed according to a rigorous protocol that respects anatomy.
Treatment tolerance largely depends on proper management of the injection plane. When a product is accurately injected at the deep plane, usually resting on the periosteum, the trajectory avoids major 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-tipped cannula, instead of a needle, also enhances safety. It allows atraumatic passage through tissues, reduces the risk of bruising, and limits nociceptive stimulation. Combined with slow, progressive injection and an appropriate product choice (low-hydrophilic, moderately cross-linked hyaluronic acid), this technique ensures excellent tissue integration and a comfortable patient experience.
Thus, although the infraorbital region presents notable anatomical complexity, it can be treated with minimal pain, provided the indication is carefully established, the injection plane is precisely respected, and the procedure is performed by a physician with full 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.
After the injection, the immediate aftermath is generally very well tolerated. There may be a slight feeling of tension or pressure at the injection site, but this does not constitute true pain. This sensation usually disappears spontaneously within a few hours or days, without the need for painkillers in most cases.
In some instances, small bruises or mild localized swelling may appear, especially in patients with thin skin or fragile capillaries. These signs are minor and temporary, are not accompanied by significant pain, and can be alleviated with cold application or appropriate soothing creams.
It is rare for treatment of the valley of tears to require social downtime, and patients can usually resume their activities immediately after leaving the office, 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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