The valley of tears corresponds to a hollowed area located between the lower eyelid and the upper part of the cheek.
Its appearance gives the face an expression often perceived as melancholic, tired, or prematurely aged. This infraorbital hollow results from a combination of pathophysiological processes: resorption of the malar fat pad, loss of skin tone, and stretching of the ligamentous and dermal supporting structures. Today, validated medical solutions exist to correct this hollow progressively, safely, and in a manner adapted to each facial morphology.
The first-line treatment of the valley of tears is based on the use of a specific hyaluronic acid, injected directly into the hollow to restore lost volume. This molecule, naturally present in the body, has remarkable hydrophilic properties, allowing immediate rehydration and filling of the hollow.
The hyaluronic acid used for this indication must meet strict criteria: low viscosity, high cohesion, and great flexibility to adapt to the movements of this very mobile area. It is injected using small cannulas, in depth, either in contact with the bone or in the subcutaneous plane, depending on the patient’s anatomy. The correction is progressive, often performed in two stages to avoid overcorrection and ensure a natural result.
The advantages of this method are multiple: immediate and reversible result, no social downtime, precise injection, and visible improvement of the eyelid-cheek transition.
However, this technique requires expert knowledge of the periocular region to avoid complications, particularly the risk of product excess, nodules, or visibility of the product under thin skin.
Rather than directly filling the groove, another approach consists of correcting the cause of the hollowing: the descent of the malar fat compartment. This technique is based on a biomechanical principle: by restoring the volumes of the midface (cheekbones, zygomatic arch), the natural support of the tissues is restored, resulting in a harmonious lifting of the sagging structures — including those responsible for the appearance of the valley of tears.
Hyaluronic acid is injected using a medical lifting technique.
This strategy offers several advantages: reduced risk of irregularities or overcorrection in the valley of tears, a more global and harmonious result, and action on the overall facial dynamics.
It requires perfect knowledge of the deep anatomical planes and the logic of traction vectors. This technique is particularly indicated for patients whose infraorbital hollowing occurs in the context of overall malar laxity.
Sculptra®, based on poly-L-lactic acid, is not a filler with immediate results. Its mechanism of action relies on the progressive stimulation of collagen synthesis: after injection into the deep layers of the dermis and subcutaneous tissue, it induces a fibroblastic response that restores skin thickness, firmness, and density.
In the treatment of the valley of tears, Sculptra® is used to rebuild the depleted dermal cushion, restore volumes in a diffuse manner, and avoid overcorrection. It provides a lasting improvement in skin quality and structure, with a subtle and natural lifting effect.
The advantages of this approach are significant: gradual, adjustable results, no “overfilled” effect, endogenous stimulation of collagen production, and physiological restoration of skin density.
This treatment is particularly suitable for patients whose valley of tears is linked to diffuse thinning of the dermis and fat tissue, often observed after the age of 40. It can be combined with other techniques for a synergistic effect, especially in patients with thin skin.
In certain cases, particularly when the valley of tears is associated with very thin, creased, or lax skin, laser photorejuvenation represents an effective adjunct treatment. Non-ablative and ablative fractional laser technologies (such as Fraxel®) stimulate collagen production, improve skin quality, and increase skin density.
Although their action is indirect, it remains essential: by enhancing skin quality, these treatments reduce its transparency, soften shadows in the infraorbital groove, and strengthen the dermal support of restored volumes. Laser treatment is particularly relevant for patients with fine lines or mild hyperpigmentation, which visually accentuates the depth of the hollow.
The benefits are multiple and fit within a therapeutic synergy approach. A notable improvement in skin quality and firmness is observed. The skin becomes denser, more supple, and visibly revitalized. This enhancement reinforces the smoothing effect of injections by acting as complementary dermal support. Furthermore, the eyes regain a refreshed appearance, with visible attenuation of signs of fatigue. This treatment requires multiple sessions, and a prior evaluation by an experienced physician is essential to choose the appropriate protocol based on phototype and skin thickness.
The choice of aesthetic treatment to correct the valley of tears depends on several factors that must be carefully assessed during the initial consultation. There is no universal solution: the strategy depends on the main cause of the hollow (fat loss, ptosis, skin atrophy), the patient’s age, skin thickness, muscle mobility, and the desired outcome.
In a young patient, whose valley of tears is mainly constitutional (linked to low insertion of the cheekbone or weak malar projection), filling with hyaluronic acid injections is often sufficient. In an older patient, who presents with volumetric loss and global midface laxity, a combined treatment associating medical lifting techniques, Sculptra® and skin densification techniques with laser is generally more appropriate.
The clinical examination must therefore be meticulous. It is based on static and dynamic palpation of the orbito-malar area, an assessment of volumes, an inspection of skin quality, and sometimes the use of imaging tools (medical photographs, polarized light, volumetric mapping). The goal is to propose a rational, coherent, and progressive therapeutic strategy to achieve a natural, stable result without overcorrection.
A combined approach, using several techniques, is often the most appropriate. The valley of tears is never caused by a single factor; it always results from a set of structural deficits: loss of bony support, sagging of fat compartments, reduced dermal density, and skin laxity. Correcting only one tissue layer is often insufficient to achieve a complete aesthetic result.
The combination of several techniques — in a logical sequence — allows treatment of the valley of tears while respecting the anatomical layers. First, restore deep volumes with cross-linked hyaluronic acid injected deeply against the bone. Then, if necessary, complement with targeted filling using a more fluid product. Next, stimulate the tissues with Sculptra®, to restore the skin’s natural thickness. Finally, strengthen the superficial skin structure through sessions of laser photorejuvenation.
This approach allows for a coherent, harmonious, and lasting result, avoiding common mistakes such as excessive and isolated filling of the valley of tears.
Even though it is now possible to achieve remarkable results through aesthetic medical procedures, certain limitations must be clearly explained to the patient. The valley of tears is a particularly delicate anatomical area: richly vascularized and subject to significant individual variations, it requires a precise and cautious approach. Some morphologies, especially those associated with very thin skin, make the treatment more technical and demand increased expertise. Several factors must be taken into account during the assessment and planning of the procedure :
In all cases, realistic management of expectations is essential. It is important to prioritize subtle corrections that respect the balance of the face. When the alterations are too pronounced, a surgical alternative may be more appropriate.
Article written by Dr Romano Valeria
SHARE THIS ARTICLE ON
