ABSTRACT
Tear troughs are one of the most requested filler indications, but due to the anatomy of the area, they are considered an advanced indication, as improper placement of Calcium hydroxylapatite (CaHA) can result in malar edema that is resistant to treatment. The tear troughs are essentially the result of the anatomy of the orbicularis retaining ligament, the zygomatic cutaneous ligament (ZCL), and the anatomical layers in between them. The ORL is, therefore, a false retaining ligament as it doesn't extend from the periosteum to the skin. The ZCL runs from the periosteum of the maxilla to its skin insertion making it a true retaining ligament. In between these ligaments from the medial canthus to the foramen, we find the tear trough deformity. Below the skin, an almost nonexistent subcutaneous fat compartment is located just over the orbicularis oculi muscle. Placement of CaHA superficial to the Malar Septum can result in malar edema.
