Treating the tear trough: A new classification system, a 6-step evaluation procedure, hyaluronic acid injection algorithm, and treatment sequences

J Cosmet Dermatol. 2018 Jun;17(3):333-339. doi: 10.1111/jocd.12514. Epub 2018 Mar 5.


Introduction: The tear trough deformity is commonly requested for correction, most often by filler injections. However, the tear trough remains difficult to treat due to its complex anatomy, a variety of other concurrent deformities, and the high risk of complications.

Objectives: To create a standardized categorization, evaluation, and treatment protocol for the management of tear troughs with fillers.

Methods: (1) Patient deformity profiles are determined using three categories of traits: A (Atrophy), B (Bulging), L (Laxity). (2) A 6-step evaluation process (Tilt, Snap, Smile, Squint, Pull, Push) aids in ABL determination. (3) Treatment is simplified into a comprehensive protocol for each category (with 6 major injection points and a variety of injection depths and volumes).

Results: The author has achieved satisfactory results using the presented protocols, with photographic examples.

Conclusion: The author proposes a comprehensive categorization system that takes into account both the tear trough and other concurrent deformities. The author also presents 6 tests to aid in categorization, and simple protocols with injection sequences, amounts, and depth.

Keywords: 6-steps evaluation; HA filler injection treatment; hyaluronic acid injection algorithm; new classification system; tear trough; treatment sequences.

MeSH terms

  • Adult
  • Algorithms*
  • Atrophy / complications
  • Cosmetic Techniques*
  • Dermal Fillers / administration & dosage*
  • Eyelids / pathology*
  • Humans
  • Hyaluronic Acid / administration & dosage*
  • Physical Examination
  • Skin Aging*


  • Dermal Fillers
  • Hyaluronic Acid