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The tear trough deformity is a natural consequence of the anatomic attachments of the periorbital tissues. A variety of techniques have evolved to address this cosmetic issue including subtractive blepharoplasty techniques, elevation of ptotic eyelid and midface tissues, and the injection or implantation of autogenous or alloplastic materials to diminish its appearance. Greater anatomic understanding of the pathogenesis of the tear trough deformity has led to more anatomically conservative and appropriate cosmetic surgical treatments. The decline in purely subtractive surgical techniques in blepharoplasty surgery and the advent of fat-repositioning techniques and new subdermal fillers have improved surgical outcomes.