Comment to: "Endoscopic Tear Trough Correction with Fat Graft During Mid-face Lift"

We read with great interest the recently published article by Ufuk Askeroglu et al., ‘‘Endoscopic tear trough correction with fat graft during mid-face lift’’ [1]. The study presents a commendable and innovative contribution to the evolving field of periorbital rejuvenation. Correction of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. The Authors propose a very interesting association including tear trough and mid face correction by endoscopic technique, but we have some elements to discuss. A key strength of this technique is the application of infratemporal fat, harvested within the same surgical field, thus avoiding secondary donor sites and enhancing procedural efficiency. The creation of a subperiosteal pocket to fill the nasojugal groove, for in vivo graft placement, also minimizes graft migration and avoids the need for fixation, which is particularly advantageous in preserving anatomical integrity and ensuring a scarless outcome. The periorbital region is of vital significance to the perception of facial beauty, as it portrays youth, health and well-being. Because of its high visibility, the malar area is an extremely critical zone, and TT deformity is one of the most common signs of the aging process. Since it is in a very sensitive area, even when not particularly evident it gives the skin an unhealthy, aged and tired appearance. With the aging process, the fullness of the face contour flattens out, and very efficient anchorage ligaments affect the chronological repositioning of the soft facial tissues, interrupting the regularity of the mid-face profile and splitting it into an alternation of concavities and depressions. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction [2, 3]. The Authors emphasized a subperiosteal placement of the fat graft; did the Authors consider the role of TT ligament in their strategy (?), and how did they manage it during a subperiosteal approach? Although TT correction should account for the individual needs of each patient, it is not merely a question of volume restoration, but should deliver esthetically pleasant results without a puffy and unnatural appearance. Irregularities in this very sensitive area could be particularly unpleasant. Although filling the hollow is one of the most common approach, the release of the firm connection between the dermis and the periosteum represents the key in tear trough correction and it should be considered for satisfactory and stable results [4, 5]. Since the role of the facial ligaments in the genesis of facial hollows is clear, their releas