Anatomical Precision in Tear Trough and Infraorbital Filler Injections: From Diagnosis to Treatment
- Admin
- 2 days ago
- 6 min read
Infraorbital hollowness and tear trough deformities are some of the most delicate areas to treat in aesthetic medicine. Patients often report looking tired, aged, or sunken, even when well-rested making this zone a focal point in facial rejuvenation. However, it remains technically challenging due to the complex anatomy and proximity to critical vascular structures.
In their 2025 study published in Life, Dr. Gi-Woong Hong and colleagues present a comprehensive, anatomy-based strategy to enhance both safety and precision in infraorbital filler treatments. Their approach emphasizes detailed diagnosis, appropriate filler placement planes, and step-by-step injection planning.
What Causes the Tear Trough and Infraorbital Groove?
The infraorbital groove is not simply a cosmetic concern, it is the visible result of multiple structural interactions beneath the skin. The tear trough, which appears as a curved shadow starting at the medial canthus, is primarily caused by ligament tethering, fat pad atrophy, and soft tissue descent. As this hollow extends laterally, it becomes the palpebromalar groove, often creating a wide, sunken look across the midface.
Figure 1: Infraorbital groove (tear trough deformity and palpebromalar groove, (A)) and hollowness (B).
The medial hollowing, directly beneath the eye, creates a fatigued look despite the patient's otherwise healthy facial tone. This is often seen in patients with strong tear trough ligaments (TTL) and loss of volume in the orbital rim area.
The groove in some patients extends laterally into the palpebromalar groove. This wider depression is not only influenced by the TTL but also by the orbicularis retaining ligament (ORL) and soft tissue volume loss across the sub-orbicularis oculi fat (SOOF). This expansion turns a tear trough into broader infraorbital hollowness.
Infraorbital grooves can appear as a tear trough (medial infraorbital groove) or extend laterally as a palpebromalar groove. In Koreans, these grooves are often more prominent but tend to show less hollowness due to thicker skin and soft tissue compared to many Caucasians. The tear trough deformity mainly affects the inner third of the lower eyelid and may progress laterally with age. In contrast, the nasojugal groove runs from the nose toward the cheek, forming a subtler line beneath the orbital rim. For effective filler placement, it’s crucial to accurately identify these anatomical landmarks to minimize the risk of complications, particularly in areas where important blood vessels like the infraorbital artery and facial vein are located.
3 Clinical Classification: Defining the Degree of Volume Loss
Dr. Hong categorizes infraorbital volume loss into three clinical classes to guide aesthetic planning:
Class I: Medial tear trough only, best suited for focused filler correction.
Class II: Includes medial and lateral depression—often involves nasojugal and palpebromalar grooves.
Class III: Global hollowing with volume loss in the medial cheek and SOOF, often accompanied by malar bags or mid cheek grooves.
This classification not only helps determine filler volume and placement plane, but also whether combination treatments may be necessary.
Technique Matters: Injection Planes, Cannula Use, and Layering Strategy
The infraorbital area is best approached with a dual-plane filler technique, adapted to the patient's class of hollowing and anatomical depth.
Deep Plane (Supraperiosteal or Submuscular)
This is the foundational layer where volume loss is most pronounced. For medial tear troughs—where SOOF is absent—inject either directly on the bone or just under the orbicularis muscle. This lifts the ligament and fills the groove from below.
Superficial Plane (Subdermal)
Used to blend surface contour irregularities and fine depressions, this layer must be handled with extreme caution to avoid complications like beading or the Tyndall effect.
The blunt-tip cannula is preferred for most infraorbital applications due to reduced risk of vascular trauma. Entry is typically made 15–20 mm below the orbital rim, along the vertical line of the lateral limbus. A retrograde linear threading or gentle fanning technique allows smooth filler distribution with minimal tissue disruption.
These are the two key filler planes in the infraorbital region:
The deep plane (supraperiosteal or sub-orbicularis), used to restore foundational volume and support.
The superficial plane (subdermal), intended for surface-level smoothing and contour refinement.
The recommended entry point for a blunt-tip cannula, typically placed around 15–20 mm below the orbital rim and aligned vertically with the lateral limbus of the eye. From this entry, the cannula is advanced upward toward the tear trough in a retrograde or fanning motion, allowing smooth, controlled filler placement. This image is crucial for visualizing safe cannula trajectory while avoiding vascular danger zones.
A side-by-side illustration of cannula versus needle use in the infraorbital region:
The cannula technique is shown creating a wide, even filler distribution with minimal trauma, making it ideal for patients with delicate skin or high vascular risk.
The needle technique offers pinpoint precision but with higher risk of bruising or vessel injury, particularly when used too superficially or aggressively.
Understanding Vascular Landmarks to Minimize Complications
The infraorbital region is rich in critical vascular structures, including the infraorbital artery, zygomaticofacial artery, and facial vein. These vessels run close to common filler sites, particularly along the nasojugal groove and lateral orbital rim. To reduce the risk of complications such as bruising, hematoma, or embolic events:
Use blunt cannulas whenever possible
Avoid bolus injections in high-risk areas
Inject slowly with minimal pressure
The pathway of the infraorbital artery is illustrated, showing its emergence from the infraorbital foramen approximately 6–10 mm below the orbital rim. To avoid complications such as embolism or ischemia, bolus injections or high-pressure filler should be avoided in this area.
Additional vascular branches, such as the zygomaticofacial artery and deep venous structures, are shown, emphasizing the importance of slow injection and minimal filler volume in the infraorbital triangle. These visuals are essential for training purposes and advanced injection planning.
Filler Volumes, Touch-Up Timing, and Avoiding Overcorrection
Dr. Hong recommends an initial volume of 0.3–0.5 mL per side, depending on severity. Overcorrection, especially in superficial layers, can result in:
Tyndall effect (bluish hue)
Visible beading under thin skin
Puffiness or migration of product
It’s best to undercorrect initially and reassess after 2–3 weeks, when swelling has subsided and filler has integrated. A second, smaller session may be scheduled to perfect symmetry and contour.
Not All Patients Are Ideal
Ideal patients:
Have mild to moderate volume loss
Retain good skin elasticity
Show limited orbital fat bulging
Avoid filler-only treatments in patients with:
Severe skin laxity
Malar bags or festoons
Post-blepharoplasty changes
For such cases, adjunctive methods like thread lifting, RF tightening, or surgery may be better suited. The best outcomes come from combining filler with collagen-stimulating or skin-tightening modalities, depending on the severity of aging and structural descent
Clinical Pearls from Dr. Hong’s Technique
Perform the "pushing test": If depression remains fixed under manual pressure, ligament release may be required.
In Class III cases, address midface volume loss before attempting direct under-eye correction.
Avoid massage post-injection; allow the filler to integrate without manipulation.
Document baseline with a classification photo for accurate follow-up and treatment planning.
Conclusion
.
The tear trough and infraorbital region are areas where millimeters matter, and anatomy is everything. Dr. Gi-Woong Hong and his team provide a meticulous, evidence-based framework that blends structure, technique, and aesthetic insight. By tailoring treatment to the unique anatomy and aging pattern of each patient, clinicians can deliver safer, more effective results—and restore the bright, youthful energy patients are seeking.
Reference:
Hong, G.-W., Lee, H., Jang, Y. J., Hong, S.-H., & Lee, W.-J. (2025). Anatomical-based filler injection diagnosis to treatment techniques: Infraorbital groove and hollowness. Life, 15(2), 350. https://doi.org/10.3390/life15020350
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