A 3-Step, Anatomy-Led Guide to Assessing and Treating Infraorbital Hollowness

Introduction

Infraorbital hollowness remains one of the most technically demanding indications for hyaluronic acid (HA) filler injection. Despite its apparent simplicity, treatment of the infraorbital groove carries a disproportionately high risk of aesthetic dissatisfaction and vascular complications when anatomical diagnosis is inadequate. Contemporary evidence increasingly supports an anatomy-first, diagnosis-driven approach rather than a purely technique-based one. Recent work by Hong et al. (2025) provides a structured framework linking infraorbital anatomy to tailored filler injection strategies, reinforcing the principle that correct diagnosis determines correct treatment. This article synthesizes anatomical concepts, clinical assessment, and injection strategies for infraorbital hollowness based on current medical literature and anatomical science.

Understanding Infraorbital Hollowness: More Than Volume Loss

Infraorbital hollowness is a multifactorial anatomical phenomenon, not simply a deficiency of soft-tissue volume. Contributors include:

• Skeletal remodeling of the maxilla and infraorbital rim

• Atrophy or displacement of deep and superficial fat compartments

• Tethering by osteocutaneous ligaments

• Skin thinning and translucency

• Orbicularis oculi muscle dynamics

Hong et al. emphasize that infraorbital hollowness should be understood as a structural contour deformity, where shadows arise from anatomical transitions between compartments rather than absolute volume loss alone.

Figure 1. Infraorbital groove (tear trough deformity and palpebromalar groove, (A)) and hollowness (B). Key Anatomical Structures Relevant to Injection

1. Infraorbital Groove and Tear Trough Complex

The infraorbital groove corresponds to the junction between the palpebral and orbital portions of the orbicularis oculi muscle, reinforced by the tear trough ligament. This fixed ligamentous attachment explains why superficial filler placement often worsens contour irregularities.

Figure 2. Tear trough deformity and nasojugal groove.

2. Fat Compartments

• Deep medial cheek fat (DMCF) provides foundational support to the infraorbital region.

• Superficial fat compartments thin significantly with age, contributing to contour visibility rather than true volume loss.
  

3. Vascular Considerations

The infraorbital artery and its branches course variably within deep planes, reinforcing the need for deep, supraperiosteal placement when volumization is required, and conservative superficial placement only in selected cases.

Anatomy-Led Clinical Assessment

An effective infraorbital assessment should be systematic and anatomy-driven: Step 1: Identify the Primary Etiology

Ask:

• Is the hollow caused by skeletal deficiency?

• Is ligamentous tethering dominant?

• Is skin quality the limiting factor?

• Is fat herniation present rather than volume loss?

Patients with pseudo-hollowness caused by malar deficiency often benefit more from cheek support than direct infraorbital filling.

Figure 3. Appearance of infraorbital hollowness. Panel (A) shows normal conditions, while panel (B) illustrates hollowness with soft tissue atrophy.

Step 2: Evaluate Skin and Soft Tissue Quality

Thin, translucent skin with poor elasticity increases the risk of:

• Tyndall effect

• Persistent edema

• Visible filler irregularities

In such cases, Hong et al. recommend deep structural support first, minimizing superficial product placement. Step 3: Dynamic Assessment Observation during smiling and squinting is critical. Dynamic orbicularis movement can displace filler, particularly when injected superficially.

Figure 4. Main vessels of the infraorbital region. Diagnosis-Driven Injection Strategies

1. Structural Support Strategy (Indirect Approach) Indicated when infraorbital hollowness is secondary to midface support loss.

• Injection plane: Supraperiosteal

• Target: Deep medial cheek fat / maxillary support points

• Product: Higher G′ HA filler

• Outcome: Elevation of the infraorbital contour without direct tear trough filling

This approach aligns with Hong et al.’s emphasis on treating the cause, not the shadow. 2. Direct Infraorbital Groove Injection (Selective Use)

Indicated only when:

• True volume deficiency is confirmed

• Skin quality is adequate

• Ligamentous tethering is minimal

  
  

Figure 5. Injection entry points and techniques for needle and cannula. A—Injection around the orbital rim using linear threading and droplet techniques; B—cannula entry point for treating grooves; orbital rim using linear threading and droplet techniques; B—cannula entry point for treating C—cannula entry point for treating hollowness. Directions toward the palpebromalar groove and grooves; C—cannula entry point for treating hollowness. Directions toward the palpebromalar nasojugal groove. Techniques include retrograde fanning, linear threading, and very slow release.

Key principles:

• Plane: Deep supraperiosteal or deep sub-orbicularis

• Volume: Minimal, incremental deposition

• Product: Low-to-moderate G′, high cohesivity HA

• Technique: Slow injection, constant aspiration awareness

Superficial dermal injection is generally discouraged due to high complication risk. 3. Combined Strategy

Most patients benefit from a hybrid approach:

• Deep cheek support first

• Conservative infraorbital correction second

This staged correction reduces filler load in high-risk zones and improves contour integration. Avoiding and Managing Complications Common pitfalls include:

• Overfilling ligamentous grooves

• Superficial placement in thin skin

• Treating fat herniation as volume loss

• Ignoring midface support deficiency
  

Risk mitigation strategies:

• Anatomy-guided depth selection

• Conservative volumes

• Cannula or needle choice based on anatomical goal

• Willingness to defer treatment when contraindicated

Clinical Takeaways Infraorbital hollowness is a structural contour problem, not merely a volume deficit.

• Anatomy-led diagnosis must precede injection technique.

• Indirect midface support often produces superior and safer outcomes.

• Conservative, deep placement remains the gold standard.

• Understanding ligamentous anatomy is key to avoiding unnatural results.

Conclusion Anatomy-led assessment transforms infraorbital filler treatment from a high-risk aesthetic procedure into a predictable, reproducible intervention. The framework proposed by Hong et al. (2025) reinforces a paradigm shift in aesthetic medicine: successful outcomes begin with anatomical diagnosis, not syringe placement. For clinicians, mastery of infraorbital anatomy is not optional—it is foundational.

Reference:

1. Hong, G.-W., Choi, W., Yoon, S.-E., Wan, J., & Yi, K.-H. (2025). Anatomical-based filler injection diagnosis to treatment techniques: Infraorbital groove and hollowness. Life, 15(2), 237. https://doi.org/10.3390/life15020237

   
   

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