With the growing interest in appearance and anti-aging, various cosmetic procedures and surgeries have been developed and studied. Aging of the periocular region, especially the lower eyelid, is a hallmark of midfacial aging. This aging process is characterized by weakening of the orbital septum, leading to orbital fat protrusion, sagging of the suborbicularis oculi fat, and formation of palpebral bags due to laxity of the lower eyelid skin [1]. Additionally, the tear trough groove, caused by atrophy of the orbicularis oculi muscle and surrounding soft tissues, as well as the prominence of orbital rim skeletonization [2,3], is considered part of a continuous process. Accurate understanding of the extent and mechanisms underlying these changes is crucial for selecting an appropriate surgical approach [4].

Noninvasive treatments, such as autologous fat grafting and filler injections, are commonly used to address lower eyelid hollowing due to aging of the midface and adjacent areas. The outcomes of autologous fat grafting can be unpredictable owing to issues with graft survival and volume loss, sometimes requiring additional supplementation. However, although filler injections are widely used to restore facial soft tissue volume, they have limitations when correcting infraorbital hollowness, such as the Tyndall effect, unnatural contours, bulging, and migration [5]. These issues stem from previous procedures to correct soft tissue volume deficiencies.

In this study, we examined the effects of hyaluronic acid (HA) filler injection using a modified sequential autologous fat injection (SAFI) method to correct skeletal deformity and soft tissue volume deficiencies in the midface and adjacent lower eyelid hollowing.

This study aimed to improve infraorbital hollowness in patients by injecting an HA filler (Elravie_Ⓡ, Premioer Ultravolume-L [HA 23 mg/0.3% lidocaine]; Humedix Co., Ltd.) to correct lower eyelid hollowing. One month post-procedure, changes in the form of the lid-cheek junction (LCJ), globe-to-orbital rim relationship, lower lid contour, and eyelid positioning were observed.

The injection sites were as shown in Fig. 1, and local anesthesia was administered using 2% lidocaine with 1:100,000 epinephrine. Following the SAFI injection sequence [6], an entry site was created with an 18 G sharp needle, and HA was injected using a 22 G, 5.0-cm long blunt cannula (Blunt & Filler Cannula, Poonglim Pharmatech). For each designated region (I, II, III, and IV), 60%–70% of the total volume was injected between the periosteum and orbital retaining ligament or just above the periosteum, 20%–30% into the deep fat layer below the orbicularis oculi muscle, and the remaining 10% into the superficial fat layer. Overall, 3.0 ml and 4.0 ml of HA filler were used on the left and right midface, respectively. Pre- and post-procedure photographs were analyzed to observe changes in the midfacial form, eyelid contour, infraorbital hollowness, and LCJ length.

Figure 1. A schematic photo for the sequential augmentation of the filler injection (SAFI). The filler was sequentially injected into the zone I, II, III and IV. The hyaluronic acid filler can was placed over the periosteum of the inferior orbital rim and beneath the orbital retaining ligament and then injected into the fat layers in the lower lid regions (Zone I and III). In the mid-facial regions (Zone II and IV), the filler was paced over the periosteum and prezygomatic space and then injected into the fat layer. A, Orbital rim; B, Zygomatico-maxillary suture line; C, Lid-cheek junction; I, zone of palpebromalar groove; II, zone of malar eminence; III, zone of tear trough deformity; IV, zone of mid-cheek depression; Blue circles, Entry sites for the filler injection; A black circle, Anterior-inferior prominence of the maxillary bone; A green colored double-headed arrow, the distance of the lid-cheek junction on the mid-pupillary line.

Morphological changes in the midface

Restoration of midface volume improved midface prominence, resulting in a smaller and narrower face (Fig. 2). Negative vector rim relationships improved significantly, shifting towards a reversed negative vector relationship, enhancing orbital harmony, and reducing lower eyelid eversion (Fig. 3). These changes resulted in a natural and revitalized facial appearance.

Figure 2. Pre-and post-operative photos after filler injection into a 36-year-ld male patient. (A) A negative globe-to-orbital relationships with a broken convex line from the lower eyelid to the cheek in profile, sagged appearance of midface with increased volume from the lateral nasolabial region, and an everted lid with downward direction of the eyelash are seen. (B) Improved everted eyelid with upward direction of the eyelash is seen. Significant volume restoration without any sagging appearance from the infraorbital and midfacial regions with approaching a positive glove-to orbital relationships and upward direction of the eyelash and improvement of lid eversion are seen. (C, D) The eversion of the lids is improved, the contour of the lower lid was changed from round shaped to less round and looked longer, the protruded orbital fat was improved in the left eyelid, rather, the orbital fat in the left eyelid was more protruded by supporting of the midface volume restoration.

Figure 3. Measurement of the change of the shape and distance of lid-cheek junction (LCJ) after filler injection into the midface and infraorbital hollowness in a 36-year-old male patient. (A) Before, lid laxity with round lid and scleral show and severe infraorbital hollowness with dark circle are observed. Vertical shaped LCJ (shown as a dotted and black colored line) are observed as the aged sign. (B) One month after, the shaped of the lower lid was changed from round shaped to less round shaped and contour of the LCJ was also changed from the vertical shaped to the less round shaped. The distances of LCJ were decreased from 18.0 mm, 20.5 mm to 15.75 mm, 15.0 mm separately. (C) Immediately after, a represents the distance of LCJ, b indicates entry sites for the filler injection, and c means injection boundary.

Changes in lower eyelid hollowing

Severe infraorbital hollowness, and dark circles were observed before treatment. However, with HA filler injection using the SAFI technique, volume restoration improved the lower eyelid contours, changing their shape from round to less round and creating a more natural contour while reducing the scleral show (Fig. 2, 3).

Lower lid and eyelash changes

Pre-treatment, the lower lids appeared round with inward eversion, causing the eyelashes to point downward. Post-treatment, the lower lid contours became less rounded, and the direction of the eyelashes shifted upward, creating a more vibrant and brighter impression. Lower lid eversion improved, enhancing the anatomical relationship between the lower lid and eyelid (Fig. 2, 3).

Lid-cheek junction shape and length changes

For objective evaluation of infraorbital hollowness improvement, changes in the V-shaped LCJ were measured at the midpupillary line (Fig. 3). Immediately post-treatment, the V-shaped LCJ values reduced from 20.5 mm to 14.5 mm on the left and from 18 mm to 14 mm on the right, transforming the LCJ to a rounder shape. One month later, the V-shaped LCJ values were maintained at 15.0 mm and 15.75 mm on the left and right sides, respectively, indicating sustained improvement. Additional volume recovery was noted compared to immediately after treatment, with LCJ values increasing by 0.50 mm on the left and 1.75 mm on the right. Before treatment, the LCJ appeared vertical (V-shaped); however, the treatment resulted in a more rounded shape.

HA filler injections using the SAFI technique effectively restored the midfacial and infraorbital hollow volume. This approach enhances the anatomical relationship between the lower lid and the surrounding structures, creating a more harmonious contour and a natural, revitalized appearance. Additionally, improvements in lower lid contours, eyelash direction, and changes in the LCJ shape and length were observed, suggesting that this procedure can contribute significantly to youthful and vibrant overall facial impressions. The impact of this treatment extends beyond simple volume restoration, helping achieve facial balance and harmony.

Facial aging involves not only soft tissue sagging but also structural changes in the skeletal framework, significantly affecting overall facial balance and appearance. Mendelson and Wong noted predictable skeletal resorption in specific areas, including the midface, maxilla, orbital rim, and mandible, which contribute to outward signs of aging. Addressing these changes is crucial for achieving effective and harmonious facial rejuvenation.

Farkas et al. [7] emphasized that understanding the interaction and transformation of the skin, soft tissue, and skeletal structures is essential for restoring a youthful appearance. While traditional theories primarily focused on soft tissue sagging, recent research highlights skeletal changes and fat compartment dynamics as key aging contributors. Enhancing midfacial skeletal proportions and reshaping the fat, skin, and muscle layers enables personalized restoration strategies. This underscores the SAFI technique’s potential to address both skeletal deformities and soft tissue volume deficiencies, achieving improved facial balance.

Tan and Kontis [8] similarly aimed to restore midface and lower eyelid harmony using fillers, such as HA, calcium hydroxylapatite, and poly-L-lactic acid. They highlighted the importance of smooth transitions between midface and lower eyelid contours, proper injection techniques, and appropriate filler selection—an approach aligned with the SAFI technique’s multilayered injection strategy targeting fine anatomical structures.

Our findings demonstrate that lower eyelid support through filler injections not only restores volume but also reshapes eyelid and eyelash contours. While traditional procedures like lateral canthoplasty address lid laxity, the SAFI technique offers volume support to improve this condition. Given the anatomical connection between the midface and lower eyelid, addressing midfacial skeletal aging first, followed by soft tissue volume enhancement, yields optimal correction of lower eyelid hollowing. The SAFI approach effectively improves midface and lower eyelid aging in a comprehensive manner.

As an initial study with limited cases, this research provides foundational data on the cosmetic potential of the SAFI technique. Further clinical studies are needed to validate its efficacy and safety, solidifying its role as a customized cosmetic solution. These findings reinforce the potential of advanced filler techniques to go beyond simple volume restoration, offering precise and personalized strategies for facial rejuvenation.

None.

The authors have nothing to disclose.