An Eye for Assessment: How to Optimally Assess for Infraorbital Filler Treatment

Firstly, it’s helpful to note that most infra-orbital complaints fall into one of the following four categories: Bags, sunken, wrinkles / grooves, dark circles.

Elementary as this point may seem, a patient’s history can actually tell the thorough practitioner quite a lot and offer immediate insights about viability. I often find a comprehensive overview of patient history to be the most critical step in filtering out unviable patients, doing so more efficiently than observation in many cases. In fact, I would recommend that any patient assessment begin with establishing a narrative around their lifestyle: Do they get enough sleep? Do their eye bags have a diurnal pattern of fluctuation? Are they vegetarian and therefore possibly anaemic? After all, our role as practitioners is to help patients achieve a desired outcome, which doesn’t always require sticking needles in them! So if a lifestyle alteration is likely to bring our patient closer to that desired outcome, we should make that recommendation before proceeding any further.

Far too often when I see practitioners performing assessments on a treatment bed or chair, their patient is lying back at a 45-degree angle (or greater in some cases). But optimal observation occurs with the patient upright as possible, a position which allows gravity to act on the face naturally and is thus the best way to assess and plan. Sometimes lying the patient back can also cause the Nasojugal fat pad, under which the angular artery runs, to spread over the tear trough groove and give the face an artificially even appearance. 

Far too often when I see practitioners performing assessments on a treatment bed or chair, their patient is lying back at a 45-degree angle (or greater in some cases). But optimal observation occurs with the patient upright as possible, a position which allows gravity to act on the face naturally and is thus the best way to assess and plan. Sometimes lying the patient back can also cause the Nasojugal fat pad, under which the angular artery runs, to spread over the tear trough groove and give the face an artificially even appearance. 

Additionally, ensure that you have good lighting wherever you choose to position the patient. A good amount of natural light is often sufficient, but if using artificial light, I’d recommend fluorescent white light directly in front of or above the patient.

Vector assessment, or the lack thereof, is another shortcoming of conventional training, and one which often causes practitioners to significantly favour treatment of patients with sunken eyes over those with under eye bags. But by understanding the anatomy of the infraorbital region, how it evolves with ageing and the different ways vectors can guide your treatment plan, practitioners can properly assess and often treat patients with puffy eyes or bags.

Vectors, which refer to the frontal cheek projection in relation to the corneal line (the perpendicular line that sits in front of the cornea), are split into positive, negative and neutral. If you’ve ever heard that treating the cheeks can improve the condition of eye complaints, vectors are the key. As the face ages, the frontal cheek volume declines and recedes. Infraorbital fat very often begins to prolapse and sit forward relative to the cheeks. This phenomenon, also known as a negative vector, gives the appearance of pronounced eye bags. By adding volume to the cheeks and doing some careful work along the tear trough ligament, a practitioner can restore a patient’s youthful, positive vector and significantly improve the appearance of eye bags. For patients with negative and, in some cases, neutral vectors, this simple assessment, which requires only a tablet or phone image, can provide an additional treatment option and give practitioners confidence in managing far more patients. Furthermore, this same technique can be used as a strong indicator to avoid those with bags under the eyes who still have a positive vector.

Assessing skin quality is another important procedural step for practitioners looking to improve success rates. Regardless of the findings from a patient history and lifestyle assessment, I recommend that practitioners look out for two specific conditions with regards to the skin. First is hyperpigmentation; no amount of deep-to-bone hyaluronic acid fillers will improve the appearance of hyperpigmentation. You can get a feel for the extent of the hyperpigmentation by stretching the skin and observing how much, if at all, the colouring fades. If minimal fading occurs, signalling that the patient has significant hyperpigmentation, a practitioner should avoid treating as normal. Rather, you should consider topical treatment or even mesotherapy with other hyaluronic acid products, which have been shown to improve hyperpigmentation.

Secondly, any practitioner should consider a patient’s skin laxity, particularly in older patients, as a factor in deciding whether or not to treat. Not only can loose skin pose a real challenge when assessing your work, but it also frequently presents an obstacle to patient satisfaction with the procedure. One method that I like to use in assessing a patient’s infraorbital skin laxity is the “Snap Test”: stretch the skin downwards and hold for two seconds, release and observe the recoil. If the recoil takes longer than two seconds, skin elasticity is suboptimal, and I would consider the skin to be lax. Properly accounting for lax skin requires a very advanced practitioner, and I would suggest avoiding treatment under such circumstances.