Welcome to this episode of the journal review, covering Dermatologic Surgery for February 2026. This month we're focusing on a single article, but it's a meaty one — a multispecialty systematic review on under-eye treatments — so we'll take our time with it.

This is a systematic review, not an original data-generating study, so think of it less as "here are new trial results" and more as "here is a curated, anatomy-driven map of the entire treatment landscape for infraorbital hollowing and hyperpigmentation," authored by a mixed group of dermatologists, a facial plastic surgeon, and an oculoplastic surgeon.

Let's start with why they bothered writing this. Infraorbital hollowing and under-eye dyschromia are among the most common aesthetic complaints you'll hear in consult, and the authors' stated rationale is that the treatment landscape has become crowded and confusing — driven partly by social media — to the point where both patients and treating physicians are often unsure which modality actually fits which anatomic problem. So the gap isn't "does treatment X work," it's "how do we match the right patient to the right modality," across specialties that don't always talk to each other.

Before getting into methods, the paper spends real time on anatomy, and this is worth dwelling on because it's the organizing logic for everything that follows. The lower eyelid is lamellar — anterior lamella of skin and orbicularis oculi, posterior lamella of orbital fat, capsulopalpebral fascia, and conjunctiva — separated by the orbital septum, and eyelid skin is under a millimeter thick, thinner than anywhere else on the body, which is why subtle changes show up so early. The deep medial cheek fat pad is doing a lot of work here — it supports the lower eyelid and gives the youthful cheek its continuity with the lid. With age, that compartment deflates and descends, the lid-cheek junction becomes disharmonious, and you get the classic tear trough deformity, which follows a fairly predictable path from the medial canthus to the midpupillary line because there's a thin strip of infraorbital fat laterally that's simply absent medially. Laterally, subcutaneous fat atrophy and suborbicularis oculi fat, or SOOF, atrophy contribute a different flavor of shadowing. The review also makes a point of anatomically separating true fat pad herniation — where a weakened orbital septum lets orbital fat pseudoherniate — from malar mounds, which come from orbicularis oculi fat herniation, and from festoons, which the authors are careful to note are not a fat herniation problem at all, but rather orbicularis laxity, skin redundancy, and edema pooling in the prezygomatic space. That distinction matters clinically because it predicts who is a surgical candidate versus who isn't. Layered on top of all this structural anatomy is a cutaneous component — thin skin unmasking vasculature, melanin deposition from things like postinflammatory change or lichen simplex chronicus, and skin laxity itself creating shadow.

Now, methods. The authors ran a PubMed search in March 2025 following PRISMA guidelines — the standard reporting framework for systematic reviews — limited to English-language studies published after 2010. Two independent reviewers screened 316 studies, excluding anything on nonhuman subjects, anything too broad in scope, or anything not directly tied to treatment outcomes, and narrowed down to 50 included articles, which they then sorted by treatment category — fillers, energy-based devices, microneedling, surgery, combination approaches, and other modalities. The two-reviewer independent screening is standard PRISMA methodology meant to reduce selection bias in what gets included, and restricting to post-2010 literature makes sense here since it's meant to capture the modern injectable and device era rather than older techniques that have since been superseded — that's my read on why they chose that cutoff, as the authors don't explicitly justify the date restriction themselves.

Now to the actual content, which is really a modality-by-modality patient-selection guide, and this is where the practical value of the paper lives.

Starting with fillers: hyaluronic acid remains the workhorse for volumizing the medial tear trough by simulating lost deep fat pad support. The ideal candidate has minimal skin laxity, good skin quality, a well-defined hollow without a separate overlying pigmentation problem. The poor candidate has orbicularis hypertrophy, real fat pad prolapse, poor skin quality, or pigment as a distinct issue that filler won't touch. On product selection, the review frames it around rheology — elasticity or G-prime, cohesivity, hydrophilicity, integration capacity — noting that softer, lower G-prime products like Belotero Balance or Volbella may reduce lumpiness and Tyndall risk, while higher G-prime products like Restylane can provide structural support when placed correctly in deeper planes. Practically, they recommend a 29-gauge needle or 25-gauge cannula, small aliquots around a tenth of a cc, capping the first session at roughly a quarter cc per side, and bringing patients back at two to six weeks for touch-up, injecting supraperiosteally, and reserving this approach mainly for younger patients with mild medial hollowing rather than more complex deformities. On safety, they cite a meta-analysis suggesting more bruising with needle technique and more edema with cannula technique, but they're appropriately cautious about over-reading that — the underlying studies are heterogeneous, samples are small, and technique wasn't standardized, so injection depth and operator skill are probably confounding the device comparison as much as the device itself. The serious, rare risks are the ones you already know — vascular occlusion with ischemia or vision loss, biofilm, infection — and the review reiterates the vascular anatomy that matters most: the infraorbital artery exiting roughly six to ten millimeters below the rim along the midpupillary line, and the facial artery's angular and dorsal nasal branches medially.

The excerpt then transitions into lasers and energy-based devices, organizing them by target chromophore and problem rather than by brand — pigment lasers such as Q-switched Nd:YAG, ruby, alexandrite, and intense pulsed light for excess melanin; vascular lasers like pulsed dye, KTP, Nd:YAG, and IPL for telangiectasias and reticular veins; and texture-and-tone devices — CO2, diode, erbium:YAG, radiofrequency, ultrasound energy — for patients whose primary issue is rhytides, laxity, and uneven texture rather than a discrete color or volume problem.

The accompanying treatment selection table is really the spine of this whole review, and it's worth walking through because it operationalizes exactly what we've been discussing. For neuromodulators, the good candidates are dynamic periorbital rhytides, strong orbicularis activity, that jelly-roll bulge, or even filler that's been malpositioned and is bulging — while fixed contour defects, lower lid laxity, scleral show, or baseline edema make someone a poor candidate. Microneedling suits a defined indentation with decent skin tone and textural complaints, but not fat prolapse, chronic edema, or a Tyndall effect from prior filler. Polynucleotides are positioned mainly for periorbital rhytides, not major structural deficits. PRP and PRF fit fine rhytides, a defined tear trough, and textural concerns, but not volume loss or herniating fat. Topicals are for good skin quality with a pigmentary — melanin or vascular — driver and no deep hollowing or laxity. Peels suit mild to moderate pigmentation in healthy skin without hypersensitivity, keloid history, coagulopathy, inflammatory disease, or active infection. And surgery is reserved for prominent fat protrusion and skin excess, specifically excluding patients with poor lower lid support, prolonged snapback, excessive lid distraction, or severe dry eye — all findings that should already be part of your preoperative lower lid assessment.

There's no separate limitations section here since this is a review rather than a trial, but the authors are transparent within the text about the evidence quality issues that do exist — they flag, for instance, that the filler complication data they cite comes from heterogeneous, small, technique-inconsistent studies, so that comparison should be read as directionally suggestive rather than definitive.

So, what do you actually take from this into your practice. This isn't practice-changing in the sense of overturning anything you're doing — there's no new trial data here that should alter your injection technique or surgical thresholds tomorrow. What it is, is a well-organized, anatomically rigorous reference for triaging infraorbital patients across modalities, which is genuinely useful given how often these patients arrive having already researched five different treatments online and are confused about which one applies to them. The most clinically useful piece for a Mohs and dermatologic oncology practice is probably the crisp anatomic distinctions — true fat herniation versus malar mounds versus festoons — and the explicit exclusion criteria in that table, since knowing who is not a filler or microneedling candidate, and instead belongs in a surgical oculoplastic referral, is exactly the kind of judgment call that keeps you out of trouble with vascular complications or unhappy patients who got the wrong modality for their anatomy.

That wraps up this month's review. Thanks for listening, and we'll be back next month with more from the literature.