Executive Summary

Evidence‑based, anatomy‑led protocol for peri‑orbital HA filler integrating technique, rheology, complication prevention and governance under Australian standards. ^{1 2 3 4 5 6 7}

1. Purpose & Scope

Provide a defensible, anatomy‑led protocol for under‑eye (tear trough and medial–midface transition) HA augmentation. Objectives: minimise vascular, visual, oedematous and aesthetic complications; standardise selection, product choice, technique, and escalation; and align documentation with Australian regulation and international safety frameworks. Applies to credentialed peri‑orbital injectors; excludes non‑HA products.

2. Indications, Contraindications & Suitability

Indications

• Deep medial tear trough groove with true volume deficit.
• Lid–cheek junction demarcation due to medial SOOF atrophy.
• Shadowing/contour irregularity not primarily due to pigment, oedema, or skin laxity.

Relative/Absolute Contraindications

• Absolute: pregnancy, lactation; active local infection; known HA/lidocaine allergy; severe immediate hypersensitivity; acute sinus/orbital infection; active herpetic lesions.
• Relative: severe festoons/malar edema, laxity, prominent fat herniation, uncontrolled autoimmune disease, anticoagulation (risk–benefit), prior granulomatous reactions, unrealistic expectations, pigment‑dominant troughs.

Suitability algorithm (quick‑checks)

• Pinch test for edema tendency; light‑reflex vector support at zygoma; distinguish pigment vs shadow and refer when indicated.

3. Peri‑Orbital Anatomy (What matters for safety)

Angular artery ascends beside the nose; infraorbital artery/nerve exit ~6–10 mm below orbital rim; anastomoses to ophthalmic system create retinal embolisation risk. Safe plane: supraperiosteal/deep sub‑orbicularis; superficial subdermal/intramuscular planes carry higher Tyndall/contour risk. Ligaments define lid–cheek junction; medial SOOF depletion is a common driver of hollow. ^{8 9 10}

4. Product Science & Selection (HA Rheology)

Choose low–moderate G′ for thin tissues; moderate cohesivity to resist migration; low hydrophilicity to reduce oedema/Tyndall; homogeneous fine‑particle gels to reduce light scatter; vigilant perfusion when using lidocaine‑containing products. ¹¹

5. Dosing Strategy & Sequencing

Restore zygomatic/medial cheek support first if lacking. Initial session 0.1–0.3 mL per side; reassess at 3–4 weeks before adding 0.05–0.2 mL. For edema‑prone patients, use smaller aliquots and optimise dermal/lymphatic status first. ¹¹

6. Technique — Cannula vs Needle

Cannula (preferred)

• 22–25G, 38–50 mm; lateral entry over zygoma; deep sub‑orbicularis/supraperiosteal plane; 0.02–0.05 mL micro‑aliquots; single‑plane fanning; avoid superficial passes.

Needle (experienced)

• 30–32G; strictly deep, supraperiosteal micro‑boluses; no superficial blebs.

Universal rules: slow rate; stable tip; continuous perfusion checks; stop for pain, blanching, livedo, or visual change. ^{4 8 9}

7. In‑Room Safety Setup

Hyaluronidase 1,500 U vials; warm compresses; nitrates (per protocol); aspirin if suitable; ocular lubricants; sterile saline/chlorhex/IPA; sterile gauze; timer. Ophthalmic pathway with same‑day referral and printed flowchart. Batch/lot/expiry photos; traceability; planes; entry points; dose; adverse signals; post‑care. ^{4 5 7}

8. Complication Prevention & Recognition

Tyndall: avoid superficial plane; low‑hydrophilicity HA; micro‑aliquots; consider cannula. Oedema/festoons: conservative staged dosing; manage lifestyle; consider malar mounds. Contour irregularity: under‑correct; smooth; avoid cross‑planes. Vascular compromise: treat immediately. Visual symptoms: ophthalmic emergency. ^{4 6 8 9}

9. Emergency Response (Snapshot)

Stop; assess perfusion/ocular symptoms; high‑dose hyaluronidase along suspected arterial path; massage/warmth; consider aspirin/nitro/oxygen; urgent ophthalmology for any visual signs; DAEN reporting; time‑stamped documentation of doses/units/photos. ^{2 4 5}

10. Aftercare & Follow‑Up

Cold compresses 10 min on/off 24 h; sleep elevated; avoid heat/exercise 48–72 h; salt moderation. Provide red‑flag list. Review at 10–14 days; defer top‑ups until 3–4 weeks. Consider partial reversal with low‑dose hyaluronidase if persistent edema/Tyndall. ¹¹

11. Governance, Insurance & Escalation

Maintain indemnity for cosmetic injectables under AHPRA. Notifications: device/medicine events → TGA DAEN; patient complaints → HCCC NSW (or state authority); serious clinical incidents → AHPRA (mandatory thresholds). Internal CAPA and NSQHS audit. Photography/privacy per OAIC APPs. ^{1 2 3 7 6}

12. Audit & Continuous Improvement

Metrics: consent completeness; traceability; time‑to‑hyaluronidase; complication incidence/closure; PROMs. Annual review: integrate audit results into training; quarterly emergency simulations. ^{3 4 5 35}

13. Patient Communication (Plain‑English Essentials)

• Filler improves shadows from volume loss; not pigment.
• Tiny staged amounts reduce swelling risk.
• Red flags: pain/colour/vision changes → contact clinic or emergency services immediately.
• Photos and batch numbers recorded for safety.

14. Cross‑References (Internal)

• Adverse Event Grading & Response SOP
• Injectables Complication & Emergency Response Protocol
• Photography & Privacy Policy
• Clinical Governance Manual (NSQHS alignment)
• Cold‑Chain & Traceability SOP

Sources

1. AHPRA, Guidelines for cosmetic medical and surgical procedures (2025), viewed 28 October 2025, https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-procedure-guidelines.aspx ↩
2. TGA, Database of Adverse Event Notifications (DAEN), viewed 28 October 2025, https://www.tga.gov.au/safety-and-shortages/database-adverse-event-notifications-daen ↩
3. ACSQHC, National Safety and Quality Health Service (NSQHS) Standards, viewed 28 October 2025, https://www.safetyandquality.gov.au/standards ↩
4. ACE Group World, Management of a vascular occlusion associated with cosmetic injections (2025), viewed 28 October 2025, https://uk.acegroup.online/wp-content/uploads/2020/10/Vascular-Occlusion-v2.5.pdf ↩
5. Australian Resuscitation Council, Anaphylaxis & BLS Guidelines, viewed 28 October 2025, https://resus.org.au/guidelines/ ↩
6. OAIC, Australian Privacy Principles (APPs) – Health Records & Clinical Images, viewed 28 October 2025, https://www.oaic.gov.au/privacy/australian-privacy-principles ↩
7. NSW Health, Clinical Governance in NSW (Policy Directive PD2025_032), viewed 28 October 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2025_032.pdf ↩
8. HCCC NSW, Complaint management and escalation, viewed 28 October 2025, https://www.hccc.nsw.gov.au/ ↩
9. Beleznay K. et al. Avoiding and Treating Blindness From Fillers: A Review of the World Literature., Plast Reconstr Surg. 2015, viewed 28 October 2025, https://pubmed.ncbi.nlm.nih.gov/26356847/ ↩
10. Cotofana S., Arteries of the Face and Their Relevance for Minimally Invasive Facial Procedures: An Anatomical Review. Aesthetic Surg J. 2019, viewed 28 October 2025, https://pubmed.ncbi.nlm.nih.gov/30688884/ ↩
11. Hong, Gi-Woong et al, Review of the Adverse Effects Associated with Dermal Filler Treatments: Part I Nodules, Granuloma, and Migration (2024), viewed 28 October 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11311355/ ↩
12. WHO, Global Patient Safety Framework, viewed 28 October 2025, https://www.who.int/teams/integrated-health-services/patient-safety ↩
13. RACGP, Cosmetic/procedural guidance (consent, documentation), viewed 28 October 2025, https://www.racgp.org.au/clinical-resources/clinical-guidelines ↩
14. NHMRC, Infection Prevention & Control Guidelines (2019), viewed 28 October 2025, https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 ↩