Due to prolonged mask wearing and technology fatigue, our clinic has seen an increase in patients complaining of infraorbital dark circles and fat protrusion. Blepharoplasty is a proven method, but many tend to avoid it due to downtime and cost. In this article, based on 18 years of clinical experience, we systematically introduce the synergistic effects of a non-invasive approach combining ULTRAcel [zi:] Dot Mode and hyaluronic acid injections, including case studies, protocols, and technical considerations.
- INDEX
Classification and Treatable Type of Infraorbital Dark Circles
Infraorbital dark circles can be broadly classified into four types: ① pigmentary (caused by friction or cosmetic irritation), ② vascular (red or blue circles caused by reduced hemoglobin retention), ③ structural (shadows caused by protruding orbital fat), and ④ mixed. This article focuses on ③structural dark circles. Orbital fat protrudes forward like a hernia, and light from above creates shadows, emphasizing an aged appearance and fatigue. The treatment strategy is designed in two stages: reducing the volume of protruding fat and remodeling the supporting structure.
HIFU Alone Treatment Protocol
Equipment and Settings
Equipment : ULTRAcel [zi:] (Jeisys)
Cartridge: Basic (narrow width) Dot mode
Depth and output: Case ①: Right 3 mm/Left 2.5 mm, 0.6 J, 50 shots/side (fat thickness measured by ultrasound and adjusted for left-right differences)
Irradiation interval: 3 sessions every 2 weeks (first session: full face; second and third sessions: lower eyelids only)
Technique
Ask the patient to adopt a slight head-tilt position and look upward, causing the fat to protrude forward. Tilt the probe 10-15° toward the bone, directing it only toward the bone area, and take care not to allow the ultrasound to enter the orbital cavity. Gently pull the skin downward to ensure adequate thickness and move the probe approximately 5 mm at a time, repeating up to three times.
Pain and Safety
In Dot Mode 0.6 J, the pain is mild. If severe pain occurs, it is a sign that the treatment is too shallow or the output is too high, so adjust the depth or parameters immediately. Eye protectors are not used, but we recommend using them when inexperienced staff are performing the treatment.
Results
In both male monitor cases, the orbital fat volume was visually reduced within three sessions, accompanied by a tightening effect on the facial contours. The improvement was particularly pronounced on the side with a higher fat content.
Combination with Hyaluronic Acid Injections
Selected formulation and injection volume
VOLUMA XC: 0.5 mL/side (0.25 mL each for SOOF* and cheek fat)
VOLBELLA XC: 0.25 mL/side (above the orbital rim)
*SOOF = Sub-Orbicularis Oculi Fat
Skin Diagnosis and Testing
Snap back test: Check skin elasticity and use as a guideline for adjusting the amount of injection into thin, weak skin.
Push test: Push the cheek upward and assess the degree of improvement in the shadows under the eyes.
Smile test: Evaluate whether the sagging under the eyes worsens when smiling, and determine the effects of previously injected fillers or muscle bundles.
Combination Treatment and Its Effects
Right after reducing fat with HIFU, VOLUMA is injected into the SOOF to support the structure. Then, VOLBELLA is injected into the tear trough to smooth out the hollows. These treatments delay the recurrence of shadows. Compared to HIFU treatment alone, the appearance is more vibrant, and patient satisfaction is improved.
Clinical Considerations and Technical Points
- Individualized irradiation depth settings: Perform ultrasound measurements in the treatment position to accurately target the center of the fat layer.
- Shot count and irradiation method: To reduce the risk of inflammation, we use a “moving multi-pass” technique, which involves overlapping shots while moving the device.
- Output adjustment guidelines: Use pain as a navigation tool to fine-tune depth and output.
- Staff training: Thorough instruction on ultrasound device usage and bone-directed irradiation is key to ensuring safety.
- Suitability for male patients: Easily adoptable even for those resistant to surgery or injections, contributing to improved first impressions for business professionals.
Summary
HIFU irradiation to the lower eyelid can safely and reliably reduces volume of orbital fat protrusion. When combined with hyaluronic acid injection, shape correction and structural support can be provided. This non-invasive treatment has minimal downtime, making it suitable for both men and women, and offers a treatment option that leads to long-term satisfaction.
