Tear trough rejuvenation remains one of the most technically demanding procedures in aesthetic medicine. The anatomy is variable, the tissue quality inconsistent, and the margin for error incredibly narrow. When complications occur—persistent swelling, irregular contours, bluish discolouration from superficial filler placement—they are rarely due to a lack of filler knowledge. More often, they stem from poor anatomical planning and a lack of visual structure.

Structured pre-procedural marking, therefore, isn’t optional. It’s essential.

In the infraorbital region, clear, intentional markings translate anatomical knowledge into real-time safety and precision. Without them, you are guessing. With them, you’re executing a mapped strategy based on structure—not shadows.

Step 1: Structural First, Aesthetic Second

Before marking anything, you must understand the landscape beneath the skin. The tear trough is not a simple groove; it is the surface expression of deeper anatomical shifts—ligamentous tethering, fat pad descent, and bone resorption.

Perform a thorough assessment:

• Palpate the infraorbital rim
• Evaluate the Tear Trough Ligament (TTL), which runs from the medial canthus to approximately the mid-pupillary line
• Assess the integrity and position of the lid-cheek junction (LCJ), a visual and anatomical transition point
• Check for malar oedema, skin laxity, or infraorbital fat pad prolapse
• Use tools such as the Arch Test, Squint Test, and Snap Test to evaluate prolapse, elasticity, and surgical candidacy

Candidates with poor skin quality, visible fat bags, or significant laxity should be managed with extreme caution—or excluded from filler treatment altogether.

Step 2: Structured Marking With the K-Y-S Protocol

The K-Y-S marking system offers a reliable, anatomical approach to infraorbital planning:

K – Medial Cheek Projection Zone

This zone targets the Deep Medial Cheek Fat (DMCF) and Sub-Orbicularis Oculi Fat (SOOF) just inferior to the LCJ.
Support here allows for indirect lift of the TTL without placing filler directly under the thin eyelid skin.
Marked in white ink, this zone is essential in nearly all patients.

White dots correspond to K points

Y – Tear Trough Thread

The Y thread is a straight line, drawn in alignment with the Tear Trough Ligament.
It typically runs medial to the Mid-Pupillary Line (MPL) but remains above the Lid-Cheek Junction (LCJ)—making it a relatively safe zone for cannula-based filler placement.
Cannula use is strongly recommended to reduce the risk of interaction with the facial vein and angular artery, especially as you approach the medial canthus.
This thread helps guide filler placement beneath the ligament to soften the tethering effect.

Note: Avoid the use of a needle medial to the MPL, particularly below the LCJ, due to the high density of vascular structures and low tissue tolerance for trauma.

White dotted lines correspond to Y-thread

S – Supraligamentous Bolus (Optional)

Marked only in patients with a pronounced “V” deformity not improved by cheek support or Y-thread correction.
Positioned carefully to avoid infraorbital foramina, this location allows a small bolus to reduce harsh shadows.
Caution is paramount here—this is not a first-line technique.

White dots correspond to S-Point

Step 3: Mark With Intention, Not Aesthetics

Use a white, skin-safe marker that won’t smudge during prep or after applying topical anaesthetic. A marker like SKRYBE offers clinical durability, ensuring your roadmap stays visible from prep through treatment.

Photograph the markings for patient education and documentation. Let the patient see the strategy—it builds trust and reinforces that the approach is both thoughtful and anatomical.

Step 4: Execute With Restraint and Sequence

• Start with K zone cheek support before approaching the tear trough
• Use blunt cannula wherever possible
• Inject sub-orbicularis, not superficially
• Avoid the temptation to over-correct in a single session
• Reassess after 2–4 weeks and consider staged augmentation

Many tear trough irregularities and complications are due to overcorrection or poor plane selection. Precise marking and cannula control help you avoid both.

Step 5: Reflect, Refine, and Repeat as Needed

After healing, re-evaluate the need for further volume or subtle touch-ups. Bluish discolouration typically results from superficial filler or poor product placement—often avoidable with careful submuscular threads and cheek-first support.

Always return to the markings. They are your reference, your restraint, and your roadmap.

Conclusion: Planning Is What Makes This Procedure Work

Tear trough filler is not about quick fixes or artistry. It is about preparation, anatomical respect, and mapped execution. The visual markings you make before you inject translate intention into precision—and that’s what defines a competent practitioner in this high-risk zone.

In this region, the most powerful tools you have are not your hands—they are your eyes, your judgment, and your marker.