When there is loss of volume in the cheek region below the under eye area coupled with under eye problems (such as tear troughs, dark circles and hollows), simply treating the under eye area alone will often lead to suboptimal and less than gratifying results.It is important to appreciate that the cheek area below the lower lid serves as a platform, or a buttressing foundation, if you will, for the under eye region. Loss of volume in this critical cheek region results, as seems to be the case here, in an elongation of the lower lid, flattening and sinking of the skin of the upper inner cheek, and hollows, tear troughs and dark circles directly under the eyes.I have been nonsurgically treating this region for more than twenty years and have found, as have others, that merely addressing the lower lid, without first reinflating (revolumizing) the cheek region below, typically results in less than optimal improvement. A nonsurgical mid-face rejuvenation with a volumizing filler, such as Juvederm Ultra Plus XC or even Voluma XC would be my first choice. Often, besides the obvious improvement in the cheek itself, there is immediate secondary improvement in the lower lid region directly above, owing to the renewed mechanical support from the reinflated area.Afterward, attention can be directed to the tear troughs and dark circles themselves, if still needed. For this purpose, I would opt for a combination of Belotero Balance (which has little or no tendency to causing the unwanted, bluish Tyndall Effect that can be seen when other hyaluronic acid products are injected superficially within this delicate region) and a tiny amount of Radiesse, a whitish-colored filler that can help to mitigate the darkness of the circles. Restylane, usually diluted, could be used in place of Belotero, but, for the reasons noted above, would not be my first choice.A sophisticated approach to rejuvenating this area requires more than one filler in more than one area and would certainly require more than one syringe. Consultation with an experienced injector with experience with all available fillers and volumizers is critical for obtaining the desired results.
