1. Patient Medical Background

✔ Yes / ✖ No

• ☐ No active infection (bacterial, viral, fungal) in the periorbital region

• ☐ No autoimmune granulomatous diseases (e.g., sarcoidosis)

• ☐ No known allergy to PLLA components

• ☐ Not pregnant or breastfeeding

• ☐ No recent major surgeries or ablative procedures in the same area

• ☐ No history of severe inflammatory reactions to fillers or biostimulators

• ☐ No uncontrolled systemic disease (e.g., diabetes with poor healing)

​

2. Periorbital Anatomical Evaluation

Skin

• ☐ Mild to moderate skin laxity

• ☐ Fine lines present but not severe crepey skin

• ☐ Adequate dermal thickness to support biostimulation

Volume & Contours

• ☐ Early tear trough shadowing

• ☐ Mild midface deflation

• ☐ No severe infraorbital fat herniation

• ☐ No marked festoons or malar edema

Structural Assessment

• ☐ Orbicularis retaining ligament (ORL) visible but not severely tethered

• ☐ Skin quality appropriate for gradual collagen stimulation

• ☐ No excessive skin redundancy requiring surgical correction

☐ Normal anatomy without palpable vascular anomalies

3. Patient Expectations

• ☐ Understands that PLLA has gradual onset (6–12 weeks)

• ☐ Accepts that multiple sessions may be needed

• ☐ Understands PLLA does not correct fat prolapse or severe laxity

• ☐ Aware that subtle improvements in texture, firmness, and shadowing are expected

• ☐ Realistic about achievable outcomes

4. Contraindications Screening (Absolute & Relative)

Absolute

• ☐ Active infection

• ☐ Active inflammatory dermatoses

• ☐ Hypersensitivity to PLLA

• ☐ Autoimmune granulomatous disorders

• ☐ Pregnancy / breastfeeding

Relative

• ☐ Very thin dermis → higher risk of visibility/nodules

• ☐ Severe under-eye bags

• ☐ History of keloids or hypertrophic scarring

• ☐ Chronic periorbital dermatitis or eczema

☐ Unstable psychological expectations