Dark circles under the eyes are a common and difficult aesthetic problem to solve. But why do some people get them and what can you do about them? The good news is that there are some effective solutions available and most cases can at least be improved.
There is no specific medical term for dark circles (DC) because the general descriptive term encompasses several conditions which alone, or in combination, give a similar appearance.
What causes a “Dark Circle”?
The causes of DC are multi-factorial but can be grouped into 3 categories. Each patient may have several problems. Careful evaluation of the patient, as well as advanced medical imaging technologies such as the Canfield VECTRA™, assist the physician in assessing the relative contributions of each factor.
- A Shadow in the Valley
The most common reason for DC is the presence of a groove under the eyelid which lies in shadow. Accentuating the problem is age-associated loss of mid-facial volume below the groove, as well as excess tissue above the groove from “eye bags” which themselves are multi-factorial. New anatomical insights regarding the fat distribution and ligamentous anatomy of the soft tissues around the eye have revolutionized our understanding of the hollow groove under the eyes. In particular, the anatomy of the orbicularis retaining ligaments (ORLs) and tear trough ligaments (TTLs) provide an anatomical basis for modern surgery and filler injection techniques.
- Superficial venous congestion
A bluish-grey colour under the eyelids may be the result of dilated superficial veins, which are more apparent in this region because of the extreme thinness of the skin and the absence of subcutaneous fat and may be more apparent in some patients than in others. Skin colour, genetic pre-disposition, and multiple local and systemic conditions, such as a fatigue, allergies, renal and liver disorders (among others) may exacerbate the venous congestion.
- Discolouration of the skin
Discolouration may be the result of true pigmentation with excess melanin and should be differentiated from skin staining. Skin staining by haemosiderin may follow even slight trauma. Excess melanin may occur following inflammation, UV exposure and may even be genetically determined as in cutaneous idiopathic hyperchromia of the orbital region (CIHOR) – a syndrome which affects many people, particularly those of Indian heritage.
There are a number of scientifically validated modalities available to treat DC. The efficacy, applicability and synergy of the various options depends on anatomical combination of problems that a patient presents with and treatment should thus be individualized.
While traditional lower lid blepharoplasty has been performed for many years, present anatomical concepts would seem to favour the trans-conjunctival approach, in combination with other surgical maneuvers. Release of the arcus marginalis and elevation of the ORL and TTL have significantly improved surgical results. Understanding the 3-dimensional volumes changes have led to surgical repositioning of the retro-septal fat, or liposculpture with micro/nano fat injections.
- Dermal fillers
Two areas need to be treated when considering this option. The deep cheek fat situated in the mid-face, below the DC is almost always treated first, as the mid-face is the aesthetic foundation of the eye. Volume augmentation with hyaluronic acid (HA) filler is the treatment of choice. This area can be effectively treated by most practitioners. Dermal filler to the tear trough and palpebromalar groove needs precise placement and is technically very challenging. Under correction by 20%, with additional follow up filler treatments is recommended. There are a wide variety of techniques described in the medical literature, but it is my practice to place filler just above the bone.
- Energy based devices
These devices are expensive to buy and maintain and marketing promises are often an over-optimization of actual results. Nevertheless, a moderate body of scientific data is available to support the devices discussed below. It is important to realize that the results of a device are related both to the device, as well as its operator. Lasers such as carbon dioxide and Q-switched alexandrite or ruby, improve both pigmentation as well as effect skin tightening. Intense Pulsed Light (IPL) and radiofrequency devices such as Pellevé® and Thermage® cause skin tightening and thickening by generating new collagen as a healing response to injury. All energy-based devices should be considered an adjunct to treatment for DC, rather than a primary modality.
- Needle based therapy
Needle-based therapies use multiple small needle punctures to effect and modify the body’s wound healing responses to cause collagen deposition and epidermal remodeling in much the same way as energy based devices. Microneedleling involves multiple punctures of the skin to a uniform depth. The deeper the puncture, the greater the effect but this is at the expense of increased discomfort and downtime. Carboxy-therapy involves serial punctures with sub-dermal deposition of a tiny bubble of carbon dioxide gas which is purported to modify the immediately adjacent cellular responses before being absorbed and ultimately exhaled. Platelet-rich Plasma (PRP) involves harvest of the patient’s own blood, isolation and concentration of the platelets and their subsequent re-injection. Platelets are the initiators of the wound healing response and will generate collagen with a lower tissue injury requirement.
- Chemical peels
Application of trichloracetic acid (TCA) and lactic acid cause a partial thickness skin burn, which stimulates the epidermal healing response. Although there is less dermal contraction than with other modalities, epidermal regeneration may be associated with improvement of the pigmentation density and lightening of the DC. Clearly only patients with primary pigmentation disorders will be effectively treated with this modality.
- Topical treatments
High SPF “Sunblock” should be a part of any anti-aging regimen, especially in patient who are prone to UV induced hyperpigmentation. Hydroquinone has had some negative publicity, but short courses (6 weeks) of 5-8% hydroquinone (often compounded in 20% kojic acid) are incredibly effective and very reasonably priced. The effects of hydroquinone induced lightening are long-lasting and the complication rate very low. Retinol (and other Vitamin A derivatives) are also useful and may have beneficial effects on fine wrinkle. Topical caffeine is a part of many OTC creams but its effect is short lived and is presumable related it its vasoconstrictor effects. Anti-oxidants, cytokines, growth factors and herbal extracts have been described as have some beneficial effects.
The following options represent my personal armamentarium for dealing with the problem of DC. Surgically, I prefer transconjunctival lower lid blepharoplasty, with extensive release of the ligaments and fat repositioning. I only use HA filler as described above and fill the tear trough using a 25G cannula. I use the Pellevé® as an adjunct. I use TCA peels only occasionally, but have had good success with 5% hydroquinone in kojic acid.
DCs have multiple causes and a careful evaluation of each patient is necessary before a comprehensive treatment plan is formulated. Patients should appreciate the complexity of this problem and need for multiple treatments. Finally, it is always preferable to achieve subtle and natural results and initial under correction is a safe option.