Dear Dr Seckel, I am 52 years old and have lines under my eyes, along with the area becoming hollow looking. I had laser resurfacing done on my entire face 2 years ago, and at first the under eye area looked good (there was swelling which plumped up the area), but after I was totally healed the areas under my eyes went back to looking hollow/thin and the fine lines came back. Would you recommend I do laser resurfacing again under my eyes, or would you recommend fat grafting, or something else? Thanks! Jenny, Salem, Oregon
Dear Jenny,
Thank you for a very important question about eyelid rejuvenation. I would not recommend laser resurfacing to treat hollow eyes or dark circles under the eyes. Laser resurfacing or laser skin rejuvenation can tighten lower eyelid skin. Although fine lines and wrinkles initially are improved, they eventually return as you point out. The fine lines and wrinkles return because the underlying eyelid muscle pulls on the skin when you smile and causes the crow’s feet and wrinkles to return. Often Botox® injections after laser resurfacing or laser skin rejuvenation can prevent the return of the crow’s feet and wrinkles.
Hollow eyes and dark circles under the eyes are caused by deeper structural changes and since laser resurfacing is a skin treatment resurfacing cannot correct hollow eyes and dark circles.
There are two major causes of hollow eyes and dark circles: Previous blepharoplasty or eyelid tuck in which too much eyelid fat was removed, and more commonly, aging of the cheek and eyelid with downward descent of the eyelid and cheek creating the naso-jugal fold or dark circle under the eye.
I don’t know if you had a blepharoplasty when you had your laser resurfacing was done, but if you did, and if too much fat was removed, you will need an operation to replace the fat. During this procedure, a small incision is made and fat is removed from another area and transplanted into the eyelid. I use an incision on the inside or pink part of the eyelid so that there is no visible scar. This is called the laser transconjunctival blepharoplasty approach-the pink part of the eyelid is called the conjunctiva-thus the term transconjunctival.
The other type of lower eyelid hollowness or dark circle, the naso-jugal fold requires a very different approach. The dark circle is caused by the fact that the lower eyelid skin and muscle is tightly attached to the bone of the eye socket, and as we age, the cheek falls and the lower eyelid falls, but the dark circle area stays attached to the bone. The lower eyelid skin above the dark circle falls over the dark circle and creates a dark shadow.
To correct this dark circle under the eye or hollow eye I do an operation called a laser transconjunctival blepharoplasty with arcus marginalis release and fat repositioning or fat grafting. I do a transconjunctival blepharoplasty as mentioned above so that there is no visible scar.
During the blepharoplasty I release the arcuis marginalis which tethers the dark circle toi the bone of the eye socket so that the dark circle or hollow area can slide down and the shadow causing the dark circle is lessened. Then I place fat on top of the bone to prevent the dark circle from attaching to the bone again. The fat graft also plumps up the dark circle. The term arcus marginalis refers to a small structure that is holding the dark circle to the bone and is released during the operation-thus arcus marginalis release.
The laser transconjunctival blepharoplasty with arcus marginalis release and fat grafting is a revolutionary new method for eyelid rejuvenation and not many surgeons are familiar with it. It produces a superb result when done correctly and it is a much more conservative operation than traditional blepharoplasty. The main benefit is that no incision is made on the outer eyelid thus eyelid shape is not changed. A major problem with traditional blepharoplasty where an incision is made on the outside of the eyelid is that the incision weakens the muscle supporting the eyelid and the eyelid turns down creating a sad eyed or hound dog appearance. The transconjunctival blepharoplasty avoids this problem. I only use the transconjunctival approach but many surgeons still use the older technique.
Finally, you asked about fat injection for correction of hollow eyes or dark circles. Fat injection can work but it is a VERY TRICKY operation and should only be done by a plastic surgeon who is very experienced in its use. During this procedure fat is removed from an area of the body where it is not needed, placed in a syringe, and injected through a needle placed under the dark circle to plump the dark circle up.
Fat injection can work but there can be problems. In my opinion it is risky to inject ANYTHING around the eye. If the fat is injected by mistake into the eye or into the blood vessels that feed the eye, blindness can result. If the fat is not injected perfectly, lumps can form where too much fat is injected. Recently, some doctors have promoted the technique of injecting soft tissue fillers like Radiesse, Cosmoderm, Cosmoplast, Restylane®, Hylaform®, Sculptra® or others into the dark circle under the eye. The problem is these fillers are not permanent and injections need to be repeated. More importantly I worry about injection into the eye or vessels feeding the eye and blindness. I do not recommend filler injections for dark circles or hollow eyes at this time. It looks so easy but the complications could be horrific.
The point is if you are considering having fat injection of the eyelid to correct dark circles, it must be done by an expert plastic surgeon who knows the anatomy of the eye and eyelid who is very experienced in eyelid surgery and this technique.
I would not recommend fat injection if the hollow eyes or dark circles are caused by a previous blepharoplasty. No one should inject fat deep in the eyelid for fear of injuring the eye. This is especially true because previous blepharoplasty would leave scarring in the tissues of the eyelid and around the eye, and injection into scar will cause bleeding which can destroy the eye.
I am guessing that the hollowness of the lower eyelid you speak of is a dark circle or naso-jugal fold. If this is the case then a transconjunctival blepharoplasty with arcus marginalis release and fat grafting is going to be the most effective procedure. I would not do laser resurfacing again, but Botox® injections may help the wrinkles and fine lines on your eyelid.
Eyelid surgery is very complex. Be sure to find a board certified plastic surgeon who is very experienced at eyelid surgery.
For further information visit my Boston Plastic Surgery Practice, read Save Your Face or contact me.
Boston, Massachusetts
Peabody, Massachusetts