Blepharoplasty is a plastic surgical operation done on the eyelids to correct dark cirlces under the eyes and remove loose skin or hooding of the upper eyelids and also to remove “bags” from the lower eyelids. Blepharoplasty is one of the most common plastic surgery operations done in the United States and has traditionally been done on people over 40 who feel their eyes have aged and are making them look older or tired.
Recently however, many younger people, many in their early 20”s are seeking Blepharoplasty to correct “dark circles under the eyes” and unfortunately the traditional blepharoplasty operation as performed by many plastic surgeons can actually worsen the appearance of dark circles under the eyes and even create a “hollow eyed” appearance. If this happens the eyes look worse than the dark circles that prompted the decision to have a blepharoplasty in the first place.
If this hollowed eyed appearance is created, especially in a younger person in their 20’s who started out with dark circles under the eyes it is a serious problem which could require further reconstructive surgery to replace fat which was removed from the lower eyelid during the blepharoplasty surgery.
Dark circles under the eyes are a very common complaint, affect all races and both sexes, and are noticed often throughout life from early childhood. However concern about dark circles under the eyes seems to increase as people enter their 20’s and begin to be concerned about facial aging. The eyelids are the first part of the face where aging changes are seen and the first complaint most people voice is that “people say I look tired and I am not”.
What Causes Dark Circles Under The Eyes?
First, it is very important to distinguish what is meant by “dark circles under the eyes” from the normal dark color of the eyelid skin which is present in all people. Look at any face and study the eyelid skin and you will notice that the lower eyelid skin is a darker color that the skin of the cheek and the rest of the face.
There is a very simple reason for this: the skin of the lower eyelid is the thinnest skin on the face. The lower eyelid skin averages 593 microns thick whereas on the chin for example the skin averages 2544 microns-thus the lower eyelid skin on average is 4 to 5 times thinner than the skin on other areas. The lower eyelid skin is so thin that you can actually see the color of the eyelid muscle which lies directly below the skin. The color of this eyelid muscle is actually purple, thus the dark color of the eyelid skin usually has a bluish or purplish hue. The presence of small blue veins in the eyelids of many people also contribute to the dark color.
Dark lower eyelid skin color CANNOT BE CORRECTED BY A BLEPHAROPLASTY. The blepharoplasty removes fat and sometimes skin, but the skin of the lower eyelid remains covering the dark muscle and the color remains after blepharoplasty. Also LASER TREATMENTS CANNOT CORRECT NORMAL DARK LOWER EYELID SKIN COLOR. Lasers only remove pigment caused by sun damage-they do not go deep enough to effect the color caused by the muscle color beneath the skin. Worse laser treatments can de-pigment the eyelid skin and cause a white “raccoon “appearance to the eyelids.
Dark Circles Under The Eyes are very different from dark eyelid skin color and are caused by a very different mechanism. Dark circles under the eyes refers to a depression or shadow under the lower eyelid, right above the bone of the eye socket and which begins at the corner of the lower eyelid next to the nose and runs along the rim of the eye socket out toward the side of the cheek.
The medical term for the dark circles under the eyes is the Nasojugal Fold, tear trough deformity, or arcus deformity. As we grow older the dark circle under the eye becomes deeper and longer and runs down and out into the cheek. This deeper, longer dark circle under the eye is called the Tear Trough Deformity—because tears run into the dark circle and out to the side of the cheek, instead of rolling straight down the cheek as they do when we cry as a child.
What actually causes the dark circle under the eye, or nasojugal fold, is that the lower eyelid skin of the dark circle is tightly connected to the bone of the eye socket unlike the skin of the rest of the lower eyelid which is simply attached to the eyelid muscle and the fat underneath the lower eyelid. As we age the eyelid skin above the dark circle begins to sag, as does the fat beneath the skin, and the lower eyelid above the dark circle (nasojugal fold) begins to fall over the dark circle and create a dark shadow.
Thus the dark circle under the eye is actually a shadow created by the adherance of the lower eyelid skin to the bone of the eye socket.
The attachment of the dark circle to the eye socket bone is caused by a small condensation of eyelid tissue called the ARCUS MARGINALLIS which is a small structure beneath the dark circle which ties the dark circle skin to the bone of the eye socket.
To remove dark circles under the eyes, the arcus marginalis must be released so the dark circle skin will not be tethered to the bone, and the shadow can disappear. In addition, fat is transplanted and placed on top of the bone to plump the dark circle and lessen the shadow.
Why Blepharoplasty Can Make Dark Circles Worse.
Traditional blepharoplasty of the lower eyelid involves making an incision below the eyelashes and removing skin and fat from the lower eyelid. While this operation does remove loose skin and puffy fat bags, this operation weakens the support of the lower eyelid and after traditional scalpel blepharoplasty many people are left with a sad eyed look or hound dog eyes where the outside of the lower eyelid towards the side of the face turns down. When the lower eyelid fat is removed, the lower eyelid sinks in and creates a hollow eye look. Both of these conditionsnoften nrequire further surgery.
More modern blepharoplasty uses a transconjunctival incision-that is through the inside pink portion of the lower eyelid called the conjunctiva (trans=across, conjunctival=conjunctiva the pink inside the eyelid=across the conjunctiva). The benefit of the transconjunctival blepharoplasty is that there is no visible scar on the eyelid, and more importantly, the lower eyelid is not weakened and the eyelid shape is not changed, therefore no “sad eyed look” or “hound dog eyes’
Both of these blepharoplasty techniques however do not correct dark circles because nothing is done to release the arcus marginalis which is causing the dark circle in the first place.
In fact, when fat is removed from the lower eyelid during a traditional blepharoplasty, a hollowed out appearance can be created which actually makes the dark circle look worse.
Transconjunctival Blepharoplasty with arcus marginalis release and fat grafting corrects dark circles under the eyes.
The most modern, effective blepharoplasty technique is the transconjunctival blepharoplasty with release of the arcus marginalis and fat grafting or repositioning over the bone which lies beneath the dark circle. This procedure truly eliminates the dark circle under the eye by releasing the tethering of the dark circle and plumping the dark circle skin to eliminate the shadow we call the dark circle under the eye or the nasojugal fold.
During the procedure the arcus marginalis is released and a small amount of the fat (which is causing the puffiness of the lower eyelid) is either repositioned or removed and transplanted back into the lower eyelid over the eye socket bone beneath the dark circle.
Some surgeons place an artificial rubber implant called a tear trough implant under the dark circle instead of fat, but I prefer to use fat-it’s the bodies own tissue, it is softer, more natural, and gives a better result in my hands.
I do this operation with a laser, the laser blepharoplasty causes less bleeding, less bruising, is much quicker and down time is much less. In my opinion, less bleeding with the laser means the operation is much safer as bleeding is the most dangerous complication of blepharoplasty.
These techniques are new and not all plastic surgeons have learned or adopted them. It is very important for people who are considering blepharoplasty ask the right questions of the doctor they consult to make certain their surgeon is up to date.
Be Informed. Properly performed modern eyelid rejuvenation surgery can produce excellent results safely. Dark circles under the eyes can be corrected but only if the proper surgical techniques are used by a skilled, board certified plastic surgeon who is up to date in his/her training.
You, the consumer need to be educated and aware. You do not want to seek eyelid rejuvenation, have a blepharoplasty and end up looking worse than you did when you started and possible ending up with a deformity which can actually damage your eye and require significant reconstructive surgery.
In Chapter 10 of my book “Save Your Face” which is titled “Don’t Let Just Anyone Touch Your Face” I give detailed recommendations on how to choose a plastic surgeon, what questions you must ask, and a list of “Red Flags” which should caution you to seek consultation from a second physician. If you want to read further details of how to remove dark circles you may find articles at Dark Circles.
Transconjunctival laser blepharoplasty with arcus marginalis release and fat grafting can remove dark circles under the eyes, but you must find a reputable, skilled, experienced surgeon if you want the best, safe result.