Dark Circles Under The Eyes-The Tear Trough or Crescent Deformity
What most people see as a dark circle under the eye is a crescent shaped or semi-circular crease or depression starting at the nose and running towards the outside of the lower eyelid running along the bottom of the eyelid just above the cheek bone. This dark circle or depression looks dark because it is attached to the underlying bone of the rim of the orbit or eye socket by a ligament called the arcus marginalis. (1)
The unattached skin of the lower eyelid above the dark circle is free to move and bulge over the depression and creates a shadow, which gives the crease a darker color. As we age and the eyelid skin above the crease becomes lax and puffy, the shadow below the eyelid, the dark circle or Tear Trough, becomes much more noticeable. Anything that causes swelling or puffiness of the lower eyelid such as allergies or fluid retention, makes the shadow and thus the dark circle under the eyelid worse.
Technically, this type of dark circle under the eye is called the naso-jugal fold. When the dark circle becomes more noticeable, usually with aging, it is called the Tear Trough Deformity or Crescent Deformity. The term Tear Trough is derived from the fact that tears run down into the dark circle and out toward the side of the cheek as opposed to running straight down the cheek as they do when we are younger and do not have the deep naso-jugal fold or Tear Trough Deformity.
The dark circle, or naso-jugal fold or tear trough gets worse or deepens as we age because the eyelid above and cheek below begin to sag with aging but the dark circle is attached to bone and cannot sag with the rest of the facial skin. Thus the lower eyelid skin hangs over the Tear Trough more because of sagging of the eyelid above and the bulging of fat beneath the eyelid, the depression deepens, the shadow gets worse and the dark circle becomes more noticeable.
Many people also describe the dark circles under the eyes as the “Tired Look”, “Eyelid Bags”, “Puffy Eyes” and “Eye Bags”. Frequently these complaints are the first issue that causes many people to seek facial rejuvenation.
To correct the dark circle under the eyes I perform an eyelid rejuvenation procedure called a transconjunctival blepharoplasty. During the procedure I release the arcus marginalis , a condensation of eyelid tissue, which frees up the dark circle or naso-jugal fold or Tear Trough. Once the dark circle is released the dark circle skin is free to move with the lower eyelid skin and the cheek skin and the dark circle or shadow is lessened. To prevent re-attachment of the arcus marginalis and to plump up the dark circle I place a fat graft underneath the dark circle. Some surgeons place an implant called a tear trough implant under the dark circle but I usually use fat.
Some surgeons (1) feel that the arcus marginalis cannot be released without an external incision on the eyelid, however I always use the transconjunctival approach through a small laser incision on the inside of the eyelid. This has the important advantage of leaving no visible scar on the eyelid and, more importantly, does not change the shape of the eyelid, a serious complication of the external lower eyelid incision.
Some doctors (2) recommend the injection of soft tissue fillers made of hyaluronic Acid such as Restylane into the Tear Trough Deformity to plump the depression and correct the dark circles under the eyes. I do not recommend the injection of fillers around the eye because of the danger of injury to the eye. Blindness (3) has been reported following the injection of a soft tissue filler around the eye. This technique has also been called the “Non-surgical Blepharoplasty” (4)
Correction of dark circles under the eyes, also called the naso-jugal fold or tear trough deformity requires proper diagnosis. This condition needs to be differentiated from dark purple eyelid color, hyperpigmentation and hollow eyes. (5) The correction of true dark circles requires a blepharoplasty operation with arcus marginalis release and fat grafting or tear trough implants. (6) In my experience the internal transconjunctival blepharoplasty approach is the safest and produces the best results with no visible scar and no change in eyelid shape.
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Boston, Massachusetts
References:
1. Kim,R.Y.,Singer,D.P., Sullivan,P. K. et al, The Anatomic Basis for the Tear Trough and Crescent Deformity at the Lower Eyelid-Cheek Junction. Paper Presented at the American Society of Plastic Surgeons meeting, October 28,2003, San Diego California
2. Kane, M.A.C., Treatment of Tear Trough Deformity and Lower Lid Bowing with Injectable Hyaluronic Acid, Aesthetic Plastic Surgery, Volume 29, #5 /October 2005, Springer New York DOI 10.1007/s00266-005-0071-7
3. Schanz , S., Schippert , W., Ulmer , A., Rassner , G. & Fierlbeck , G. (2002)
Arterial embolization caused by injection of hyaluronic acid (Restylane®).
British Journal of Dermatology 146 (5), 928-929.doi: 10.1046/
j.1365-2133.2002.04707.x