Dark circles under the eyes has often been referred to as the tear trough deformity or crescent deformity but experience particularly with tear trough implants designed to correct the tear trough deformity has often failed to correct dark circles under the eyes, particularly the portion of the dark circle under the eye near the nose, often the deepest and most troubling part of the dark circle under the eye.

The tear trough deformity is most commonly found in older individuals, is a sign of more advanced facial aging and is seen as a depression running beneath the cheek bone or Zygoma out toward the side of the face. The key event in the production of the tear trough deformity is the sagging or downward displacement of the cheek into the lower portion of the face, a condition referred to as the herniation of the cheek fat pad.

A youthful appearance of the face is characterized by a full youthful cheek, a plump cheek appearance with the fat and skin of the cheek high attached to the cheek bone. Remember the “chubby cheeks” of childhood. As facial aging occurs and the facial tissues become lax and descend in the face, the cheek fat pad, also called the malar fat pad, descends into the midface, leaving a hollow beneath the cheek bone which is the tear trough deformity, because tears roll out to the side of the face rather than straight down the cheeks as they did in childhood. The arcus marginalis ligament and other fascial attachments of the cheek on the cheek bone do tether the skin to the higher cheek bone and contribute to the tear trough deformity, but the descent of facial skin and the malar fat pad are the predominant event causing the tear trough deformity. The true tear trough deformity occurs in the 5^th or 6^th decade in most patients I see-this is very different from my experience with patients complaining of dark circles under the eyes.

Patients seeking correction of dark circles under eyes are typically in their 20’s and 30’s. have noticed the dark circles all of their lives, and typically do not have facial sagging and herniation of the cheek fat pad. They complain of a dark circle and depression which creates a shadow which is beneath the lower eyelid starting at the nose and running out toward the side of the face. However, this depression curves upward to follow the lower eyelid but does not turn downward and extend into the cheek as does the tear trough deformity. As pointed out in several previous articles the dark circle under the eye is caused by the attachment of the arcus marginalis a condensation of tissue beneath the eyelid, attached to the bone of the eye socket, which tethers the lower eyelid skin to the bone creating a depression which creates a shadow beneath the lower eyelid. With aging of the eyes and skin, laxity of the lower eyelid skin and fat creates a slight bulge of the lower eyelid above the dark circle under the eye, which I now call the arcus deformity, and causes the dark circle to be more noticeable usually starting in the 30’s and early 40’s

The arcus marginalis, the tissue beneath the lower eyelid, attached to the bone of the eye socket and holding the lower eyelid skin to the bone, plays a causal role in both dark circles under the eyes and the tear trough deformity. However it is very important to make the distinction, and understand the difference between the arcus deformity or dark circle under the eye and the tear trough deformity because successful treatment requires very different approaches.

Dark circles under eyes  which I call the arcus deformity or arcus marginalis deformity, occurs in younger patients who seek correction in their 20’s and 30’s and requires a release of the arcus marginalis and fat repositioning or fat grafting to correct. The procedure I use is called a transconjunctival blepharoplasty with arcus marginalis release and fat grafting or repositioning. This condition is to be differentiated from dark eyelid color also often referred to as dark cirlces under the eyes.

A tear trough implant, in my experience, frequently fails to extend beneath the dark circle near the nose and is often displaced toward the side of the cheek by the action of the overlying lower eyelid muscle. In older patients who also have puffy eyes or eye bags, the dark circle under the eye is accentuated by the shadow cast by the protruding eyelid skin and fat above the dark circles under the eyes. These patients are also dramatically improved by the arcus marginalis release and fat repositioning.

The tear trough deformity occurs in older patients and includes a depression in the cheek toward the side of the face and is seen when the cheek has descended down lower in the face. While tear trough implants can be useful when the tear trough deformity occurs, in my experience a cheek lift, mid face lift or face lift which replaces the cheek or malar fat pad higher in the face , back on the cheek bone where it belongs is a more successful approach.

These are my own opinions and observations based on my considerable experience in dealing with facial and eyelid aging over the past 25 years. For more information of facial and eyelid aging contact me or read Save Your Face. Be sure to sign up for my free email newsletter.

Dr. Seckel

Concord, Massachusetts

Boston, Massachusetts

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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.

To learn more contact me or read Save Your Face.

Dr Brooke Seckel

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

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However, many people who complain of dark circles under their eyes frequently have a condition more appropriately termed “hollow eyes’ which is a distinct anatomical condition very different from dark circles under the eyes. Recognition of the “hollow eye syndrome” is very important because the technique frequently used to treat “dark circles under the eyes” does not correct the hollow eye look and can actually make the ‘hollow eye syndrome’ worse.

To clearly understand the difference between the varying lower eyelid conditions which many people have and seek treatment for, it is important to understand the difference between “Dark Eyelid Color”, Puffy Lower Eyelids, Dark Circles Under the Eyes, Hollow Eyes, and Festoons:

Dark Eyelid Color- The color of the lower eyelids is darker than the surrounding facial skin on almost every human face. This is a normal condition. The dark lower eyelid color is caused by the fact that the lower eyelid skin is very thin, so thin that you can see through it. The eyelid muscle beneath the lower eyelid skin is a purple color, thus the purple color of the muscle shows through the thin eyelid skin and the lower eyelid looks darker than the surrounding skin. People often complain that the lower eyelid looks blue or purple. The fairer your skin, the thinner your lower eyelid skin and thus the darker your eyelids will appear. In many thin skinned individuals the veins running under the eyelid skin also show through the eyelid skin making the blue color more pronounced. This is a normal condition and cannot be treated. No laser, cream or surgery can correct this. The only solution is a concealer such as Dermablend or Cover mark.

Puffy Lower Eyelids- As we age many people notice that the lower eyelid skin becomes puffy or bulges outward. People often refer to this condition as “bags under the eyes”. Bags under the eyes is caused by a combination of weakness and sagging of the lower eyelid skin and tissues cased by aging changes, and protrusion of fat which lies beneath the lower eyelid skin and underneath the eyeball. Younger healthy lower eyelid skin and tissues normally are taut and prevent the fat from protruding, however with aging and laxity of the lower eyelid skin the fat pushes forward and protrudes, like a hernia. This condition, bags under the eyes or puffy eyelids is technically called fatty orbital herniation, that is a hernia of the fat which is normally contained in the orbit or eye socket. The Plastic Surgery operation called a lower eyelid blepharoplasty often includes removal or repositioning of the protruding fat to lessen the appearance of bags under the eyes.

Dark Circles Under The Eyes- The phrase Dark Circles Under The Eyes refers to a dark depression below the lower eyelid which starts near the corner of the lower eyelid near the nose and runs along the cheek bone below the lower eyelid out towards the ear. Technically this is called the naso-jugal fold, and at advanced stages of facial aging runs into the Tear Trough Deformity, a dark depression that runs out and down the cheek towards the side of the face. The dark circle under the eye or naso-jugal fold is caused by a combination of factors. Most importantly the skin of the dark circle is tethered tightly to the underlying bone of the eye socket, called the orbital rim, by a ligament called the arcus marginalis. Since the skin of the dark circle is tethered to the bone, it cannot sag downward with the lower eyelid and cheek skin as the skin ages and becomes lax. Thus the lower eyelid skin as it sags and is pushed forward and down by the protruding lower eyelid fat, puffs and falls over the tethered dark circle and creates a dark shadow, the Dark Circle Under The Eye. The only truly effective technique to remove Dark Circles Under The Eyes is called arcus marginalis release with fat grafting or repositioning. During this procedure, the arcus marginalis is released from inside the lower eyelid and fat is placed beneath the dark circle to plump the dark circle and prevent the arcus marginalis from re-attaching and recreating the Dark Circle Under The Eyes.

Hollow Eyes- Hollow Eye Syndrome describes a condition in which the entire lower eyelid appears “sunken in” and can be a natural or normal human condition or can be caused by trauma or following a lower eyelid blepharoplasty during which too much lower eyelid fat has been removed. The primary cause of the normal Hollow Eye Syndrome is a congenital lack of orbital fat beneath the eyeball that allows the lower eyelid skin and tissue to sink in, or by an eye socket, also called the orbit, which is larger than normal and allows the lower eyelid, fat and tissues to sink in causing the Hollow Eye appearance. Abnormal Hollow Eye Syndrome occurs when too much fat has been removed during a blepharoplasty or when the bone beneath the eyeball has been broken, most commonly by a fist or baseball striking the eye, breaking the floor of the orbital bone and pushing the fat surrounding the eyeball through the break in the bone down into the sinus cavity beneath the bone. To correct the abnormal Hollow Eye Syndrome, either fat must be surgically replaced, or in the case of a fracture, the fat must be pulled back under the eye and the broken bone repaired.
In the case of normal Hollow Eye Syndrome, fat must be surgically replaced to correct the fat deficiency and in some patients, who have an unusually large eye socket because of a deficiency of the bone, an implant to must be placed to make up for the deficiency of the bone of the orbital rim at the top of the cheek bone. This implant is called a tear trough implant.

Festoons- Festoons are puffy skin on the cheeks which lie just below the lower eyelids, at the top of the cheeks and just below the Dark Circles Under The Eyes. Festoons, technically called Malar Bags, are cheek skin, not lower eyelid skin, a very crucial distinction. Their primary importance is that they must be recognized, and you must know that they will not be improved or removed during a blepharoplasty. In fact, a blepharoplasty during which puffy eyelid fat is removed and lax lower eyelid skin is tightened will in fact make the festoons look more prominent and worse. Festoons are poorly understood and difficult to treat. Traditionally the only method was direct surgical excision and removal, however this method usually leaves unacceptable, visible scars on the cheeks. Sometimes a partial face-lift called a cheek lift can improve Festoons. Laser resurfacing can improve them, but the skin color becomes lighter which makes this method risky. Recently newer skin tightening methods using Infrared and Radiofrequency energy hold much promise.

In summary, the normal anatomical variation and the aging changes of the lower eyelids are very complex, and often poorly understood by both patients and many physicians. A proper and clear understanding of lower eyelid and cheek anatomy and the effects of aging on these areas is crucial if proper aesthetic correction of the lower eyelid is to be achieved. Newer eyelid rejuvenation therapy must employ techniques that address the intraorbital fat, the arcus marginalis, and the festoons if pleasing aesthetic results are to be achieved and serious deformity avoided. True Hollow Eye Syndrome requires fat volume replacement and in some cases implant placement to correct bony volume deficiency. It is important to distinguish Hollow Eyes from Dark Circles Under The Eyes because their correction requires decidedly different reconstructive techniques. The recognition of Festoons is very important because standard blepharoplasty eyelid rejuvenation techniques will make Festoons more noticeable. For further information contact me , read Save Your Face  or call 978-369-4499.

Brooke R. Seckel, M.D., FACS

Boston, Massachusetts

Concord, Massachusetts 

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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.

Contact me, read Save Your Face or call my office at 617.262.2208, or 978.531.0550 for more information or to schedule a consultation.

Dr Seckel,

Boston, Massachusetts

As we age the dark circle which starts underneath the eyelid near the nose begins to move down into the cheek creating a depression called the Tear Trough Deformity which gives the face a tired, aged, haggard appearance. The dark circle is called the Naso-jugal Fold.

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Many plastic surgeons perform an eyelid operation called blepharoplasty to correct this problem, but when fat is removed during the Blepharoplasty, the dark circle or Naso-jugal Fold and hollow appearance can be made worse.

One procedure which can produce dramatic improvement in this condition is an Arcus Marginalis Release with Fat Grafting during which the Arcus Marginalis, the structure causing the dark circle is released and fat is grafted beneath the dark circle to plump the skin and decrease the shadow of the dark circle.

One problem in the past is that attempts to correct dark circles under the eyes have been done through an eyelid incision and after the operation, the eyelid turns down creating a sad eyed look called an ectropion.

Over the past 12 years I have developed a laser blepharoplasty surgery technique that avoids the visible eyelid incision by using a revolutionary new technique through a small incision on the inside of the eyelid during a procedure called the transconjunctival laser blepharoplasty. The transconjunctival blepharoplasty avoids the outer eyelid incision and prevents ectropion and the sad eyed look. My procedure is published in the Journal of Plastic and Reconstructive Surgery.

The result of this new laser blepharoplasty surgery technique is that patients heal faster, have less bruising, have no visible scar or incision, and most importantly the eyelid shape is not changed, there is no downturn of the eyelid and no sad eyed look.

After 2300 laser blepharoplasty surgery procedures during the past 12 years, the correction of dark circles is now a reliable procedure which can produce dramatic and safe results.

Contact me or read Save Your Face or follow this link to learn about eyelid rejuvenation or other facial rejuvenation procedures.

Dr Seckel

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There are 4 different conditions which can cause dark skin under the eyelid which people call dark circles under the eyes:
1. Dark purple skin color on the lower eyelid skin
2. Brown pigment on the lower eyelid skin
3. A hollow eye appearance in which the lower eyelid is sunken in.
4. A depression or deep line along the lower edge of the eyelid just above the cheek called the naso-jugal fold or tear trough deformity, the true dark circle under the eyelid and most common form of dark circle under the eyes

1. Dark Purple Color of the Lower Eyelid Skin

When the skin of the lower eyelid is a dark purple or bluish color people often say they have dark circles under the eyes. If you look closely EVERYONE has darker skin color on the lower eyelid than on the skin of the rest of the face. This is because the lower eyelid skin is the thinnest skin on the face, so thin that you can see through the skin and see the purple color of the eyelid muscle showing through the skin. In people with thicker skin the color looks more bluish, but everyone’s lower eyelid skin is darker because of the color of the muscle beneath the thin skin. There are familial and racial differences in skin thickness and muscle color so there is great variation in the darkness of lower eyelid skin. I do not call this normal phenomena dark circles under the eyelid, rather I call this normal phenomena dark purple lower eyelid. The only solution for this problem is to use a cover up make up like Covermark® or Dermablend®.

2. Brown Pigment on the Lower Eyelid Skin

Sun damage to the skin, birth control pills and other medications, and the “Mask of Pregnancy” and other metabolic conditions can cause the deposition of brown pigment in the lower eyelid skin. This is not called dark circles under the eyes but is called hyperpigmentation. The treatment is the removal or correction of the underlying cause-stop the medication, sun protection etc. Once the cause is corrected there are several remedies. Skin bleaching agents such as hydroquinone and Kojic Acid can help as can microdermabrasion®. Laser resurfacing or Microlaserpeel®, deep exfoliation techniques can also be helpful. IPL also called Photo Facial can also help. Very goods results can be achieved with these modalities.

3. A Hollow Eye Appeance

Some people have a very sunken in or hollowed eye appearance. This is caused by a deficiency of the normal fat which surrounds the eyeball and plumps the lower eyelid skin. This deficiency of fat can be caused by heredity, racial factors, malnutrition, general disease, dehydration or trauma to the orbital bone which supports the eyeball.

The correction involves the correction of the underlying disease or medical problem when there is a medical cause.

For people who have this appearance because of heredity or racial factors, the fat must be grafted into the lower eyelid to replace the deficiency. I do this by performing a blepharoplasty through an incision on the inside pink portion of the lower eyelid called the transconjunctival approach. This avoids a scar on the outside of the lower eyelid. I then harvest or take fat from an area of the body where the fat will not be missed (hip or abdomen) and transplant the fat graft to the lower eyelid to plump the lower eyelid.

4.The Naso-jugal Fold or Tear Trough Deformity-the True Dark Circle Under the Eye.

The true dark circle under the eye is a crease or depression starting at the nose and running towards the outside of the lower eyelid running at the bottom of the eyelid just above the cheek. This dark circle or depression looks dark because it is attached to the underlying bone of the rim of the orbit or eye socket, and the unattached skin of the lower eyelid above the depression is free to move and bulge and creates a shadow which gives the crease a dark color. The cheek skin below the dark circle is also free to move and bulge and is higher than the dark circle, which contributes to the shadow.

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 skin, so the lower eyelid skin hangs over more from sagging and bulging of fat, the depression deepens, the shadow gets worse and the dark circle becomes more noticeable. The dark circles under the eyes or tired look is the first thing that causes most people to seek facial rejuvenation. Usually there are eyelid wrinkles and crow’s feet and facial skin wrinkles occurring at the same time. As the eylid ages, fat pushes out on the lower eyelid causing eyelid bags.

The dark circle or naso-jugal fold or tear trough is tethered or held tight to the bony rim of the eye socket bone by a condensation of lower eyelid tissue called the arcus marginalis.

To correct the dartk circle I perform an eyelid rejuvenation procedure called a transconjunctival blepharoplasty. During the procedure I release the arcus marginalis ligament which frees up the dark circle or naso-jugal fold. 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.

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. The correction of true dark circles requires a blepharoplasty operation with arcus marginalis release and fat grafting or tear trough implants. Contact me for further details or read Save Your Face to learn more about facial aging and facial and eyelid rejuvenation.

Dr Seckel

Boston, Massachusetts