Key points
- The causes of dark-looking under-eyes fall into pigment, structure, blood vessels, and combinations of these [1].
- A systematic review of 39 studies concluded that fillers and fat grafting using your own fat are effective for volume loss and eyelid surgery for sagging skin, but noted that high-quality evidence is lacking [1].
- In a systematic review of tear trough fillers, results lasted 8 to 12 months, and side effects such as bruising and swelling were generally mild [2].
- Although rare, blood vessel complications such as skin necrosis and vision loss have also been reported, so treatment by someone with a thorough knowledge of the anatomy is important [3].
- If bulging fat or sagging skin is the cause, lower blepharoplasty may be considered, so the cause should first be identified through an examination [4, 5].
Are dark circles and tear troughs the same thing?
Darkness around the eyes (periorbital hyperpigmentation), commonly called dark circles, does not come from a single cause. The causes are described as pigment in the skin, structural factors such as hollowing, blood vessels, and combinations of these [1].
Tear trough deformity is closely tied to the structural causes. The literature explains that the lower eyelid should be assessed not only for the tear trough but also for sagging in the cheekbone area, forward-bulging fat, eyelid laxity, and changes in skin texture [4]. Under-eyes that look equally dark may need different treatment if the cause is different, so it is important to identify the cause first.
Treatment depends on the cause
A 2021 systematic review of 39 studies summarized lasers, topical creams and serums, fillers, chemical peels, carboxytherapy, platelet-rich plasma injections, eyelid surgery, and normobaric oxygen therapy as treatments reported to be effective [1]. The authors drew the following conclusions by cause [1].
However, the authors noted that high-quality evidence supporting these results is lacking, so the recommendations should be interpreted selectively, and that more randomized clinical trials are needed [1]. It is unrealistic to expect a single treatment to improve every kind of dark circle.
- When volume loss is the cause: soft-tissue fillers and fat grafting using your own fat
- When sagging skin is the main cause: eyelid surgery
- When pigment is the cause: various topical creams and chemical peels
- When blood vessels and pigment are the cause: lasers (mild to moderate benefit)
Filling the tear trough with filler
Hyaluronic acid filler is the most widely used filler around the eyes and has been reported to be effective [3]. A 2022 systematic review of tear trough fillers analyzed 23 studies and found that results lasted 8 to 12 months [2].
Injection methods varied between studies, but most involved placing small amounts in several passes with a fine needle in a deep layer near the bone lining, beneath the orbicularis muscle and in front of the lower rim of the eye socket, usually with a topical numbing cream [2]. The authors stressed that treatment conditions in this area differed widely between studies, and that choosing the right product and understanding the anatomy are important for safe, natural-looking results [2].
An expert panel discussion also focused on whether to use a blunt cannula or a needle for injections under the eyes and in the cheek, and how to avoid and manage complications [6].
Filler side effects and rare serious risks
The side effects reported in the tear trough filler review were generally mild and included bruising, swelling, a bluish-gray discoloration, and contour irregularity [2]. A review of fillers around the eyes found that 90% of adverse reactions were mild and resolved on their own within 1 month [3].
A delayed complication specific to the area around the eyes is swelling over the cheekbones (malar edema), reported in 11% of patients [3]. When a hyaluronic acid filler was used, this is described as manageable with an enzyme that dissolves the filler [3]. Granulomas, filler migration, and xanthelasma (yellowish deposits on the eyelids) were also reported, and outcomes of treatment varied from case to case [3].
The most serious risks, though rare, are complications involving blood vessels, including skin necrosis and vision loss [3]. There is no top-level evidence on how to treat vision loss, and only two cases of recovered vision were found in the literature [3]. For this reason, fillers around the eyes should be performed carefully and with a thorough understanding of the anatomy [2, 3].
When surgery is considered
When under-eye fat bulges or the skin is loose, lower blepharoplasty may be considered. Lower blepharoplasty includes many techniques, such as an approach through the skin or through the conjunctiva, removing or moving fat, an orbicularis sling, outer-corner fixation, and skin removal [4].
One review summarized that the conjunctival approach is mainly used for younger patients with prominent bulging fat and no excess skin, and the skin approach for patients who need skin removed, adding that moving fat to correct under-eye hollowness is now also emphasized [5]. Surgery calls for weighing recovery time and risks more carefully than fillers, so whether it is needed is decided through an examination.
What to ask during your consultation
Dark circles and tear troughs can have mixed causes, so a single treatment may not bring the change you hoped for [1]. Results and recovery depend on your individual skin condition and anatomy, so it is a good idea to go over the following points.
- Whether the main cause of the darkness is pigment, blood vessels, hollowness, or sagging
- Which options fit the cause, such as fillers, lasers, or surgery, and the evidence behind them
- For fillers, how long results are expected to last and whether touch-up treatments will be needed
- How common side effects such as bruising, swelling, and discoloration, and rare blood vessel complications, would be handled
- For surgery, the approach, recovery time, and complications
Frequently asked questions
- Can fillers improve dark circles?
- It depends on the cause. A systematic review found that fillers and fat grafting using your own fat are effective for dark circles caused by volume loss, but that other treatments are considered when pigment or blood vessels are the cause [1]. The review also noted the limitation that high-quality evidence is lacking [1].
- How long do tear trough fillers last?
- A systematic review of tear trough fillers reported that results lasted 8 to 12 months [2]. How long they actually last can vary with the product used, the injection method, and your individual condition, so it is a good idea to ask during your consultation [2].
- Are under-eye fillers safe?
- Most reported adverse reactions were mild and resolved on their own within 1 month, but there are also complications that appear later, such as swelling over the cheekbones [3]. Serious blood vessel complications such as skin necrosis and vision loss have been reported in rare cases [3], so you should have the risks and how they would be handled fully explained by a medical team that knows the anatomy well.
References
- Michelle L, Pouldar Foulad D, Ekelem C, et al. Treatments of Periorbital Hyperpigmentation: A Systematic Review. Dermatol Surg. 2021.PubMed 32740208DOI
- Trinh LN, Grond SE, Gupta A. Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review. Facial Plast Surg. 2022.PubMed 34192769DOI
- Mandal P, Gama F. The use of periocular fillers in aesthetic medicine. J Plast Reconstr Aesthet Surg. 2021.PubMed 33546985DOI
- Branham GH. Lower Eyelid Blepharoplasty. Facial Plast Surg Clin North Am. 2016.PubMed 27105798DOI
- Bhattacharjee K, Ghosh S, Ugradar S, et al. Lower eyelid blepharoplasty: An overview. Indian J Ophthalmol. 2020.PubMed 32971612DOI
- Kontis TC, Bunin L, Fitzgerald R. Injectable Fillers: Panel Discussion, Controversies, and Techniques. Facial Plast Surg Clin North Am. 2018.PubMed 29636152DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
