Infraorbital dark circles represent a common and multifactorial challenge in the world of aesthetic medicine and a common issue in everyday ophthalmic practice.
■■■Common infraorbital dark circles etiologies include:
Thin eyelid skin revealing the anatomy underneath the eyes such as the orbicularis muscle and blood vessels
Lack of fat and bone structure under the eyes resulting in a hollow look,
Ethnic pigmentation
Hyperpigmentation from previous procedures, such as laser treatment
Iron deposits from the blood circulation such as allergic shiners
■■■Pathoanatomy of infraorbital dark circles:
Ligaments and bones:
•Relative orbital rim recession and midfacial and malar bone volume loss with age, lead to tightening of the orbital and facial retaining ligaments.
•Facial fat descends and fat volume decreases, so the relatively inflexible ligaments result in tethering and associated orbital rim and facial hollowing.
Midface soft tissue:
•A variety of pathologic and age‑related processes result in increased permeability of the local vasculature resulting in pigmentary changes.
•The lower eyelid tissues may have an increased tendency to accumulate fluid due to local processes such as atopy as well as systemic fluid retention. This fluid often takes on a purplish colour due to the prominent role of the orbicularis muscle in the lower eyelid
•Extravasation of haemoglobin breakdown products contributes to visible pigmentation changes in the cutaneous and S.C layers.
•Age‑related anatomic changes of the midface soft tissue include subcutaneous fat atrophy and volume loss and volume loss in the malar region. These features further accentuate the appearance of dark circles.
Skin contributions:
•The thin eyelid skin results in a darkened appearance due to prominence of the underlying midface soft tissue including the vascular network and the orbicularis oculi muscle.
•Skin ageing and environmental‑related changes throughout the face include a loss of elasticity and turgor as a result of collagen and/or elastin loss.
•Hyperpigmentation of the periorbital skin. Causes may include melasma, nevi, dermal melanocytosis, excessive ultraviolet light exposure, hemosiderin deposition, hormonal changes, Inflammation from various conditions including atopy and contact dermatitis, medications such as oral contraceptives or ophthalmic prostaglandin F2a use or a multifactorial aetiology.
■■■MANAGEMENT:
The first step in managing infraorbital dark circles is to identify the specific constellation of aetiologic factors present so that a customised therapy can be crafted. A spectrum of interventions exist, including:
Non‑invasive options:
•Concealers and cosmeceuticals
•Intense pulsed light (IPL)
•Radiofrequency (RF) devices
•Q‑switched lasers
•Pulsed dye lasers
Minimally invasive treatments:
•Chemical peel
•Platelet Rich Plasma (PRP)
•Mesotherapy
•Carboxy therapy
•Medical tattoos (blepharopigmentation)
•Ablative laser resurfacing
*CO2 and (Er: YAG) lasers are the most commonly used non‑fractioned laser technologies.
*Fractional CO2 laser
•Volume augmentation (hyaluronic acid gel soft tissue fillers)
Invasive treatments:
•Fat transfer
•Surgical implants (Tear trough implants and cheek implants)
•Lower eyelid blepharoplasty