After many years of experience, and over 2,400 laser eyelid rejuvenation procedures my understanding of the condition often referred to as dark circles under the eyes has evolved to, I believe, a better understanding of this common condition and a newer more effective surgical strategy for the correction of dark circles under eyes.
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 5th or 6th 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