After many years of experience, and over 2400 laser eyelid rejuvenation procedures called blepharoplasty 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.

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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

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.

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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.

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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.

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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.