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Medical Causes of Dark Circles Under The Eyes

There is much confusion regarding what people mean when they say they have dark circles under the eyes, often referred to as the tired look.

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There are 4 different conditions which can cause dark color beneath the eyes or under the eyelids 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. This is dark purple eyelid skin color not dark circles under the eyes.

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 refer to it as a 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. The ActiveFX Laser Peel, a deep exfoliation technique can also be helpful.IPL also called Photo Facial can also help. A new laser, the ActiveFX is the most up to date method for removing superficial eyelid skin pigmentation. Very goods results can be achieved with these modalities.

3. A Hollow Eye Appearnce

Some people have a very sunken in or hollow eyes appearance which some mistakenly call dark circles under the eyes. 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 treatment 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 to the lower eyelid to plump the lower eyelid.

4.The Naso-jugal Fold or Tear Trough Deformity-the True Dark Circles Under the Eyes.

The true dark circles under the eyes 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 under the eye 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 eyelid tissue called the arcus marginalis.

To correct thbags and dartk circles under the eyes I perform an eyelid rejuvenation procedure called a laser transconjunctival blepharoplasty. During the procedure I release the arcus marginalis, a condensation of eyelid tissue connected to the bone of the eye socket 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 bags and 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 under the eyes requires a blepharoplasty operation with arcus marginalis release and fat grafting or tear trough implants.

To learn more about dark circles under the eyes read Save Your Face or contact me.

Dr Seckel

Boston, Massachusetts