Dark Circ les

Etiology and Management Options

Daniel P. Friedmann, MDa,*, Mitchel P. Goldman, MDb,c

KEYWORDS

Under-eye circles
Infraorbital hyperpigmentation
Tear trough
Nasojugal groove

Suborbicularis oculi fibroadipose tissue
Intense pulsed light
Fractionated resurfacing

Soft-tissue augmentation

KEY POINTS

Under-eye dark circles are an unsurprising source of aesthetic concern of patients owing to the
fatigued and less youthful appearance that they can impart.

The etiology of under-eye circles is multifactorial and includes periorbital volume loss and skin
laxity, orbital fat prolapse, increased prominence and density of subcutaneous vasculature, and
excessive pigmentation.

The ease of use, minimal incidence of complications, and lack of downtime associated with hyal-
uronic acid fillers make these products nearly ideal for treating infraorbital volume loss.

Long-pulsed lasers target lower eyelid vasculature; Q-switched lasers and fractionated resurfacing
treat cutaneous pigmentation. Skin laxity can be improved with fractionated resurfacing and micro-
focused ultrasound.

Standardized pretreatment and posttreatment digital photography is essential. Variations in lighting
alone may mask or worsen lower eyelid appearance.

INTRODUCTION eyelid begins at the free palpebral margin and

extends caudal to the inferior orbital rim, merging
Periorbital cutaneous and structural changes play into the superior aspect of the cheek. It is bor-
a significant role in the perceived age of individuals dered laterally by the lateral canthus and malar
of all ages and races.1–3 The relative darkening of eminence and medially by the medial canthus
lower eyelid skin, commonly referred to as and lateral nasal sidewall. The tear trough is an
under-eye (infraorbital) dark circles or periorbital anatomic depression found in all age groups
hyperpigmentation, can impart a fatigued and that extends obliquely from the medial canthus
less youthful appearance to the face. Dark circles along the medial third of the lower eyelid.6 It is
are therefore an unsurprising source of significant bound medially by the anterior lacrimal crest
aesthetic concern for a number of patients.4,5 and inferiorly by the inferior orbital rim, lying within
the limits of the orbicularis oculi muscle and cor-
ANATOMY
responding to the anatomic location of the
Any evaluation of lower eyelid dark circles must lacrimal sac.6,7 The tear trough forms the superior
begin with an appropriate understanding of the anatomic aspect of the nasojugal groove, which
underlying periorbital anatomy (Fig. 1). The lower extends below the orbital rim.7–9
plasticsurgery.theclinics.com

Funding Sources: None.

Conflict of Interest: Consultant for SkinMedica, Inc and speaker for Lumenis Ltd (D.P. Friedmann); Consultant
for SkinMedica, Inc, Consultant and speaker for Lumenis Ltd (M.P. Goldman).
a
Westlake Dermatology Clinical Research Center, Westlake Dermatology & Cosmetic Surgery, 8825 Bee Cave
Road, Suite 100, Austin, TX 78746 USA; b Cosmetic Laser Dermatology, 9339 Genesee Avenue, Suite 300, San
Diego, CA 92121, USA; c Division of Dermatology, University of California, San Diego, 9500 Gilman Drive,
San Diego, CA 92093, USA
* Corresponding author.
E-mail address: [email protected]

Clin Plastic Surg 42 (2015) 33–50

http://dx.doi.org/10.1016/j.cps.2014.08.007
0094-1298/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
34 Friedmann & Goldman

Excessive Pigmentation
Excessive pigmentation of the lower eyelids owing
to a number of underlying causes can also lead to
under-eye circle formation.12–16 Melasma is an
acquired facial hypermelanosis common in South-
east Asian and Hispanic populations with Fitzpa-
trick skin types III-IV that may predominate in the
infraorbital areas. UV light exposure, pregnancy,
exogenous hormones (including oral contracep-
tives), and genetic predisposition all likely play a
role.17 Nevi of Ota in Asian populations are either
congenital or develop during childhood and are
thereby easily differentiated.18

Orbital Lipodystrophy from Prostaglandin F2a

Periorbital changes have also been reported with
ophthalmic and topical use of the prostaglandin
F2a analogs, including bimatoprost 0.03% (Lumi-
gan or Latisse; Allergan, Inc, Irvine, CA), travoprost,
or latanoprost.19 An acquired orbital lipodysotrophy
characterized by hollowing of lid sulci may rarely
develop from local adipocyte atrophy owing to the
potent anti-adipogenic effects of prostaglandin
F2a. Improvement is typically noted after cessation
of therapy or change to an alternative prostaglandin
analog.20 Ophthalmic use of prostaglandin F2a
analogs can also lead to reversible periocular hyper-
Fig. 1. Periorbital landmarks. Dotted line overlies the
orbital rim. LCa, lateral canthus; LCo, lateral commis-
pigmentation owing to increased melanogen-
sure; MCa, medial canthus; MCo, medial commissure; esis.21–23 The risk of pigmentation seems to be
NJG, nasojugal groove; STC, superior tarsal crease; dramatically lower with topical bimatoprost for
TT, tear trough. eyelash hypotrichosis because of minimal cuta-
neous contact via brush application.24,25

Subcutaneous Fat and Veins

ETIOLOGY
The minimal infraorbital subcutaneous fat, superfi-
The formation of dark circles is often multifactorial, cial location of the orbicularis oculi muscle, and
with a number of factors reported to play a role thin, translucent skin of the lower eyelid can impart
(Table 1). A retrospective evaluation of periorbital a violaceous appearance to the entire area as a
hyperpigmentation in Southeast Asian patients re- result of prominent underlying intramuscular
vealed a predominantly vascular etiology, followed vasculature. Excess subcutaneous telangiectatic
by constitutional (ie, periorbital melanosis), postin- and reticular veins may also play a role.5,26 Greater
flammatory hyperpigmentation (PIH), and shadow- dermal vessel congestion and stasis-related
ing types.11 extravasation during episodes of physical and
mental stress, including menstrual periods and
Shadowing Effect pregnancy, may also worsen dark under-eye
circles.
Infraorbital skin laxity and volume loss with sub-
cutaneous fat atrophy result from a combination EVALUATION
of advancing age and chronic photodamage.
These factors, along with hypertrophy of orbicula- A thorough history and clinical assessment of the
ris oculi muscles, pseudoherniation of suborbicu- lower eyelids and cheeks is necessary to determine
laris oculi fibroadipose tissue, and/or volume loss the underlying cause of a patient’s dark circles,
of the malar cheek, create a shadowing effect on choose the most appropriate course of treatment,
the tear trough.8 This shadowing is lighting depen- and avoid complications. A history of ocular proce-
dent, often masked with the use of direct flash dures, trauma, or allergies and the presence of
photography. autoimmune and neuromuscular disorders should
 Dark Circles 35

Table 1
Etiology of dark under-eye circles

Type Mechanism Treatment Option

Hollowing/ Age-related infraorbital skin laxity and volume loss Hyaluronic acid filler
shadowing SOOF pseudoherniation Fractional ablative CO2
Orbicularis oculi muscle hypertrophy laser resurfacing
Excessive Periorbital melanosis (“constitutional type”, may be an IPL
pigmentation extension of pigmentary demarcation lines)10 Q-switched laser
Postinflammatory hyperpigmentation (allergic contact Nonablative fractionated
dermatitis, atopic dermatitis) resurfacing
Melasma
Oculodermal melanocytoses (bilateral nevus of Ota-like
macules)
Rare: Acanthosis nigricans, fixed drug eruptions, and
erythema dyschromium perstans
Prominent Thin, translucent skin Long-pulsed laser
vasculature Excess subcutaneous vascularity IPL
Venous stasis Hyaluronic acid filler
Fractional ablative CO2
laser resurfacing
Exogenous Penicillamine-induced periorbital pigmentation Hyaluronic acid filler
Bimatoprost-induced periorbital hollowing and Fractional ablative CO2
hyperpigmentation laser resurfacing
IPL
Q-switched laser

Abbreviations: IPL, intense pulsed light; SOOF, suborbicularis oculi fibroadipose tissue.

first be elicited. Genetic or acquired diseases that Evaluating and documenting the presence of a
may predispose patients to bleeding and infections prominent tear trough deformity is essential. The
must also be ruled out. Depending on individual medial and central aspects of the tear trough may
underlying factors, a baseline comprehensive be accentuated with an upward gaze, whereas
ocular examination may be warranted. the lateral border may be accentuated with an up-
The cutaneous lower eyelids should be evalu- ward outward gaze contralaterally.7 Moreover, the
ated systematically to maximize consultation importance of standardized, high-quality pretreat-
time and prevent oversights. Both epidermal and ment and posttreatment digital photography with
dermal features (textural irregularities, dyspigmen- appropriate lighting cannot be overstated, given
tation, photodamage, atrophy, or vessel promi- that different lighting conditions may mask or
nence) and subcutaneous findings (atrophy, accentuate tear troughs and other aspects of the
hollowing, or prolapse) ought to be assessed. lower eyelids (Fig. 3). Manual stretching of lower
The presence of bilateral asymmetry should be eyelid skin can help to differentiate between true
noted. A detailed history and review of prior photo- pigmentation and shadowing effect. Although the
graphs can help to distinguish normal anatomic former retains its appearance with stretching, the
variation from age-related changes.27 Imaging latter improves or resolves entirely. An increase in
with the VISIA system (Canfield Scientific, Inc, violaceous discoloration on manual stretching of
Fairfield, NJ) can highlight blood vessels and the lower eyelids, on the other hand, is consistent
pigmentation with UV light and cross-polarized with a translucent skin and/or hypervascular
flash photography (Fig. 2). etiology.

Fig. 2. (A) Clinically evident dark circles due to volume loss combined with mild underlying (B) erythema and (C)
hyperpigmentation visualized by the VISIA multispectral imaging system. (Canfield Scientific, Inc, Fairfield, NJ.)
36 Friedmann & Goldman

Fig. 3. The effect of lighting conditions on tear trough appearance. Note its accentuation with hard light from
direct flash photography versus masking with 45 soft light from a strobe light source.

Eyelid skin laxity and tone should also be prop- treatments, respectively. IPL glasses or laser
erly assessed before any procedure using distrac- eyewear with an optical density of 51 are also
tion or snap tests, respectively.6 Extensive lower mandatory for device operators and ancillary staff.
eyelid laxity and/or orbital fat herniation on evalua-
tion precludes the benefits of noninvasive treat- Intense Pulsed Light
ment options, warranting operative intervention.
Lumenis IPLs (M22 or Lumenis One, Lumenis Ltd,
Yokneam, Israel) emit 515- to 1200-nm wave-
PROCEDURES
lengths via interchangeable cutoff filters ranging
Preoperative
from 560 to 755 nm. An integrated chilled sapphire
A history of keloids, conditions that may impair crystal tip, a thin layer of cold gel, and periproce-
wound healing, recent oral retinoid use, preg- dural cold air cooling (Cryo 5, Cynosure, Westford,
nancy, breastfeeding, photosensitivity, and/or MA) combine to guarantee proper epidermal
abnormalities localized to the treatment area protection and minimal patient discomfort during
(active infections, malignant lesions, scarring, or treatment. The cold, water-based gel also en-
burns) should be ruled out before undertaking hances optical coupling between the crystal and
any procedure. Any nonessential medications or treatment area, decreasing the index of refraction
supplements that may predispose patients to of light and leading to deeper energy delivery.28
bleeding should be stopped if possible 2 weeks Treatment parameters with a 35-  15-mm crystal,
before any injectable treatment. Given the area, individualized for each patient based on skin type,
prophylactic antiviral therapy for herpes simplex are described in Table 2. Darker skin types should
virus is not routinely performed. be treated with greater caution using higher cutoff
All patients should have photographs and written filter, lower fluences, and/or double to triple puls-
informed consent obtained upon arrival. The treat- ing with longer interpulse delays to help spare
ment area is then washed with a neutral cleanser to epidermal melanin.
remove any makeup or other impurities. Topical For lower eyelid hyperpigmentation, 3.0-ms
anesthesia is generally unnecessary given the double pulsing is performed, with mild darkening
limited treatment area. Moreover, tetracaine- of pigmented areas noted almost immediately
based topical anesthetics may cause transient posttreatment. Sequential 4.0-ms pulses are used
erythema and should be avoided before intense for telangiectasias or diffuse erythema; transient
pulsed light (IPL) or vascular lasers. vessel spasm is the treatment endpoint for discrete
Any laser or IPL treatment of lower eyelid skin vascular lesions. Large-caliber telangiectasias or
within the borders of the bony orbital rim requires reticular veins (1 mm) can be safely double pulsed
intraocular metal eye shields. Otherwise, disposable with higher fluences (19–26 J/cm2) and longer
adhesive and stainless steel or polymer-based pulse durations (4–12 ms) using a smaller 15- 
ocular shields of an appropriate, wavelength- 8-mm crystal. Minimal pressure should be applied
specific optical density are used for IPL and laser against the skin with the hand piece to avoid
 Dark Circles 37

Table 2
Intense pulsed light parameters

Settings Used
Fitzpatrick
Skin Types Cutoff Filter (nm) Delay (ms) Initial Fluences (J/cm2)
I-II 560 10–15 15–19 (increased by 10%–20% with subsequent
treatments, based on clinical response)
III-IV 560 or 590 20–50 14–16
V-VI 695 or 755 Triple pulsing 14–16

compression of target vessels. A typical patient settings because they have different pulse charac-
requires 1 to 3 sessions to achieve significant teristics (eg, wavelength range, pulse duration, and
improvement, with subsequent semiannual main- energy distribution).
tenance treatments.
Twelve subjects treated with 2 to 4 sessions with
Q-Switched Lasers
an older version IPL (Quantum, Lumenis Ltd) with
2.6/4.0 ms double-pulsing (20 ms delay) and fluen- Cutaneous melanin has a broad, polychromatic
ces of 36 to 37 J/cm2 demonstrated significant absorption spectrum that peaks in the UV range
lightening (P 5 .024) of lower eyelid idiopathic and declines steadily as a function of increasing
hyperpigmentation, as rated by 7 independent wavelength (Fig. 4). Although significantly attenu-
observers.29 Pigment recurrence was not seen at ated past 755 nm, energy absorption is still likely
the 1-year follow-up. All subjects experienced with wavelengths up to 1064 nm, allowing for
posttreatment PIH (mean, 6.7 months). A prior treatment of deeper pigment and darker Fitzpa-
study by the same group30 found greater impro- trick skin types. Given that melanosomes have
vement in under-eye hyperpigmentation with fewer thermal relaxation times of less than 1 ms, ultra-
adverse events using IPL compared with Q- short pulse durations are required to selectively
switched ruby laser (QSRL). confine photothermal and photoacoustic effects
Other IPL systems may also be used, but treat- to these structures.31 Multiple Q-switched lasers
ment should proceed with more conservative with nanosecond (and recently picosecond) pulse

Fig. 4. Absorption spectra for water, oxyhemoglobin, deoxyhemoglobin, and melanin in the visible light and
near-infrared wavelength range.
38 Friedmann & Goldman

durations and wavelengths within the absorption spot sizes and 4 to 8 J/cm2. Lower fluences may
range of melanin are currently available. The lead to equal efficacy with decreased PIH.38
typical clinical endpoint of these treatments is im- A novel QSAL (PicoSure, Cynosure, Inc) with en-
mediate lesion whitening without pinpoint ergy delivered in picoseconds (as low as 550 ps)
bleeding. Lower energy settings should be used may produce greater tensile stress on melano-
initially to minimize the occurrence of PIH. somes than nanosecond pulse durations,
enhancing their photomechanical and photother-
Q-switched ruby lasers mal destruction. Collateral tissue heating and
The 694-nm wavelength of QSRLs is moderately associated adverse events are minimized owing
absorbed by melanin, yet poorly absorbed by to the lower fluences required.39 As a result,
competing chromophores such as hemoglobin.32 potentially all skin types may be treated with this
Rapid delivery of high-intensity energy at this device. A 3- to 5-mm spot size and 1.5 to 2.83 J/
wavelength disrupts melanosomes within kerati- cm2 fixed fluence are favored.
nocytes, melanocytes, and melanophages, mak-
ing them ideal for pigmented epidermal and Q-switched Nd:YAG lasers
superficial dermal lesions in Fitzpatrick skin types With a wavelength of 1064 nm, these devices allow
I-II.33 for much deeper energy penetration and minimal
QRSL treatment is performed with 2 to 4 J/cm2 melanin absorption compared with QSRL or
using a 5-mm spot size (or varied accordingly) at QSAL. Fitzpatrick skin types V and VI can thereby
1.5 Hz (Fig. 5). The clinical endpoint with this de- be treated with minimal risk of posttreatment dys-
vice is immediate lesion whitening that resolves pigmentation. The Spectra (Lutronic, Inc, Fremont,
over 20 minutes, followed by erythema and CA) 1064-nm Q-switched neodymium-doped
edema. Lowe and colleagues34 showed greater Nd:YAG laser uses a collimated hand piece to
than 50% improvement in infraorbital hyperpig- deliver a high peak power over very short pulse du-
mentation in 23.5% and 88.9% of 17 subjects after rations (10 ns), maximizing selective photother-
1 and 2 sessions, respectively. Another study of molysis of cutaneous melanosomes. As
QSRL (6 to 7 J/cm2) for under-eye dermal melano- demonstrated in treating melasma, repeat ses-
cytoses showed greater than 40% improvement in sions with low-fluence, Q-switched Nd:YAG treat-
4 subjects after 1 to 5 sessions.35 Combining ments can decrease stage IV melanosomes,
QSRL with topical hydroquinone and tretinoin damage melanocytes, and reduce expression of
before and after treatment has also led to signifi- melanogenesis-associated proteins.40 Greater flu-
cant improvement in this location.36 ences (4 to 5 J) can be used with a 3-mm spot size
for other types of lower eyelid hyperpigmentation.
Q-switched alexandrite lasers Thirty female Chinese subjects with under-eye
The more deeply penetrating 755-nm wavelength circles owing to dermal melanin deposition
of the Q-switched alexandrite laser (QSAL) has a received 8 low-fluence treatments (3.5-mm spot
lower absorption coefficient for melanin and is size, 4.2 J/cm2, 2 passes) at 3- to 4-day intervals.
emitted over a longer pulse duration (50–70 ns) Blinded evaluators rated a mean global improve-
than that of QSRL, which may serve to decrease ment of 50% to 75% at 3 and 6 months, and
adverse events (eg, PIH) in dark-skinned patients 93.3% subjects reported good to excellent results
as a result of gentler melanosomal heating.37 without significant adverse events.41
QSAL treatments of Fitzpatrick skin types of IV or Frequency-doubled Nd:YAG or potassium-
lower are typically performed with 3- to 5-mm titanyl-phosphate lasers (532 nm) can also

Fig. 5. Significant improvement in infraorbital hyperpigmentation after a single treatment with combination Q-
switched 694 nm ruby laser (SINON, Alma Lasers Ltd, Buffalo Grove, IL) for hypermelanosis and long-pulsed
1064 nm Nd:YAG laser (CoolTouch VARIA, CoolTouch Inc, Roseville, CA) for reticular veins.
 Dark Circles 39

effectively target pigmentation with nanosecond (greater than 70 J/cm2) for their thermocoagulation.
pulse durations. A split-face study of 10 female sub- Nevertheless, long-pulsed 1064 nm Nd:YAG de-
jects with bilateral acquired nevus of Ota-like mac- vices are ideal for the treatment of larger, deeply sit-
ules compared 532 nm with a combination of 532/ uated facial vessels (eg, reticular veins) owing to the
1064 nm.42 Parameters included a 4-mm spot size superior penetration of laser energy at this wave-
with 1.2 J/cm2 (532 nm) and 4 mm with 6.5 J/cm2 length. Fitzpatrick skin types V and VI can be
(1064 nm). Objective measures of pigmentation treated with low risk of epidermal injury, given the
and subject- and blinded physician-graded low absorption coefficient for melanin at 1064 nm.
improvement were significantly better with combi- The CoolTouch VARIA (CoolTouch, Inc, Ro-
nation treatment at 6 months after a single session. seville, CA) dispenses cryogen cooling before
and/or after laser pulse delivery, maximizing
Pulsed-Dye Lasers treatment-related safety and reducing procedural
discomfort.46 Treatment parameters for periorbital
Unlike prior flashlamp-pumped pulsed-dye lasers
veins are based directly on vessel size and a
with short pulse durations (0.1 to 0.45 ms) and
3.5-mm (range, 2 to 10) spot size; 1-mm reticular
577-nm light emission, current pulsed-dye lasers
veins are treated with a 25-ms pulse duration
deliver 585 and 595 nm wavelengths over
and fluences of 160 to 190 J/cm2, whereas 1- to
extended pulse widths (less than or equal to
3-mm veins require up to 50 ms and 190 to
40 ms) that allow for selective photothermolysis
210 J/cm2 (Fig. 6). Both have cryogen cooling of
of larger, deeper ectatic vessels and a far greater
20 to 30 ms delivered immediately after the laser
purpuric threshold.43,44 Although pulse stacking
pulse to quench transmission of heat from thermo-
and multiple passes at subpurpuric fluences with
coagulated blood vessels to the epidermis.
adequate epidermal protection (cryogen or con-
A distal (superior) to proximal (inferior) technique
vection cooling) lead to significant improvement
ensures sufficient chromophore (hemoglobin)
in vessel clearance without added adverse events,
within subsequent areas of treatment. Vessel
multiple treatment sessions may still be needed.45
spasm or thrombosis is the endpoint of treatment,
Superficial telangiectasias are treated with pulse
evidenced by immediate vessel blanching or dark-
durations and fluences of 6 ms and 7 to 9 J/cm2
ening. Although pulse stacking or overlapping
(less than 0.6 mm) or 10 ms and 8 to 12 J/cm2
should be avoided to prevent bulk heating of
(greater than 0.6 mm) using a 7-mm spot size,
treated areas, a second pass can be attempted
with marginally overlapping pulses. Thicker facial
after an interim of several minutes. One to 2
vessels (w1 mm) require 20 to 40 ms pulse widths
monthly sessions are required.
and subpurpuric fluences as high as 13 to 15 J/
Twenty-six Chinese subjects with under-eye
cm2. One to 3 sessions at 4- to 8-week intervals
dark circles owing to prominent reticular veins
are often needed. Diffuse erythema can be tar-
(1.0 to 2.5 mm) were treated with a mean of 1.6
geted with a 10-mm spot size and 6 or 10 ms at
(range, 1 to 3) monthly sessions using a contact-
5 to 8 J/cm2 or 20 ms at 7.5 to 9 J/cm2. Dark-
cooled long-pulsed Nd:YAG laser.47 Parameters
skinned patients should be treated with longer
included a 6-mm spot size, 120 to 140 J/cm2
pulse durations and lower fluences. Treatment
fluence, and 6- to 10-ms double-pulsing with a
endpoint is immediate vessel spasm and transient
20-ms delay. At 12-month follow-up, all subjects
purpura indicative of intravascular coagulation.
were found to have complete vessel resolution. A
Care should be taken when using cryogen cooling,
retrospective study confirmed nearly 100% sub-
because the cryogen is likely to enhance PIH.
jective and objective improvement after 1 to 2 ses-
Given that pulsed-dye laser wavelengths lie
sions with appropriate settings.46
within the absorption coefficient for melanin,
hyperpigmentation can be targeted with a 7-mm 532 nm frequency-doubled Nd:YAG
spot size using a single 10-ms pulse, low fluences KTP lasers emit energy across millisecond pulse
(7 to 8 J/cm2), and no epidermal cooling. Unlike the durations, leading to purpura-free treatment of
treatment of cutaneous vessels, pulse stacking or superficial cutaneous vessels. The high absorption
multiple passes should be avoided. coefficient for melanin at 532 nm restricts their use
to light-skinned individuals, yet renders them
Long-Pulsed Nd:YAG Lasers effective for hyperpigmentation, despite their
1064 nm Nd:YAG long-pulsed energy delivery.48
Although dermal vessels strongly absorb 532 and
Traditional Ablative Lasers
595 nm, approximating the absorption peaks of
oxyhemoglobin, 1064 nm energy is poorly ab- Pulsed CO2 traditional ablative lasers emit
sorbed and requires significantly greater fluences 10,600 nm energy preferentially absorbed by
40 Friedmann & Goldman

Fig. 6. Lower eyelid reticular veins before (left) and 2 months after (right) a single treatment with a cryogen-
cooled, long-pulsed 1064 nm Nd:YAG laser. (Courtesy of Richard E. Fitzpatrick, MD, San Diego, CA.)

water, leading to confluent epidermal vaporization resurfacing (AFR) using a CO2 laser (25% coverage,
and thermal damage of the superficial dermis. 30 W, 1-ms dwell time) by Tierney and col-
Erbium:YAG lasers, on the other hand, allow for leagues.58 At 6-month follow-up, 2 blinded physi-
more precise epidermal vaporization as a result cians found a mean improvement of 65.3% and
of the larger absorption coefficient for water at 62.1% in laxity and rhytides, respectively. Another
2940 nm. The amount of nonspecific thermal dam- study found 50% to 100% tightening in 68% of sub-
age produced by erbium:YAG devices is directly jects after a single session with 1 to 3 passes (25 to
contingent on dwell time, with only longer (milli- 35 J, 1-ms dwell time, 100 spots/cm2).
second) pulse widths producing significant ther- We prefer the Encore UltraPulse (Lumenis Ltd)
mal contraction and denaturation of collagen. with single, nonoverlapping passes of Deep FX for
Shorter (microsecond) pulse widths thereby allow deep wrinkles, followed by Active FX to target fine
treatment of darker skin types with minimal risk lines and irregular pigmentation (Fig. 8). Technique
of dyspigmentation or scarring.49 video on lower eyelid ablative fractionated re-
Pulsed CO2 and erbium:YAG lasers have both surfacing with appropriate treatment parameters
demonstrated significant improvement in eyelid and aftercare instructions can be accessed on-
wrinkling and laxity after a single treatment line at: http://www.plasticsurgery.theclinics.com.
(Fig. 7).50,51 CO2 laser resurfacing has also been Although treatment of pretarsal skin within the
shown to improve infraorbital hyperpigmentation margin of the superior tarsal crease is avoided, lower
by up to 50%.52,53 Lower eyelid rhytides and PIH eyelid skin up to 1 to 2 mm from the ciliary margin
may likewise be improved with a 2790-nm can be treated without adverse events. Manual
erbium:yittrium-scandium-galium-garnet stretching of eyelid skin during treatment avoids
laser.54,55 overlap or skip areas and ensures proper, per-
pendicular delivery of laser energy. Eyelid rhytides
Ablative Fractional Lasers and redundancy improved by 53.1% and 42.0%,
respectively, in a study of 15 subjects treated with
Fractionated lasers are becoming increasingly a single session of Deep and Active FX.59
popular owing to the prolonged and meticulous
postoperative care, need for general anesthesia,
Nonablative Fractional Lasers
and potential adverse effects associated with
traditional resurfacing, all of which are mitigated Despite the advances of fractionated ablative
with fractionated resurfacing. Instead of producing lasers on their traditional counterparts, a subset
confluent thermal damage, fractionated lasers of patients refuse to undergo a procedure that is
create columnar microthermal treatment zones associated with greater discomfort, side effects,
that leave up to 95% of the cutaneous surface a weeklong downtime, and an intense postope-
intact, providing an endogenous reservoir for rapid rative regimen. Although both cause dermal coag-
healing and barrier to infection.56,57 Significant ulation necrosis limited to microthermal treatment
improvement in deep wrinkles, fine lines, texture ir- zones eventuating in collagen remodeling, non-
regularity, laxity, and dyschromia can be achieved AFR (NAFR) spares the overlying epidermis,
with a single treatment. leading to rapid recovery and reduced adverse
Twenty-five subjects with lower eyelid laxity were events after the procedure.57 Greater procedural
treated with 2 to 3 sessions of ablative fractional and postoperative tolerability must, however, be
 Dark Circles 41

Fig. 7. Periorbital resurfacing with a traditional ablative CO2 laser, before (left) and 3 months after (right) a single
treatment session.

weighed against the need for a minimum of 4 to 6 to their M22 system with spot sizes of 5 to 18 mm,
monthly treatments to appreciate substantial pulse energies of 10 to 70 mJ, and densities from
improvement. 50 to 500 spots/cm2 (Fig. 10).
The Fraxel DUAL re:store (Solta Medical, Inc,
Hayward, CA) houses both erbium-doped Soft-Tissue Augmentation
(1550 nm) and thulium (1927 nm) laser fibers in a Under-eye dark circles resulting from infraorbital
single device. Although the absorption coefficient volume loss and shadowing can be addressed
for water is far greater at 1927 nm, making it ideal with a number of commercially available fillers or
for superficial resurfacing and hyperpigmentation autologous fat transplantation. Both techniques
(Fig. 9), the 1550-nm wavelength is able to target can effectively restore volume to aging tear
laxity and fine lines owing to its greater depth of troughs and infraorbital hollows, rebuilding the
penetration. A study by Sukal and colleagues60 natural convexity of the lower eyelid–midface tran-
found 50% to 100% improvement in eyelid skin sition zone.62
tightening in 55% of subjects after 3 to 7 sessions
(17 to 20 mJ, 500 to 750 microthermal treatment Fat autologous muscle injection
zones per cm2) with a 1550-nm NAFR. Standard The placement of small volumes of fat within or
treatment parameters for lower eyelid treatment adjoining muscles of facial expression for facial
with this device are listed in Table 3. A number rejuvenation is a technique known as fat autograft
of other erbium, diode, and Nd:YAG devices are muscle injection (FAMI).63 Prolonged cosmetic
also currently available. Lumenis recently launched results after fat transplantation are likely a combi-
a contact-cooled 1565-nm fiber upgrade (ResurFX) nation of adipocyte survival within these highly

Fig. 8. Fractional ablative CO2 resurfacing demonstrating marked improvement in lower eyelid wrinkling and laxity.
42 Friedmann & Goldman

Fig. 9. Expected posttreatment erythema and crusting after 1927-nm nonablative fractional resurfacing (Fraxel
DUAL re:store, Solta Medical, Inc, Hayward, CA). Note the significant improvement in lower eyelid and malar
hyperpigmentation at 2 months posttreatment.

vascular recipient sites and subcutaneous fibrosis Approximately 1 to 1.5 mL of centrifuged fat is
in response to grafted adipose tissue.64 A study of typically required for each infraorbital area.
fat transfer in 10 subjects with under-eye circles Autologous fat transfer, although effective, may
owing to thin, translucent skin showed a mean have the adverse effect of variable “take” of the in-
78% improvement in lower eyelid discoloration jected fat. This may lead to areas of excessive fat,
and contour.65 Fig. 11 presents the FAMI proce- presenting clinically as palpable and/or visible
dure for infraorbital volume augmentation.66 lumps. In addition, transferred fat may calcify.

Table 3
Nonablative fractionated resurfacing of lower eyelids with the Fraxel DUAL

Fiber Settings Purpose

1550 nm Pulse energies: 30–50 mJ (with 8–20 mJ for Skin laxity, fine lines, reticular
pigmentation only, despite reports61 of 70 mJ) dermal pigmentation
Treatment levels based on skin type: I–III: 7–11
(20%–32% coverage); IV–VI: 4–7 (11%–20%
coverage)
1927 nm Pulse energies: 5–20 mJ with treatment levels 1–4 Skin texture and tone, epidermal
(20%–35% coverage). Melasma: Pulse energy of and superficial dermal
5–10 mJ and treatment level 5 (40% coverage) pigmentation
1550 1 Same pulse energies, but total combined coverage
1927 nm should not exceed 70%
 Dark Circles 43

Fig. 10. (A) Variable pattern shapes and (B) densities ranging from 50 to 500 spots/cm2 with the ResurFX (Lumenis
Ltd, Yokneam, Israel), a novel contact-cooled, 1565-nm erbium doped fiber laser with nonsequential delivery of
laser energy. (C) Single-pass with ResurFX (above) compared with 5 passes with the 1550-nm Fraxel DUAL re:store
(below), both leading to 500 spots/cm2 at 20-mJ pulse energy.
44 Friedmann & Goldman

Fig. 11. (A) Fat is harvested from fully tumesced donor fat with a 12-gauge Klein finesse cannula attached to a 10-mL
syringe; negative pressure is achieved manually by pulling back on the plunger. (B) Syringes of fat are inverted, al-
lowing separation of supranatant fat from infranatant and oil fractions, which are discarded. (C) Fat is then further
concentrated via centrifuge (3 min at 3600 rpm), and the new infranatant is discarded. (D) Concentrated fat is trans-
ferred to 1-mL syringes. (E) An entry site (via an awl or noncoring needle) in the lateral mid cheek at the level of the
bony orbital rim is preferred for targeting the infraorbital portion of the orbicularis oculi muscle and the overlying
subcutaneous plane. Pretreatment nerve blocks (lidocaine 1% with epinephrine 1:100,000) are performed at level of
the infraorbital foramen. (F) Aliquots of fat are injected in a retrograde fashion with low injection pressure by means
of a curved, blunt-tipped cannula. (Courtesy of Kimberly J. Butterwick, MD, San Diego, CA.)

Therefore, we now favor the use of other fillers (24 mg/mL) homogeneous nonparticulate gel.70
described. Given that Juvederm is 6 times more hydrophilic
than Restylane, significantly greater posttreatment
Hyaluronic acid soft-tissue fillers edema is expected and overcorrection should be
The market for injectable hyaluronic acid (HA) avoided.71 Both contain 0.3% lidocaine to
dermal fillers continues to expand rapidly. Accord-
ing to the American Society for Dermatologic
Surgery, nearly 1 million filler (primarily HA) proce- Box 1
Desirable characteristics of dermal fillers
dures were performed in 2012 by dermatologic
surgeons, a 10.4% increase over the previous Safety
year.67 The ease of use, minimal incidence of com-
Biocompatible
plications, and lack of downtime associated with
these products make them nearly ideal for treating Lack of hypersensitivity
infraorbital volume loss (Box 1). The biocom- Lack of clinical inflammatory response
patibility of HA across all species also safeguards Nonmigratory, nonclumping
against hypersensitivity reactions. Retrospec-
tive studies of periorbital HA have demonstrated Negligible pain
85% to 89% patient satisfaction after 1 to 3 Efficacy
sessions.68,69
FDA-approved
Despite being approved by the US Food and
Drug Administration for correction of moderate to Reproducible technique/result
severe nasolabial wrinkles and folds, the use of Ease of use (room temperature storage; re-
HA products in the under-eye area is off-label. quires minimal to no preparation; effortless to
We prefer to use the non-animal, bacterium- inject)
derived stabilized HA fillers Restylane-L (Medicis, Results (long-duration; good contouring ability;
a division of Valeant Pharmaceuticals, Inc, Scotts- collagen-stimulating)
dale, AZ) or Juvederm Ultra XC (Allergan, Inc) for Cost effective
infraorbital volumization. Restylane is a medium-
sized, particle-based HA with a concentration of FDA, Food and Drug Administration.
Adapted from Carruthers J, Cohen SR, Joseph JH,
20 mg/mL and the highest G0 (measure of stiffness) et al. The science and art of dermal fillers for soft-
of any currently available HA filler. On the other tissue augmentation. J Drugs Dermatol 2009;8:335–50.
hand, Juvederm is a higher concentration
 Dark Circles 45

minimize procedural discomfort when injecting Topicals

with prepackaged 27-G needles and obviate the
A number of topical products have been reported to
need for topical anesthesia.
improve lower eyelid pigmentation, laxity, and rhy-
Technique video on periocular rejuvenation with
tides. A study by Mitsuishi and colleagues77 found
an HA filler can be accessed online at http://www.
subjective improvement in under-eye hemostasis
plasticsurgery.theclinics.com. Although a number
and wrinkling with use of a gel containing 0.1%
of techniques have been described in the litera-
retinol and vitamins C, E, and K for 8 weeks. Other
ture,62,72–74 we have found that injecting a sup-
uncontrolled studies of creams with vitamins C, E,
raperiosteal bolus into the area underlying the
and K or vitamin K and retinol have demonstrated
tear trough and nasojugal groove using minimal
improvement in infraorbital pigmentation in 93%
injection points leads to excellent results with min-
to 100% of subjects, albeit with variable results.78,79
imal risk of bruising. Volumes of 0.4 to 1.0 mL per
Vitamin C in particular may serve to thicken eyelid
side are used, depending on the product and
dermal tissue, masking hemostasis-related dis-
extent of volume loss. Gentle digital massage of
coloration.80 Although hydroquinone has been the
the area helps to smooth the product into place.
gold standard for hyperpigmentation, a recently
Results typically last up to 1 year (Figs. 12 and
released hydroquinone-free topical product target-
13). We have not found any added benefit from
ing all major biochemical pathways of cutaneous
the infraorbital use of blunt-tipped cannulas
pigmentation may lead to equivalent results without
compared with needles.
safety concerns associated with long-term use.81,82
Topical application of growth factors may also help
Microfocused Ultrasound to reverse under-eye photodamage and laxity.83,84
Microfocused (or intense focused) ultrasound is a
novel technology for the correction of mild to mod- COMPLICATIONS AND AFTER CARE
erate skin and soft tissue laxity introduced in 2009
The risk of complications after laser and injectable
(Ultherapy, Ulthera, Inc, Mesa, AZ). Short duration
procedures is low when experienced practitioners
(25 to 50 ms) pulses of transcutaneous ultrasound
utilize appropriate treatment settings and/or
energy with frequencies in the megahertz (MHz)
proper technique. If they occur, adverse events
range create precise areas of spatially focused,
are typically mild and transient. Apart from frac-
chromophore-independent thermal coagulative
tionated resurfacing, little to no after care regimen
damage, sparing intervening tissues or overlying
is required for these procedures.
skin.75 A single treatment session has been shown
to increase reticular dermal collagen and
Intense Pulsed Light
thickness.76 Suh and colleagues76 showed objec-
tive and subjective improvement in infraorbital skin Mild-to-moderate erythema lasts between hours
laxity at 6 months after 1 to 2 sessions, each with and 3 days. Postprocedure topical steroid use,
110 to 280 lines. We use 7-MHz, 3.0-mm (0.25 to however, is rarely necessary. Areas of increased
0.45 J) and 10-MHz, 1.5-mm (0.15 to 0.25 J) trans- pigmentation may develop scattered crusting
ducers with a combined 25 to 50 parallel lines per within days of treatment.85 Employing a 10%
eyelid (Fig. 14). overlap between pulses minimizes reticular

Fig. 12. Lower eyelid rejuvenation with a single session of a non-animal–stabilized hyaluronic acid filler.
(Restylane-L, Medicis, a division of Valeant Pharmaceuticals, Inc, Scottsdale, AZ.)
46 Friedmann & Goldman

Fig. 13. Treatment of tear trough deformity with a double-crosslinked, nonparticulate hyaluronic acid filler. (Be-
lotero Balance, Merz Aesthetics, Inc, Greensboro, NC.)

footprinting. Subsequent treatment with the IPL purpura that resolves over 1 to 2 weeks. More effi-
should be performed with the crystal rotated 90 . cient cooling mechanisms help to limit epidermal
Purpura formation is uncommon with appropriate thermal injury (eg, dyspigmentation, crusting, blis-
settings. tering, or scarring) in dark skin types.87
Blistering and persistent dyspigmentation are un-
common and likely to be a direct result of excessive Long-Pulsed Nd:YAG Lasers
overlapping, exorbitant fluences, poor epidermal
cooling, and/or insufficient delay between sequen- Treatment of veins within the orbital rim with a
tial pulses, particularly in dark-skinned or tanned 1064-nm laser places patients at significant risk
individuals.86 Nevertheless, scarring is exceedingly of macular holes, uveitis, and pupillary abnormal-
rare. Given the ability of IPL to permanently damage ities. The combination of metal corneal shields,
dark-colored terminal hairs, IPL treatments are pulling infraorbital skin away from the eye, and
generally avoided in hair-bearing skin of the male aiming the laser away from the orbit prevent intra-
beard area. ocular injury during treatment.88 When treating the
lower eyelid, veins at or medial to the mid pupillary
line should likely be avoided owing to their
Q-Switched Lasers
drainage into ophthalmic veins and cavernous
Erythema and edema resolve over 24 to 48 hours. sinus.89
Mild transient crusting is expected after higher
fluence treatment of pigmented areas. Blistering Fractionated Resurfacing
or bleeding may result if excessive fluences are
used. Overly aggressive treatment in darker Cold, sterile saline compresses are applied imme-
skin types increases the risk of PIH or diately post-AFR. An occlusive ointment is then
hypopigmentation. applied every 4 hours for 4 to 7 days until reepithe-
lialization is complete, at which point the use of a
noncomedogenic, ceramide-based moisturizer
Pulsed-Dye Lasers
and mineral-based (zinc oxide or titanium dioxide)
Posttreatment erythema usually resolves within sunscreen is advised. A mid potency topical
hours, but can persist for up to 2 days. Short pulse steroid (eg, fluocinolone 0.025% ointment BID)
durations with excessive fluences may induce is started at day 3 or 4 to decrease erythema,

Fig. 14. Improvement in lower eyelid skin laxity after microfocused ultrasound. (Ultherapy, Ulthera, Inc,
Mesa, AZ.)
 Dark Circles 47

pruritus, and PIH. After NAFR, a ceramide-based 4. Freitag FM, Cestari TF. What causes dark circles
moisturizer and mineral-based sunscreen are under the eyes? J Cosmet Dermatol 2007;6:211–5.
applied every 6 to 8 hours for 3 to 5 days until 5. Roh MR, Chung KY. Infraorbital dark circles: defini-
erythema and/or crusting have resolved. tion, causes, and treatment options. Dermatol Surg
The risk of adverse events is low with NAFR. 2009;35:1163–71.
Although blistering, scarring, infection, pigmentary 6. Stutman RL, Codner MA. Tear trough deformity:
changes, herpes simplex virus reactivation, and review of anatomy and treatment options. Aesthet
acneiform eruptions (in acne-prone patients) are Surg J 2012;32:426–40.
still possible, they are far more likely with AFR. 7. Hirmand H. Anatomy and nonsurgical correction of
the tear trough deformity. Plast Reconstr Surg
Soft-Tissue Augmentation 2010;125:699–708.
8. Sadick NS, Bosniak SL, Cantisano-Zilkha M,
Injection-related adverse events including bruis-
et al. Definition of the tear trough and the tear
ing, erythema, tenderness, and edema are rela-
trough rating scale. J Cosmet Dermatol 2007;6:
tively common. Not unexpectedly, all are more
218–22.
severe with FAMI. Papules, nodules, or bluish
9. Haddock NT, Saadeh PB, Boutros S, et al. The tear
discoloration secondary to Tyndall effect are
trough and lid/cheek junction: anatomy and impli-
possible if HA fillers are injected too superficially,
cations for surgical correction. Plast Reconstr
but are readily reversed with hyaluronidase
Surg 2009;123:1332–40.
(10–30 U). However, a novel double-crosslinked,
10. Malakar S, Lahiri K, Banerjee U, et al. Periorbital
nonparticulate HA filler, Belotero Balance (Merz
melanosis is an extension of pigmentary demarca-
Aesthetics, Inc, Greensboro, NC), now allows for
tion line-F on face. Indian J Dermatol Venereol Leprol
superficial product placement without these side
2007;73:323–5.
effects. Irregularities after superficial placement
11. Ranu H, Thng S, Goh BK, et al. Periorbital hyper-
of fat are more difficult to treat and may require
pigmentation in Asians: an epidemiologic study
intralesional corticosteroids or excision. Arterial
and a proposed classification. Dermatol Surg
occlusion with embolization and/or injection site
2011;37:1297–303.
necrosis have not reported with under-eye place-
12. Ortonne JP, Sharma V, Verschoore M, et al. Deter-
ment of HA fillers or FAMI.90,91
mination of melanin and haemoglobin in the skin
of idiopathic cutaneous hyperchromia of the orbital
SUMMARY region (ICHOR): a study of Indian patients. J Cutan
Given their multifactorial nature and the fact that Aesthet Surg 2012;5:176.
individual patients may have more than a single 13. Cho S, Lee SJ, Chung WS, et al. Acquired bilateral
underlying cause, cosmetic practitioners should nevus of Ota-like macules mimicking dark circles
be well versed in a number of potential treatment under the eyes. J Cosmet Laser Ther 2010;12:
options encompassing all facets of under-eye 143–4.
dark circles. New therapeutic options are also 14. Marks MB. Allergic shiners: dark circles under the
forthcoming. Longer-lasting HA fillers, wavelength eyes in children. Clin Pediatr 1966;5:655–8.
tunable laser devices, and topicals speeding up 15. Safoury El OS, Fatah El DS, Ibrahim M. Treatment
healing and enhancing results after fractionated of periocular hyperpigmentation due to lead of
laser therapy will all serve to make the future of kohl (surma) by penicillamine: a single group
dark circle treatment unabatedly bright. non-randomized clinical trial. Indian J Dermatol
2009;54:361–3.
16. Peters NT, Conn H, Côté MA. Extensive lower
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