Solutions for the Lower Eyelids
Lower Eyelid Dark Circles

Leesburg | Loudoun | Ashburn | Virginia

One of the most common concerns seen in our office for consultation is dark circles under the eyes.  The reasons for dark circles under the eyes are multi-factorial and include:

  • Loss of volume in the upper cheek eyelid junction which is no longer able to camouflage the underlying orbital bone
  • Increased sun exposure of the lower eyelids as the lower eyelid sits on a shelf on the upper cheek
  • Stretch of the lower eyelid skin as the cheek falls with age causes the lower eyelid skin to wrinkle and darken
Given these findings, the treatment strategy to addressing the dark circles of the lower eyelid are:
  • Add volume to the upper cheek eyelid junction with fillers or fat transfer
  • Forever Young BBL to bleach the dark abnormal pigment of the eyelid skin
  • Surgical removal of excess lower eyelid skin if necessary.

The dark circles under the lower eyelids are the result of many concurrent reasons.  

Loss of volume in the upper cheek eyelid junction 

  • The loss of volume seen in the region of the lower eyelids where it joins the cheek is one of the principle reasons for the development of dark circles.  The fat in this reason normally supports the eyelid and camouflages the visibility of the orbital bones.  Volume is lost as you age beyond your mid-twenties.  As that volume is lost, the remaining cheek tissue will sag, and the combination will expose the orbital bone.  Because the bone is dark and the bone is circular, the resulting visual is a dark circle below the lower lids.

Increased sun exposure of the lower eyelids

  • The lower eyelids are normally supported by the upper cheek.  And the upper cheek acts as a shelf with extra exposure to the sun.  Sun exposure on the cheek reflects light onto the lower eyelid which in turn results in extra tanning of the tissues in this area.  The tanning over time will permanently darken the skin pigment.

Stretch of the lower eyelid skin as the cheek falls with age 

  • An unfortunate fact is that everything falls with age.  The immediate cause is a loss of volume and tissue turgor and the break-down of tissue collagen.  As the volume is lost in the eyelid cheek junction ( see first bullet point ), the tissue around the upper cheek begins to deflate and sag.  The tissue will pull downwards causing the lower eyelid skin to stretch.  The stretched skin is extra skin that folds onto itself causing dark shadowing

Treatment strategies for the dark circles of the lower eyelids revolve around the three reasons for developing dark circles.   These include treatment options for addressing:

  • Loss of volume in the cheek eyelid junction and orbital bone exposure
  • Darkening of the eyelid skin due to excessive sun exposure
  • Excess skin and wrinkles from skin stretch over time and age
Depending on your individual issues, the strategy for addressing your concerns may require treating all 3 findings.  The first step in most patients is to address the volume loss and the skin pigment as these issues are relatively easy to address before considering the treatments for reducing skin excess and wrinkless

Volume loss in the lower eyelid cheek junction is inevitable and is the primary reason for the visibility of dark circles of the lower eyelid area.  

The volume loss is addressed either by injection of facial fillers like Juvederm or Voluma or the addition of fat by fat transfer.  

Facial fillers like Juvederm or Voluma 

Facial fillers can be injected into the area of volume loss.  This simple procedure can often be performed on the same day as your consultation.  The procedure will take about 10 minutes.  There is no down-time.

Fat Transfer

Fat Transfer is more of a surgical procedure.  Fat is obtained by liposuction from the abdomen or thighs.  The fat is processed during the same procedure to remove blood and other fluids from the fat.  The fat is then re-injected into the area that requires volume.  Facial fat transfer will take about 30 minutes.  Most patients will experience swelling and some bruising but will return to work in about one week.

Bleaching of the lower eyelid skin can be obtained by using skin lightening products such as hydroquinone in Obagi Clear or using the Forever Young BBL.  The most effective and most common method we use is the Forever Young BBL.

Forever Young BBL

BBL stands for broad band light, and is the the newest and most advanced version of IPL intense pulsed light therapy.  As the name states, the Forever Young BBL uses a broad range of light waves to capture and treat different skin pigmentations changes more effectively.  In the process, the broad bands of light have been shown to rejuvenate cellular DNA; giving the device its name Forever Young.  

The Forever Young BBL can be used for the eyes, face in general, neck, chest, or any other area.  Treatment for the eyelids takes only 5-10 minutes with no downtime.  The treatment may need to be repeated once or twice for optimal results.  Results after treatment can be visualized after 1-2 weeks.

Hydroquinone Products

Hydroquinone is a popular bleaching agent that works to bleach the pigment from skin melanin.  While effective, it is not as effective as a BBL treatment.  In addition, the results will take weeks to months to achieve.  We suggest it mostly as part of a maintenance regimen or for patients not ready for a BBL treatment.

The goals of the upper eyelid surgery are to reduce the appearance of fullness and heaviness caused by the development of extra eyelid skin, fat growth and herniation, and reduce the contribution of forehead droop if necessary.  

The procedure is most commonly performed under local anesthesia without general anesthesia in the office if you are not having any other procedures.  Patients with more complicated procedures or are having multiple concurrent procedures will benefit from general anesthesia at the hospital or surgery center.

  • The procedure begins with the injection of an anesthetic to numb up the area as well as to reduce the degree of bruising.
  • An incision is placed in the normal upper eyelid crease.  You can see your own in the mirror if you lift up any excess skin.  The fact that the incision is located in this “normal” crease makes it relatively inconspicuous
  • The skin excess above the upper eyelid crease is taken up and removed in a crescent shape.
  • Once the superficial skin is removed, it is easy to visualize the excess and protruding fat.  The fat is conservatively removed.  Aggressive removal gives the appearance of hollowing.
  • Once the extra fat is removed, the skin is closed with a combination of absorbable sutures and sutures that need to be removed depending on the situation

The goals of the upper eyelid surgery are to reduce the appearance of fullness and heaviness caused by the development of extra eyelid skin, fat growth and herniation, and reduce the contribution of forehead droop if necessary.  

The procedure is most commonly performed under local anesthesia without general anesthesia in the office if you are not having any other procedures.  Patients with more complicated procedures or are having multiple concurrent procedures will benefit from general anesthesia at the hospital or surgery center.

  • The procedure begins with the injection of an anesthetic to numb up the area as well as to reduce the degree of bruising.

  • An incision is placed in the normal upper eyelid crease.  You can see your own in the mirror if you lift up any excess skin.  The fact that the incision is located in this “normal” crease makes it relatively inconspicuous
  • The skin excess above the upper eyelid crease is taken up and removed in a crescent shape.  

  • Once the superficial skin is removed, it is easy to visualize the excess and protruding fat.  The fat is conservatively removed.  Aggressive removal gives the appearance of hollowing.  

  • Once the extra fat is removed, the skin is closed with a combination of absorbable sutures and sutures that need to be removed depending on the situation

The principle goal is to perform the procedure in a way that appears natural.

The goals of the upper eyelid surgery are to reduce the factors that contribute to their appearance of fullness and heaviness.  These include:

  • The removal of any extra eyelid skin
  • The conservative removal of any fat growth and herniation
  • Raise the forehead or temple if a drooping brow contributes to hooding of the lateral upper eyelid

Facelift or Mini-Facelift – for lower facial droop and jowling

Forehead lift- for brow droop 

Lower eyelid surgery- for dark circles, extra skin, or fat bags

Fat transfer or Facial fillers-  for facial volume

Forever Young BBL – For dark skin pigment, sun spots, age spots

Profractional Laser Peel – For fine lines and textural changes of the skin

Micropeel – For fine lines and textural changes of the skin

Botox

The appearance of looking “startled” after upper eyelid surgery are due to poor assessment, judgement, and technique on the part of your surgeon.  The most common reason is over-elevation of the brow if a browlift is performed at the same time as the upper eyelid surgery.  This is particularly true in men ( Think Kenny Rogers ) given that men actually look better and more distinguished with slightly low brows.  

The first step therefore is to find a talented plastic surgeon with a good understanding of facial aesthetics ( not your eye doctor or dermatologist ).  Second, avoid over-elevation of the brows if a forehead lift is needed at the same time.  

 

More often than not, upper eyelid surgery is performed without general anesthesia if it is performed as the only procedure.  

The procedure is most commonly performed under local awake anesthesia.  A long acting ( 6 hours ) is injected directly into the eyelid.  Most patients are also given a valium-type drug to help them relax.  

  • The best plastic surgeon near you should have the following qualifications
  • In practice for at least 3 years
  • Performs at least 1 upper eyelid surgery per week
  • Is a board certified plastic surgeon ( as opposed to a ENT, optholmolagist, or dermatologist )
  • Look at reviews in google

Complications of upper eyelid surgery are fortunately rare.  The most worrisome complications are the removal of too much upper eyelid skin ( lagopthalmos ) and blindness.  I thankfully have never seen either of these in my own practice.  And short of journal reports, I have never known of any patient to have experienced blindness.

The more common and realistic complications include:

  • residual hooding ( extra skin ) in the lateral eyelid.  This is usually due to the contribution of a heavy forehead and brow.  My patients are always told of this possibility if they have preexisting lateral brow droop and they are not having a brow lift.  

  • residual fat protrusion of the medial eyelid near the nose.  The medial fat compartment is deeper and situated near the medial eyelid muscles.  Conservative rather excessive removal of the fat in this compartment is often prudent to avoid complications of muscle involvement.

  • Milia and small cysts along the suture line.  This complication is unfortunately very common.  They resemble pimples and are easily removed in 3 to 6 months and usually without extra charges.  

Upper eyelid scars are hidden in the normal existing upper eyelid crease.  This natural crease provides excellent camouflage for the scar.  The scar is red at first but easily hidden with make-up for first 3-6 months.  After about 3 months, the scar will begin to whiten and lighten.

The recovery from upper eyelid surgery is mostly cosmetic as opposed to functional.  That is, most patients are capable of work from a pain and discomfort standpoint in 2-3 days.  But because of the visibility of bruising most patients will not return to work for 7-10 days.  

Patients can work from home nearly immediately.  

Bruising will take up to 2 weeks to resolve.

Bruising of the upper eyelid is almost always present.  The bruising will show as a dark blue in the first week and as a yellow green in the second week after surgery.  Make-up can be used to cover up any bruising once the sutures are removed in 7 to 10 days.  

Candidates for upper eyelid surgery will complain of the following:

  • Upper eyelids feel and appear heavy particularly at the end of a day
  • The eyelids appear to close off the appearance of the eyes

 

For my patients:

  • First follow up visit is usually 1 to 2 days after surgery.  Out of town patients and some patients who are more comfortable can skip this appointment and replace it with a text image of your eyes from home.

  • Ice the eyes for the first 2-3 days to reduce bruising and swelling

  • Avoid any physical activities for 3-7 days to reduce bruising and swelling

  • Suture removal appointment in 7-10 days

Upper eyelid blepharoplasty is the medical term for upper eyelid surgery

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