Thank you for your question.
You submitted your question with two photos. And you stated in your question that you are
not happy with the dark color under your eyes. And that no matter how much you sleep, you
are not happy with the under eye appearance. And you submitted the photos to help explain
your situation.
Well, I can certainly share with you my perception of what I see with the photos and how I advise
our patients who have similar concerns in my practice. A little bit of background, I’m
a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years. Helping people with
the under eye area to help not look tired has been a central significant part of my
practice. The entire time I’ve been in practice, often patients come in saying essentially
the same thing and in not so many words, they’ll say that they’re tired of looking tired.
We live in a time when there’s a lot of variables that we can actually address and
customize the treatment plan for our patients based on certain anatomic aspects of their
situation.
Essentially to begin with, the analysis should begin with anatomy. A lot of times, people
look at themselves and they diagnose what they call or refer to their condition as dark
circles. And it’s kind of a broad term and naturally, the first thing that people do
is go to the store and buy creams for dark circles. And essentially, they figure out
that they’re not getting what they want because the creams doesn't do anything specifically
for what they want. Essentially, it might moisturize the skin, it might help tint the
skin.
So when we look at the under eye area, we’re basically looking at it in a systematic way.
First we want to look is there something called lower eyelid fat prolapse. What that means
is that the fat pockets that are normally around the eyes have prolapsed, pushed forward
and they create a hill. What’s fascinating is that a lot of these people don't notice
the hill but rather the sunken appearance so they think they have hollow eyes. And so,
right below that hill of fat is an area called the tear trough. And the tear trough is this
area where it looks very sunken. It can also look dark. Now part of the explanation for
this has to be with variables that include skin quality, skin pigmentation, the vascularity
or the blood vessels under the skin.
So the strategy with addressing this issue has to do with the relative projection and
prominence of the under eye bags and I’ll explain further. For many years, the gold
standard for anyone having under eye bags was to do some kind of surgical procedure
because essentially the underlying issue is a hernia, a hernia of fat. So routinely, for
a situation like this, we would consider surgery. However, we also now have an option which
many people are exercising and actually, a lot of people are getting this done in situations
where it really doesn't meet the criteria for optimal management and that is a procedure
such as the use of an injectable filler usually in the hyaluronic acid family. And what we
do, I place into that tear trough area the hyaluronic acid filler with minimal trauma
using blunt cannulas to help soften the transition between the tear trough and the puffiness.
So what’s the threshold as to when you do one procedure versus another? Well, as a surgeon
of course, I am not limited by any procedure. I do all these procedures and so I basically
advise my patients as follows: If the under eye area puffiness is so prominent that if
you’re adding filler that it can actually make it look worse, then that’s the time
when you don't do that. If the puffiness is actually extending past the tear trough and
the eyes are too puffy, then you’re not going to have a place to actually place the
filler. And there are those patients who are kind of in the in between stage.
A lot of times what we’ll do first is we’ll say, okay, you understand that surgery is
probably a critically a strategic approach to helping your issue. It’s not even considering
the other anatomic issue such as the cheek volume but let’s just focus in that area.
Then what we can do is we can try placement of a hyaluronic acid filler in the tear trough
area and then we follow our patients and we see our patients two weeks after and see how
they look. Generally speaking, in the right patients, you can get a pretty nice result.
Now there are patients who come to us who have had this approach done elsewhere and
they end up with tremendous puffiness under their eyes from the hyaluronic acid filler
or from just the volume of the filler. And we end up using hyaluronidase to actually
dissolve the filler and actually see what’s the underlying anatomy. And then we discuss
options with those patients. Sometimes options include an alternative hyaluronic acid filler
or to move forward with the surgical procedure.
One doesn't really negate the other. When someone has relative hollowness, you can also
think of the eye and cheek volume relationship. And so, it’s really a combination of two.
You can reduce the puffiness, reevaluate and then add volume in the tear trough to try
to balance and improve the appearance. There’s an area called the V deformity that can sometimes
also benefit from volume and as well as the projection of the cheek. So you can imagine,
there are a lot of different scenarios.
To speak towards the surgical scenario, when this puffiness like what you have, it’s
pretty common for me to do a procedure called a transconjunctival blepharoplasty. This is
a procedure where I address those fat pockets from the inside of the eyelid that way you
avoid an external excision and you are able to, more definitively, address the puffiness.
And when patients are afraid of surgery because they’re afraid of general anesthesia and
the potential complications of surgery, well I explain to them that the procedures are
done in my office operating facilities as opposed to going to a hospital or surgery
center. And it is done under local anesthesia with LITE™ sedation. So in many ways, it
has so many comparatively similarities to an injectable procedure. And it is, in so
many ways, one can argue, invasive as an injectable but of course it is a little more involved.
But that being said, if that’s the procedure that’s optimal then you want to do it in
the safest and most predictable way and that’s what we’ve been able to show our patients
for over 20 years. That for me is an optimal approach.
So I think beyond that, if you are talking about color, you can also address the area
with things to help skin quality. But I think skin quality whether it’s improved with
laser or platelet-rich plasma (PRP) is a secondary issue compared to what is the primary which
is the dual balance of a hollow or the valley next to the mountain.
So meet with qualified, experienced cosmetic surgeons who do a lot of lower eyelid surgery
and are very comfortable with the injectables. This way, you avoid the bias. What I find
is the bias is that, there are so many more doctors who offer injectables because there
are fewer doctors who are actually surgeons, just proportionately, that a lot of patients
who would otherwise benefit from surgery are ending up getting fillers because the doctor
simply just doesn't want to refer them for surgery and just the harsh reality of the
business of medicine.
So meet with a surgeon who does all these and this way, there is no bias one way or
the other but rather, more comprehensive solutions to be provided and what’s right for you.
Three dimensional evaluation is what’s necessary in order to get a more definitive answer and
of course the experience of the doctor also determines what they would recommend for you.
So I hope that was helpful, I wish you the best of luck and thank you for your question.