Lidlift Keneth D. Steinsapir, M.D.
Cosmetic, Facial & Eye Plastic Surgery

Do you or someone you know have dark circles?

You are not alone! Dark circles under the eyes are one of the most common concerns that brings men and women of all ages to consult Dr. Steinsapir. He is one of the few cosmetic surgeons in the world who have made treating dark circles and under eye hollows a major focus of his professional practice. He is multi-fellowship trained in both cosmetic surgery and eyelid plastic surgery. He is an elected Fellow of the American Academy of Cosmetic Surgery, the American Academy of Ophthalmology, and the American Society of Ophthalmic Plastic and Reconstructive Surgery. He is also a board certified Ophthalmologist and an Associate Clinical Professor of Ophthalmology at the prestigious Jules Stein Eye Institute at the David Geffen School of Medicine at UCLA. It just makes sense to see a specialized eyelid plastic surgeon for this problem rather than a generalist like a board certified general plastic surgeon, dermatologist, or other type of doctor. It is no wonder that people travel from all over the world to consult Dr. Steinsapir and benefit from his considerable and innovative technical and artistic skills.

Allergic Shiners

If you have researched dark circles under the eyes, what you have mostly read about are untested theories. Does a sick liver or allergies cause dark circles under your eyes? Mostly these are wives tales: stories that have the air of plausibility. Pediatricians like to talk about allergic shiners to deflect maternal concerns. Would you be surprised to learn that in the last 40 years there have only been four articles on the subject of allergic shiners in the peer reviewed literature? Not exactly a lot of useful information.

So do allergies or sinus problems really cause dark circles? It may be that children who are prone to allergies do more eye rubbing and eye rubbing may stretch out some of the soft tissue ligaments around the eye and there are anecdotal studies supporting this.

There are very few studies on other possible causes of the under eye dark circle. These primarily focus either on pigment in the skin or vascular structures under the skin accounting for the discoloration. One study looked at skin biopsies taken from individuals with dark circles. Some of these biopsies showed increase melanin in the skin; the evidence of increase vascularity was unimpressive. This has not stopped companies and physicians from making a range of under eye products justified on the basis of covering up or treating these problems. We will consider camouflage type products shortly as well as other proposed treatments for dark circles.

Dr. Steinsapir’s Insights

Dr. Steinsapir pioneered the vertical midface lift using a hand carved orbital rim implant and, as a leading authority on this surgery. He has done as much midface surgery as anyone in the world. In analyzing midface anatomy from his surgical experience and comparing it to written descriptions, Dr. Steinsapir found that many of the anatomic descriptions in the medical literature are inaccurate. This is a problem because doctors rely on these descriptions to perform midface and lower eyelid procedures. As you might imagine, the surgery based on an inaccurate anatomic understanding has lead to many unsatisfactory surgical outcomes with less than ideal results. Dr. Steinsapir devotes a significant portion of his surgical practice to fixing these types of awful plastic surgery outcomes.

His insights into midface anatomy lead him to develop the Deepfill™ method of treating dark circles and under eye hollows. Intimate first hand knowledge of the midface anatomy has given Dr. Steinsapir unique insights into what makes the under eye dark circle. His patients have enormously benefited from this pioneering insight. It is important to understand that there are several factors that contribute to the under eye hollow and dark circle. These various causes create a set of conditions that represent a spectrum of effects that evolve as we age. Not all of these problems are amenable to treatment. Conversely, many do spectacularly well with the correct approach.

Skin Optics

Dr. Steinsapir has found that the most significant issue contributing to the appearance of an under eye dark circle is optical. He is not alone in coming to understand the importance of optics to the facial complexion. A newly emerging field of skin optics aims to exactly understand these effects from what makes a radiant face to how to measure the blood sugar of a diabetic based on the optical properties of the skin surface.

There are four components to these complexion phenomena: reflection, transmission, diffusion and absorption. To understand this, let’s think about the appearance of the cheek compared to the adjacent lower eyelid. The cheek is full because under the skin is a thick pad of yellow fat known as the malar fat pad. Think of the malar fat pad as a big reflector. When light strikes the surface of the skin, some of the light is reflected from the surface, some of the skin is scattered (diffusion) in the outer layers of the skin, and some of the light penetrates the skin to reach the deeper layers. Melanin, which gives skin a brown color, mostly resides in the skin at the junction between the superficial and deeper layers of the skin. The concentration of melanin has a direct effect on the transmission of light in the skin and tends to absorb light.

What happens to the light that makes it through the skin? This very much depends on what the light encounters as it penetrates through the skin. In the cheek, the malar fat pad reflects much of the light back into the skin where it contributes to complexion radiance. In younger people, a thin layer of fat extends from the cheek just underneath the eyelid skin, in continuity with the cheek fat. In contrast, in individuals with the so-called tear trough hollow, and dark circles, this layer of fat is missing or has descended into the cheek (the supporting ligaments stretch out over time). Instead, light transmitted through the skin encounters a layer of red muscle that adheres to the thin lower eyelid skin. This muscle is the orbicularis oculi muscle. In contrast to the excellent reflective properties of the yellow malar fat pad, the dark red muscle of the orbicularis oculi absorbs almost all of this transmitted light. Compared to the adjacent cheek, very little of this light is reflected and scattered back into the lower eyelid skin causing the area to look dark compared to the adjacent cheek skin.

Contour Issues

The shape of the cheekbone also contributes to the dark circle. The cheekbone should be strong and well projected. This projection provides support to the cheek and lower eyelid. In addition from the inner corner of the eye in the direction of the outer corner of the mouth, the cheekbone has a slight groove. However, this feature can be much more pronounced in certain individuals. This allows the cheek soft tissue to “fall into” this groove. The consequences are lack of support exaggerating the tear trough area and dark circle. The bowing in the lower eyelid and top of the cheek also causes shadowing that tends to make the dark circle worse. Some individual have fullness in the lower eyelid in the form of herniated orbital fat. This is commonly referred to as a lower eyelid bag. Note that this is different than a “festoon” which is a bag that occurs on the cheek just below the lateral aspect of the eye.

Solving the Problems

Dr. Steinsapir spent many years perfecting the vertical midface lift, which provides volume along the orbital rim and lifts the cheek soft tissue back into the lower eyelid. The results are truly amazing (see Midface Surgery). However, there is an indisputable problem with this procedure: it requires major facial surgery! Dr. Steinsapir recognized that there are people who absolutely need this surgery and they are prepared to endure the time and expense required to obtain these fabulous results. However, not everyone is prepared to have surgery. In particular some individuals who seek him out have been wrecked by prior surgery. Emotional trauma prevents them from having a definitive surgery to address their issues. Therefore Dr. Steinsapir searched for a practical non-surgical method of addressing dark circles and lower eyelid hollows.

Figure 1.

This led him to develop the Deepfill™ method of filling the under eye hollow with Restylane®. This method is effective in improving lower eyelids with dark circles. The key to this method is the deep placement of Restylane® along the orbital rim. (figure 1) This is a very safe location to place the filler. The procedure is surprisingly comfortable. Topical numbing cream is first applied to the lower eyelid skin. The hollow area is then filled with Restylane®. Filling this area has a very favorable affect on the skin optics thereby improving the appearance. Dr. Steinsapir has come to prefer this filler to all others because it can be molded to the desired shape and adjusted if there are any lumps or bumps following the procedure. Restylane® is composed of a sugar gel that occurs naturally. The material is extremely well tolerated and lasts in many patients about one year. We encourage prospective patients to come to the office for a personal consultation with Dr. Steinsapir to learn if the treatment is right for them. If the patient chooses, treatment can be performed at the time of consultation.