The Management of Lower Eyelid Dark Circles: Skin discoloration texture and tone changes of the lower eyelid area is a common cosmetic concern for many patients.  There has been very little comprehensive discussion and treatment options available for patients until the last few years.  In a cosmetic centre like ours we focus on all of the treatment options available for this unique annoying challenge in selected patients.

1. Increased pigment (Hyperpigmentation)
   genetics
   race
   post-inflammatory
     -atopic dermatitis
     -post injury – irritation
2. Atopic patient – extra skin folds (Dennie’s line)
3. Vessel network pattern
     -periorbital reticular blue veins
     -telangiectatic arborizing and linear vessels (venous pattern)
4. Baggy lower eyelids
     -herniated fat pads - medial, middle, and lateral causing reflected light
     -with or without wrinkly skin
5. Wrinkles
     -crow’s feet animation only
     -crow’s feet extending to subciliary portion of lower eyelid – present with animation and relaxed
     -genetics
     -aging
     -smoking (including 2^nd hand smoke)
     -accumulated sun exposure
6. “Tear Trough” deformity creating a shadow on the lower eyelids
7. Festoons – lower eyelids. Festoons are loose muscle hammocks of the orbicularis oculi draped from the medial canthus to the lateral canthus. They can be the sole cause of baggy lower eyelids and dark circles or one of the contributing factors.
   
   Types of Festoons:
     -Preseptal
     -Orbital
     -Jugal
   
   Causes of Festoons:
     -Genetics
     -Actinic – lifetime of sun exposure in skin types 1, II and III patients
     -Smoking
     -Natural aging process in selected patients

Treatment options for dark circles under the eyes:

1. Kinerase (cream, lotion) used daily over a period of months.  (improved texture, tone, and fine lines in the periorbital area).
2. Neostrata Dark Circle Night Cream -1% vitamin K + 0.075% Retinol (not very effective).
3. Chemical peels – difficult to blend and feather in actinic damaged faces.
4. Q-Switched pigment lasers, Q-Switched 532 nm, Q-Switched Alex 755 nm and Q-Switched YAG 1064 nm, Q-Switched Ruby 694 nm.
5. Resurfacing with a combination of UltraPulse CO₂ Encore laser with a cool scan in low density combined with Erbium Yag laser.
6. Vascular lasers including long pulsed 1064 YAG combined with the Vasculight VL head and the VersaPulse 532 system.
7. The orbital and cubital festoons can be treated with radiofrequency – ThermaLift (Thermage).
8. Tear trough deformity treated with Restylane filler or equivalent.