Dark circles, wrinkles and bags under the eyes have been common complaints since the advent of mirrors. Until recently, though, aesthetic practitioners had few effective solutions for patients whose concerns were primarily cosmetic.
“The complaints are not necessarily due to aging. Dark circles and puffiness can be the result of problems such as hypothyroidism, allergies or eczema, and it is important to rule out medical possibilities before proceeding with any treatment,” says Mitchell Chasin, MD, medical director of Reflections, Center for Skin & Body in Livingston and Martinsville, New Jersey. “Then you need to consider genetics. Fat deposits under the eye can be hereditary as can excess vascularization. Typically, however, when patients in their 30s or 40s come in with complaints of dark circles, the cause is hollowing, venous congestion
New York plastic surgeon Andrew N. Kornstein, MD, FACS, agrees and adds, “Any ongoing inflammation affects melanocyte production and deposition, and can lead to dark circles. In addition, bone loss in the area can change the angle of inclination of the lower lid, leading to shadowing. Prominent eyelid fat pads can compound the strain to this area leading to progressive dysfunction of the skin, darkening it in response to chronic stress.”
The undereye area is complex and there are usually multiple factors involved in the sagging, bagging and discoloration. “It is the physician’s job to detect the factors and then to work backwards to tease out any environmental, genetic or behavioral causes,” says Lisa A. Zdinak, MD, chief surgeon and medical director, Precision Aesthetics, New York. She questions patients thoroughly to uncover any medical conditions, possible allergic reactions or injuries that might be causing circulatory outflow interruption.
“Outflow disturbances must be dealt with first or other treatments will fail,” adds Dr. Zdinak. “If I suspect a nasal obstruction, I send the patient to an ENT for endoscopic evaluation. If not, I generally give the patient a trial of nasal steroids plus antihistamine. I see the patient back after about a month. Most are feeling better already so we proceed to address any other factors in play.”
Discovering the factors involved in creating undereye complaints is just the first step. Deciding which treatment to use is equally challenging. Treatments and outcomes vary and there is no consensus on the best approach to diminish wrinkles, discoloration, volume loss and hollowing under the eye.
Filling Out Hollows
“Aging of the lower lid compartment and cheek is generally acknowledged to be a process of bone and soft tissue atrophy, which can start as early as the late 20s,” says Dr. Kornstein. “My preferred treatment is autologous fat transfer, which creates volume and actually reduces bone atrophy due to its inherent stem cell effect. I also use soft tissue fillers; they don’t arrest the aging process but they do slow the descent of the overlying soft tissues as can noninvasive skin tightening, such as Ultherapy (Ulthera, www.ultherapy.com).”
Dr. Kornstein extracts the small amount of fat needed for the undereye area with hand-held liposuction, centrifuges it and then reinjects. “The key is in the reinjection process. It is important not to traumatize the area, to keep tissues and blood flow intact while shaping the injected fat aesthetically. In my opinion fat grafting is the only reliable means of treatment that has persistent, long-term benefits for undereye dark circles and bags,” he says. “The only question we are still studying is whether fat grafts can be improved by multiplying the stem cells in a transplant graft.”
Sydney R. Coleman, MD, TriBeCa Plastic Surgery, New York, is equally enthusiastic about fat grafting for volume loss under the eye. “The injected fat immediately provides an optical barrier, hiding the circulating blood that is often the cause of dark circles. It fills the tear trough, supporting any undereye pouches, which can cause shadows, and over the following months, it gradually thickens the skin,” he says. “Results can be seen within one month but the real effect won’t be visible until about six or seven months later.”
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