Aesthetic Procedures: Undereye Solutions

Physicians are finding new strategies to reduce undereye bags and dark circles.

Undereye Solutions

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
and/or hyperpigmentation.”

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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Dr. Coleman began developing his procedure, known as Lipostructure, in 1987. “It involves harvesting the tissue under low pressure, using a syringe, then placing it in a centrifuge to isolate and concentrate the living fat. We use only the densest fat in lower lids, which has more regenerative cells. Finally, we use a 1mL syringe and two or three tiny cannulae to place minute amounts of the fat under the skin all across the lower lid, adding more in the tear trough to soften any herniated fat pads. Building the cheeks a little bigger provides a structure to support the necessary fat pads under the eye,” Dr. Coleman adds.

Simon Ourian, MD, Epione, Beverly Hills, California, has a different point of view. “I used to use fat transfer instead of synthetic fillers, but in my experience the results were not reliable,” he says. “You never knew how much of the fat would be absorbed so there was a tendency to overcorrect. The size of the fat cells harvested from other areas of the body can vary and cause pillowy, unnatural results. All in all, I found fat transfer more cumbersome and less reliable than synthetic fillers; it caused more bruising and was more expensive for the patient than newer fillers.”

Cost is certainly a factor for many patients. A fat transfer procedure to correct the undereye area can cost $5,000 to $10,000, and there is a
higher risk of complications.

Dr. Ourian prefers Restylane (Medicis, www.restylaneusa.com), Perlane (Medicis) or Radiesse (Merz Aesthetics, www.radiesse.com) for undereye corrections. “The Radiesse must be injected deep into the skin between bone and muscle to avoid lumps, bumps and granulomas,” says Dr. Ourian.

Dr. Chasin also prefers dermal fillers for correcting undereye hollows. “Autologous fat is a great filler but it is just too unpredictable for the undereye area. Most patients want an in-and-out type of procedure that can be easily reversed if they don’t like the results. I use Belotero (Merz Aesthetics, www.merzaesthetics.com) or Restylane, which are much better for this area than any of the other fillers,” he says. “They don’t absorb a lot of water, which means there is less swelling.

“I almost always use cannulae instead of a syringe to inject fillers in the eye area,” says Dr. Chasin. “Using cannulae means less bruising and less pain. I make a small opening and inject a mixture of lidocaine with epinephrine before inserting a Dermasculpt Cannula (www.dermasculpt.net) or Magic Needle (Needle Concept, www.magic-needle.com), really a cannula. I place it right against the bone. Placing filler deep means less risk and it lasts longer, typically two to three years. Deep placement is imperative in the lateral part of the eye. Shallow placement increases risks of lumpiness and it typically lasts only about a year.

“When fillers are placed deep, there is a residual effect even after three years because the filler treatment stimulates collagen synthesis,” Dr. Chasin continues. “I always mix lidocaine with epinephrine into the fillers I use, even if the filler already contains some lidocaine. The additional mixture restricts blood vessels to minimize bruising and makes the filler less viscous so it is easier to place.”
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Dr. Zdinak also prefers Restylane for linear tear trough defects, but when the tear trough is very broad, she uses the patient’s own blood to fill out the majority of the deformity. “I use the Selphyl Platelet Rich Fibrin Matrix System (Aesthetic Factors, www.selphyl.com) to convert plasma to dermal filler,” she says. “Then, in about three weeks, I have the patient come back and I take care of any residual hollowing using a hyaluronic acid product. I do not like any other fillers beneath the lower eyelids, and I especially avoid fillers with particles for fear of transportation of the particles and vascular occlusion. I have seen several people treated overseas with particulate fillers that grew out of control forming popcorn-like growths beneath the eyelid skin.”

We are unlikely to see a resolution to the question of whether fat grafting or synthetic fillers are better for the tear trough anytime soon. The latest research on the subject (Dermatologic Surgery, May 2013), which was done at the Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea, gives high marks to collagenase-digested fat cell grafts for correcting dark circles around the eyes. The authors treated 82 patients with fat aspirated from the medial thigh using the Coleman method and digested with Clostridium histolyticum-derived type II collagenase. They injected the fat grafts into the infradermal layer using blunt 22-gauge needles. Results of evaluations performed using photographic evidence showed improvement in 67% of patients and no change in 28%. The condition of four of the patients had worsened since preoperative findings. Bruising and edema were minimal for all. The authors concluded that collagenase-digested fat grafts provide a viable treatment option for dark circles around the eyes and recommended further study.

Improving Vascularization

Hollowing is only one cause of dark circles under the eyes. Vascular pooling is another. “The capillary network of the lower eyelids can become congested for a variety of reasons,” says Dr. Zdinak. “Normally, the tears drain from the eyelids into the nose, but if there is some obstruction due to chronic nasal congestion from seasonal allergies, for example, or a nasal fracture, the drainage doesn’t function well, and the blood flow to the lower eyelids becomes sluggish, giving rise to the boggy blue tinge known casually as ‘allergic shiners.’ The lack of appropriate oxygenation to the lower eyelid skin allows the bluish cast to show through the thin skin of the eyelids. Carboxytherapy works to improve the capillary network of the lower eyelids, as well as to increase the dermal collagen layer in the lower eyelid skin. By injecting a small amount of carbon dioxide gas into the affected areas, blood flow is increased and improved capillary networks are formed for longer lasting circulatory benefit. The bluish cast is replaced with a healthy pink tone. Once a series of four to six sessions is completed, the skin has a more luminous appearance that lasts approximately six months.”

Dr. Zdinak designed and conducted the first study in the English literature using carboxytherapy for rejuvenating the undereye region (the fellowship study was never submitted for publication).  She found that by injecting a small amount of carbon dioxide gas just beneath the skin of the lower eyelid, circulation was increased and dark undereye circles were markedly improved. The treatment takes only five minutes, and is virtually painless.

Carboxytherapy is not widespread. Lasers are usually the preferred method for treating excess vascularization under the eye. “I recommend a 532nm laser to reduce the size of veins and capillaries under the eye,” says Dr. Ourian. “Some doctors use sclerotherapy, but I think there is more chance of adverse side effects with that approach.”
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Lightening Hyperpigmentation

Sun damage can cause both wrinkles and excess pigmentation around the eyes. “Wrinkles alone are best treated by laser resurfacing,” says Dr. Ourian. “I use fractional CO2… to treat most wrinkles in the eye area. The laser stimulates collagen production that firms the skin over a period of two to three months. If dynamic wrinkles are involved, I will recommend Botox Cosmetic (Allergan, botoxcosmetic.com), with the caveat that Botox injections in the lower lid area must be done by an experienced doctor, especially in patients older than 60. The looseness of skin in older patients makes it more difficult to place the Botox precisely and improper placement can cause eyelid ptosis.”

“My two favorite devices for treating fine lines under the eyes are Ulthera, with the l.5mm transducer, for patients who want less downtime or a fractional CO2 laser like the Fraxel Repair (Solta Medical, fraxel.com) for older patients with more skin laxity or those who can tolerate more downtime,” says Dr. Chasin. “If photodamage is the main concern, I’ll use the Fraxel Dual for patients who want less downtime. If the problem is just congestion and hyperpigmentation, a Q-switched Nd:YAG such as the Revlite (Cynosure/ConBio, conbio.com) will do the trick.”

Dr. Kornstein is also a proponent of the Ulthera System, which gained FDA approval for focused ultrasound brow lifts in 2009 and approval for treating skin on the neck in 2012. “Ulthera is an invaluable adjunct to facial-shaping and antiaging for most patients who are unwilling or unable to go through facial surgery,” he says. “The results are not only consistent, but remarkable, with no bruising, no swelling, and no redness in the vast majority of cases.”

Dr. Coleman follows many fat grafting sessions with an intense pulsed light (IPL) or broadband light (BBL) treatment (Sciton, sciton.com). “These work well to lighten discolored skin and also help with the bruising,” he says.

Dr. Zdinak doesn’t use lasers on the delicate undereye area. “For hyperpigmentation, I generally give the patient a plant-based bleaching agent rather than hydroquinone for home use. If the pigmentation is severe, a series of light AHA peels can be helpful to kick-start the home regimen,” she says.

Linda W. Lewis is a contributing editor to MedEsthetics.

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