Upper eyelid surgery (blepharoplasty) is the most common procedure done around the eyes, as long as you don’t include Botox injections. The upper lid procedure concentrates primarily on removing excess skin to eliminate or reduce the extra fold that appears as we age. A lower lid blepharoplasty is more of a contouring surgery where fat pockets are addressed.
There are three fat pockets in the lower eyelid that are held in place with a very fine membrane which runs from a plate (tarsus) near the eyelid margin to the orbital bone which forms the lower rim of the eye socket. Over time, because of aging, genetics, sun exposure, allergies and some thyroid conditions, that membrane, known as the orbital septum, gradually begins to lose its elasticity. As a result, the fat pockets begin to bulge forward causing lower eyelid bags to appear.
The Shadow Effect
As most of the light that we are exposed to comes from above, it reflects off of the most prominent part of the bulge which then casts a shadow along the lower extent of the lid where it is attached to the lower orbit just above the upper margin of the cheek. This shadow is generally the largest contributing factor to dark circles on the lower lids which is already depressed from the attachments to the bone of the orbital rim. This depression is known as a ‘tear trough deformity’.
Fat pockets that are enlarged can be partially removed in a lower lid blepharoplasty to reduce the bulge and can also be repositioned into the ‘tear trough’ to lessen the depression in that area to help to reduce or eliminate the dark circle appearance. Some muscle tightening and a small amount of skin removal is also typically performed during the surgery to improve the contour on the lower eyelid.
Nonsurgical procedures designed to reduce the dark circles and tear troughs involve injecting a filler into the area which can reduce the depression and delay the need for lower eyelid surgery. The most common fillers used for treating a tear trough deformity are Juvederm® and Restylane®. It is not uncommon for patients to have these filler injections to avoid surgery or to prolong the period of time before they commit to surgery. It is possible to get significant bruising after filler injections so it is important to avoid taking medications that can thin your blood for a couple of weeks before the injection procedure such as aspirin and ibuprofen.
Bleaching Creams and Lasers
Some patients have actual darkening of the skin in the area of the lower eyelids, which contributes to the dark appearance. This is a form of hyperpigmentation that can sometimes be improves with 4% hydroquinone cream applied twice per day. A better improvement can be obtained with a combination of the cream and a series of Fraxel laser treatments designed to target pigment spots in the skin.