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Dark Eye Circles and Eye Bags

Dark eye circles and eye bags contribute to a tired, aged and sad appearance. These conditions bother a lot of people.


Optimal treatment of these two conditions are often in combination. An in-depth understanding of the underlying changes of aging, presentation of each individual component is crucial to accurate diagnosis and treatment plan.

  • How do dark eye circles form?

    Various factors lead to the formation of dark eye circles.

    To begin with, Asian population have a weaker and less pronounced bony skeleton when compared to Caucasian population. This is the base which supports the overlying soft tissues. Underlying bony structure starts to get resorbed and become less prominent with aging.

    Next is the key ligaments: the orbicularis retaining ligament and the malar ligament.

    These ligaments divide the eyelid and cheek fat into the upper orbital fat and the lower suborbicularis oculi fat.

    Together with bone that resorbs, loses volume and becomes flatter as we age, these inflexible ligaments start to tether to the overlying skin, resulting in tear trough and midfacial hollowing. These hollows can further worsen the shadows

    From our 30s, we start losing about 1-1.5% of collagen per year. The rate of loss is dependent on several factors including hormonal changes, genetics, ethnicity, UV rays, radiation, smoking et cetera. Collagen is an essential scaffold protein that gives smoothness and elasticity to the skin. As we age, the degradation is more than its production. Fortunately, there are various modalities of aesthetic treatment that will stimulate new collagen production to restore youthful and healthy skin.

    The skin in the eyelid region is the thinnest in the whole body, thus allowing features under the skin to be easily accentuated. Under this thin layer of skin, we have the orbicularis oculi muscle and minimal to no subcutaneous fat layer. There is minimal natural camouflage coverage. Furthermore, there is a robust vascular network beneath the skin. These underlying muscle and vascular network lead to a darkened appearance of the skin. Other contributing factors include fluid accumulation in the lower eyelid skin, pigmentation from haemoglobin breakdown like haemosiderin and biliverdin.

  • How does eye bags form?

    Eye bags from as we age and the orbital septum starts to stretch out, allowing for the orbital fat to herniated out.

    This condition needs to be distinguished from malar oedema, malar bags and festoons, as these will persist after lower blepharoplasty. These are often present from a younger age as puffiness over the prezygomatic area.

  • Treatment of dark eye circles

    The first step is to get an accurate assessment of the causes of the dark eye circles. Most often multifactorial in nature and thus would also need various approaches to deal with each different precipitating factor. A spectrum of treatment is possible from non-invasive options like camouflage and concealers, topical skin care products and lifestyle changes, minimally invasive treatments like skin boosters, fillers and laser resurfacing of the skin to more invasive procedures like surgical interventions.

  • Non-invasive methods

    Concealers that contain optical diffusers to aid with reflection of light.

    Certain components in skin care products to include in your regime can include:

    • Retinoids to stimulate collagen synthesis
    • Hydroquinone to reduce pigmentation by stabilizing melanin production.
    • Arbutin, Kojic acid, Niacinamide to reduce pigmentation
    • Topical caffeine to help reduce lower eyelid oedema and pigmentation
    • Certain peptides that will help modulate fibroblast activity and increase type I and III collagen production within specialized dermatologically crafted skin care products.
    • Reduce salt intake, especially at night.
    • A combination of lymphatic periorbital massage and cold compress to help with eyelid oedema.

    Sun protection

    A combination of oral and topical sun protection is important in the prevention of further photodamage to the skin. Topical sunblock should be applied every 6 hours if feasible.

    BBL Hero
    Is the gold standard machine of the intense pulsed light range. It will aid with reduction in both epidermal and dermal pigments as well as improve the skin tone and clarity of the skin

    Radiofrequency devices
    There are various treatment modalities available, we use the Ultraformer HIFU to create a thermal effect that will stimulate collagen synthesis, tighten the overlying skin. The effects are of course less subtle when compared to more invasive lasers that will ablate and fractionate the skin. However, there is no downtime with this modality

    Fotona Starwalker laser
    Is a Q-switched Nd-YAG 532/1064nm laser that will selectively target the melanin hyperpigmentation that contributes to the dark eye circles. These are more suitable for patients with Fitzpatrick I to IV skin types. A combination treatment with topical therapy will effect greater changes.

    Picosure laser
    This is Q-switched Alexandrite 755nm laser which has increased safety for higher Fitzpatrick skin type patients that also selectively target the melanin hyperpigmentation that contributes to the dark eye circles. We will use each different laser based on our assessment of your suitability.

  • Minimally invasive procedures

    Chemical peels
    There are a wide range of types of chemical peels and depths that each individual peel can affect on the skin textural irregularities and underlying pigmentation. With repeated treatments or deeper treatments with increasing concentration, peels will help with skin resurfacing, improving skin thickness and texture.

    Deka laser – Fractional ablative laser resurfacing
    This is a powerful tool to improve the skin irregularities, improve skin thickness and pigmentation. Following laser resurfacing, the skin that regenerate will improve in thickness and these regenerated skins are less pigmented. The stimulated collagen will also improve the volume loss. There is very bearable downtime with this procedure. The area treated will be red for 2-3 days, following that, there will be miniscule scabs which maybe slightly dry for about 7 days. Moisturization and sun protection is an important part of the post treatment regime.

    Certain overlying skin aging changes like milia, actinic and seborrheic keratosis can be individually ablated away to improve the overall appearance.

    Injectables – Hyaluronic fillers
    This is to target volumisation in a quick fix fashion. Hyaluronic fillers generally last for about 6 to 9 months and there will be a need for repeated treatments. There are 3 separate periorbital hollows that can benefit from placement of fillers in each individual anatomical plane. The underlying bony volume loss from the malar bones can be managed with a high G-prime filler. Ligamentous structure can also be directly filled with a high G-prime or moderate G-prime filler, this will expand these dense attachments to aid in lifting and improving the contours of the hollow. The last plane is beneath the skin with a softer filler to smooth out any remaining contour deficiencies.

    Injectables – Biostimulators
    These are a class of its own, what they do is to allow for collagen to be stimulated and formed over a period of time. The results are more gradual as it takes time for these particles to incite an inflammatory reaction for the type I and III collagen fibers to be stimulated to replace the volume loss. These can be specifically placed into the periosteal plane of the malar region to improve the volume or within the submalar region of the cheek to aid with lifting.

    Botox
    A small dose can be used to treat hypertrophic inferior orbicularis oculi muscle. This can reduce the fullness of the muscle roll and reduce the accentuation of the lower tear trough or infraorbital hollow.

  • Invasive Treatment

    Morpheus 8 Microneedling Radiofrequency
    With the Morpheus8 microneedles, we can choose various settings for the needles to penetrate to target the herniated fat of the eyebags, based on our assessment of the depth required. These microneedles will allow the radiofrequency heat to be transmitted to the herniated eye bag fats, causing shrinkage. The procedure will likely need to be repeated 2 or 3 times over a period of 3 months to consecutively shrink the eyebags. This maybe a suitable modality for patients with smaller developing eyebags, or for patients who are not prepared for surgical lower blepharoplasty. The microneedling treatment will also improve the skin quality and texture by stimulating collagen synthesis and remodelling. This treatment can also be performed throughout the whole face for simultaneous facial rejuvenation.

    Fat transfer
    Is a good alternative to both fillers and biostimulators. The benefit is that it is natural product that is easily obtained from either the lower abdomen or inner thighs. This can be done under local anaesthesia in the procedure room, or under intravenous sedation of general anaesthesia should it be more comfortable to you. A significant volume can be harvested at the same time for concurrent fat transfer into various parts of the face for volumisation, making it more economical. These fat grafts also contain within it adipose derived stem cells which will aid with rejuvenation of the injected areas. Generally, about 70% of these injected fat grafts will retain and survive in the injected areas. They can be used to fill in any plane of the face, from the deep periosteal layer for deeper volumisation, within the ligaments for a lifting effect and can also be processed into nano-fat for more superficial injection into the wrinkles and subdermal layers.

    Lower eyelid blepharoplasty
    Dark eye circles as a result of the bulge of herniated fat through weakened septum and deep tear trough from a resorbed malar bony structure is most adequately treated surgically with a lower eyelid blepharoplasty. This is often combined with fat transposition or fat grafting to improve the tear trough hollow. Eye bags must be clearly distinguished from malar bags / festoons which will not improve with lower blepharoplasty.

    The goal of lower blepharoplasty is to restore a smooth lower eyelid to cheek contour.

    There are two approaches to this. One within the conjunctival region of the orbit called the Transconjunctival approach and one from the skin just underneath the lower eyelashes called the Subciliary approach. Both methods have its own advantages and disadvantages and needs to be individually tailored to each patient based on their presenting aging conditions and the extent of the rejuvenation required. Surgery is a more powerful treatment method that can effectively remove the herniated eye bags, tighten the weakened septum, excise excess skin and orbicularis oculi muscle, smooth the tear trough hollow simultaneously.

    There will be a longer downtime as compared to the other modalities. The bruising and swelling will be most apparent during the first week, over the next month, they will mostly settle. However, as the eyelid skin is thin and prone to accumulation of fluid, the final result of the surgery will only become more natural over the next 3 to 6 months as the swelling gradually subside.

About Dr. Lee Hanjing

MBBS (UK), MRCS (Edin), MMed (Surg), FAMS (Plastic Surgery)

Portrait of Dr. Lee

Dr Lee Hanjing is a female Consultant Plastic Surgeon. After graduating from the Guys Kings and St. Thomas School of Medicine in the University of London, she completed her postgraduate training at the National University Hospital (NUH) in 2016. Dr Lee Hanjing specialises in Paediatric Plastic Surgery, Breast Reconstruction and Cosmetics Surgery. Read more 

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Portrait of Dr. Lee