Many people of all ages complain of dark circles under their eyes. The phrase "dark circles under the eyes" is used to describe a wide variety of different conditions, but the phrase dark circles under the eyes refers to a very specific anatomical condition of the lower eyelids that is easy to diagnose and readily corrected by modern techniques. However, many people who complain of dark circles under their eyes frequently have a condition more appropriately termed "hollow eyes' which is a distinct anatomical condition very different from dark circles under the eyes. Recognition of the "hollow eye syndrome" is very important because the technique frequently used to treat "dark circles under the eyes" does not correct the hollow eye look and can actually make the 'hollow eye syndrome' worse.

To clearly understand the difference between the varying lower eyelid conditions which many people have and seek treatment for, it is important to understand the difference between "Dark Eyelid Color", Puffy Lower Eyelids, Dark Circles Under the Eyes, Hollow Eyes, and Festoons:

Dark Eyelid Color- The color of the lower eyelids is darker than the surrounding facial skin on almost every human face. This is a normal condition. The dark lower eyelid color is caused by the fact that the lower eyelid skin is very thin, so thin that you can see through it. The eyelid muscle beneath the lower eyelid skin is a purple color, thus the purple color of the muscle shows through the thin eyelid skin and the lower eyelid looks darker than the surrounding skin. People often complain that the lower eyelid looks blue or purple. The fairer your skin, the thinner your lower eyelid skin and thus the darker your eyelids will appear. In many thin skinned individuals the veins running under the eyelid skin also show through the eyelid skin making the blue color more pronounced. This is a normal condition and cannot be treated. No laser, cream or surgery can correct this. The only solution is a concealer such as Dermablend or Cover mark.

Puffy Lower Eyelids- As we age many people notice that the lower eyelid skin becomes puffy or bulges outward. People often refer to this condition as "bags under the eyes". Bags under the eyes is caused by a combination of weakness and sagging of the lower eyelid skin and tissues cased by aging changes, and protrusion of fat which lies beneath the lower eyelid skin and underneath the eyeball. Younger healthy lower eyelid skin and tissues normally are taut and prevent the fat from protruding, however with aging and laxity of the lower eyelid skin the fat pushes forward and protrudes, like a hernia. This condition, bags under the eyes or puffy eyelids is technically called fatty orbital herniation, that is a hernia of the fat which is normally contained in the orbit or eye socket. The Plastic Surgery operation called a lower eyelid blepharoplasty often includes removal or repositioning of the protruding fat to lessen the appearance of bags under the eyes.

Dark Circles Under The Eyes- The phrase Dark Circles Under The Eyes refers to a dark depression below the lower eyelid which starts near the corner of the lower eyelid near the nose and runs along the cheek bone below the lower eyelid out towards the ear. Technically this is called the naso-jugal fold, and at advanced stages of facial aging runs into the Tear Trough Deformity, a dark depression that runs out and down the cheek towards the side of the face. The dark circle under the eye or naso-jugal fold is caused by a combination of factors. Most importantly the skin of the dark circle is tethered tightly to the underlying bone of the eye socket, called the orbital rim, by a ligament called the arcus marginalis. Since the skin of the dark circle is tethered to the bone, it cannot sag downward with the lower eyelid and cheek skin as the skin ages and becomes lax. Thus the lower eyelid skin as it sags and is pushed forward and down by the protruding lower eyelid fat, puffs and falls over the tethered dark circle and creates a dark shadow, the Dark Circle Under The Eye. The only truly effective technique to remove Dark Circles Under The Eyes is called arcus marginalis release with fat grafting or repositioning. During this procedure, the arcus marginalis is released from inside the lower eyelid and fat is placed beneath the dark circle to plump the dark circle and prevent the arcus marginalis from re-attaching and recreating the Dark Circle Under The Eyes.

Hollow Eyes- Hollow Eye Syndrome describes a condition in which the entire lower eyelid appears "sunken in" and can be a natural or normal human condition or can be caused by trauma or following a lower eyelid blepharoplasty during which too much lower eyelid fat has been removed. The primary cause of the normal Hollow Eye Syndrome is a congenital lack of orbital fat beneath the eyeball that allows the lower eyelid skin and tissue to sink in, or by an eye socket, also called the orbit, which is larger than normal and allows the lower eyelid, fat and tissues to sink in causing the Hollow Eye appearance. Abnormal Hollow Eye Syndrome occurs when too much fat has been removed during a blepharoplasty or when the bone beneath the eyeball has been broken, most commonly by a fist or baseball striking the eye, breaking the floor of the orbital bone and pushing the fat surrounding the eyeball through the break in the bone down into the sinus cavity beneath the bone. To correct the abnormal Hollow Eye Syndrome, either fat must be surgically replaced, or in the case of a fracture, the fat must be pulled back under the eye and the broken bone repaired.
In the case of normal Hollow Eye Syndrome, fat must be surgically replaced to correct the fat deficiency and in some patients, who have an unusually large eye socket because of a deficiency of the bone, an implant to must be placed to make up for the deficiency of the bone of the orbital rim at the top of the cheek bone. This implant is called a tear trough implant.

Festoons- Festoons are puffy skin on the cheeks which lie just below the lower eyelids, at the top of the cheeks and just below the Dark Circles Under The Eyes. Festoons are cheek skin, not lower eyelid skin, a very crucial distinction. Their primary importance is that they must be recognized, and you must know that they will not be improved or removed during a blepharoplasty. In fact, a blepharoplasty during which puffy eyelid fat is removed and lax lower eyelid skin is tightened will in fact make the festoons look more prominent and worse. Festoons are poorly understood and difficult to treat. Traditionally the only method was direct surgical excision and removal, however this method usually leaves unacceptable, visible scars on the cheeks. Sometimes a partial face-lift called a cheek lift can improve Festoons. Laser resurfacing can improve them, but the skin color becomes lighter which makes this method risky. Recently newer skin tightening methods using Infrared and Radiofrequency energy hold much promise.

In summary, the normal anatomical variation and the aging changes of the lower eyelids are very complex, and often poorly understood by both patients and many physicians. A proper and clear understanding of lower eyelid and cheek anatomy and the effects of aging on these areas is crucial if proper aesthetic correction of the lower eyelid is to be achieved. Newer eyelid rejuvenation therapy must employ techniques that address the intraorbital fat, the arcus marginalis, and the festoons if pleasing aesthetic results are to be achieved and serious deformity avoided. True Hollow Eye Syndrome requires fat volume replacement and in some cases implant placement to correct bony volume deficiency. It is important to distinguish Hollow Eyes from Dark Circles Under The Eyes because their correction requires decidedly different reconstructive techniques. The recognition of Festoons is very important because standard blepharoplasty eyelid rejuvenation techniques will make Festoons more noticeable.

Brooke R. Seckel, M.D., FACS