Management of Infraorbital Dark CirclesA Significant Cosmetic ConcernJeffrey S. Epstein, MDDespite the frequency with which it occurs, little has been written in the scientific literature onthe treatment of infraorbital dark circles. I have developed a technique that simultaneously treatsthe 2 contributing causes of these circles: hyperpigmentation of skin and pseudoherniation oforbital fat. The technique involves simultaneous transconjunctival blepharoplasty an deep-depthphenol chemical peel. Successful outcomes have been obtained in patients with Fitzpatrickclassification skin types 1 to 5, with a low incidence of complications. Adequate preoperativecounseling regarding prolonged erythema and careful postoperative monitoring with, ifnecessary, medical intervention are essential if both surgeon and patient are to be satisfied withthe outcomes. Despite the lack of attention received in the plastic surgery literature, infraorbitaldark circles can be a significant cosmetic problem. While there are no statistics giving thefrequency of its occurrence, judging from the amount of advertising of cosmetics marketed totreat it, dark circles under the eyelid are a cosmetic concern for a large number of individuals. Inmy practice, while patients in consultation may not mention infraorbital discoloration, many areinterested in having it treated once they are informed that it is a treatable condition.CAUSE OF INFRAORBITAL DARK CIRCLESThere are several causes for the appearance of dark circles under the eyelids. The most commonprimary cause is excessive pigmentation, which is seen in such conditions as dermalmelanosystosis and postinflammatory hyperpigmentation. Dermal melanosystosis is due to bothcongenital as well as environmental causes, including excessive sun exposure and occasionallythe taking of exogenous estrogens. Postinflammatory hyperpigmentation usually has allergic oratopic components.Infraorbital dark circles due to hyperpigmentation usually appear as a slightly curved band ofbrownish skin approximating the shape of the underlying inferior orbital rim. These circlesappear even darker when present below the bulging of the lower eyelids that is due topseudoherniation of orbital fat. In effect, the bulging lower eyelids are casting a shadow on theskin below. When the lower-eyelid skin is manually stretched, the area of pigmentation is spreadout, without any blanching or significant lightening.Blanching of this area with skin stretching would be consistent with the second common primaryof infraorbital discoloration, the visible prominence of the subcutaneous blood vessel plexus.This hypervascular appearance is due to some combination of exceptional transparency of theoverlying skin and excessive subcutaneous vascularity. In these cases, the entire lower eyelid hasa purplish appearance that on closer examination is revealed to consist of prominent bloodvessels, covered by a thin layer of skin. While involving the entire lower lid, the vascularity ofusually concentrated along the lower aspect of the eyelid, occurring (similar as with primaryhyperpigmentation) usually just beneath any pseudoherniated orbital fat.It can be deduced that lower-eyelid ballooning due to pseudoherniated orbital fat is commonlyassociated with, and usually exacerbates, the appearance of infraorbital dark circles. Further, ithas been proposed that excessive infraorbital fat can increase lower-lid subcutaneous vascularity.In addition, chronic allergies cannot only exacerbate but perhaps even cause postinflammatory
hyperpigmentation as well as edema of lower-eyelid fat. Excessive pseudoherniation of orbitalfat, thus, is usually intimately related to the presence of infraorbital dark circles.TREATING INFRAORBITAL DARK CIRCLESAs described above, the cause of dark infraorbital circles is most commonly due to acombination of hyperpigmentation and some degree of lower-lid bulging due to fatpseudoherniation. For a treatment to be effective, both of these problems need to be addressed,ideally synchronously. I have developed a safe and effective surgical treatment, including animportant preprocedure- and postprocedure-care protocol.The treatment basically consists of simultaneous lower-lid transconjunctival blepharoplasty(TCB) and Litton formula phenol peeling (phenol, 44 ml; distilled water, 44 ml; and croton oil, 1ml; creating a phenol concentration of 48%). The TCB is an effective surgical procedure forreducing excess lower-lid fat, first described in 1924 by Bourquet.5 Contemporary proponents ofTCB have popularized this approach, so that in 1999, it has widespread acceptance. Whenperformed properly, TCB has a low incidence of complications and is effective for treatingalmost all cases of lower-lid fat pseudoherniation. In most cases, skin does not need to beexcised, and, when performed through a retroseptal approach (which is my approach)simultaneous lower-lid skin peeling can be performed, permitting the reversal of dermatochalasisand rhytidosis, and, as in my approach, the reversal of skin hyperpigmentation.There are several types of phenol peel formulations, all with effective phenol concentrationsbetween 40% and 48%. At these concentrations, the phenol penetrates down to the reticulardermis, thus repairing damaged elastotic skin. Similarly, at this concentration the usual adverseeffect of phenol peeling is hypopigmentation. Phenol decreases skin pigmentation by reducingthe ability of melanocytes to produce melanin. While the Baker and Gordon phenol peel is themost common of the phenol chemical peel formulas, I prefer to use the Litton phenol peel.METHODSPreprocedure CareThe goal of pretreatment care is to prepare the skin for the peeling procedure, and to minimize itsability to produce pigmentation. In addition to the strict avoidance of sun for the preceding 7days, patients are begun on Kligman formula (hydrocortizone, tretinoic acid, and hydroquinone)as early as 3 months before the procedure. Patients are advised to first observe the resultsobtained with this topical agent, in the hopes that significant improvement is obtained, so thephenol peel process then is not necessary. In the majority of cases, however, while there is someimprovement in the dark circles and rhytidosis, in most cases it is insufficient for the patient.ProcedureThe procedure is usually performed under light intravenous sedation. Before the surgery, withthe patient in a sitting position, the areas of lower-lid orbital fat pseudoherniation are marked. Inthose cases where upper-lid blepharoplasty is being performed, these incisions are also marked.After the administration of the sedation, the conjunctiva and cornea are anesthetized with 0.5%topical tetracaine, followed by the local infiltration of he conjunctiva, fat pockets, and eyelid skinwith 2 to 3 ml. of 2% lidocaine with 1:100 000 epinephrine. Under sterile conditions, atransconjunctival incision is made just below the tarsal plate directly over the ballotting fat
created by gentle pressure to the globe by a Jaeger lid plate (FIgure 1). Through a retroseptalapproach that has been well described in the literature, the excess fat is excised using a hand-heldhigh temperature cautery unit. Once the surgeon is satisfied that the appropriate amount of fathas been removed, such that the minimal pressure on the globe there is no fat ballotting abovethe level of the orbital rim, the conjunctival edges are laid back together without sutures.Figure 1. Sagittal view of lower eyelid illustrating transconjuctival blepharoplasty through aretroseptal approach. A Desmarres retractor everts the lower eyelid, exposing the conjunctiva,while a Jaegar eyelid plate applies gentle pressure to the globe to produce a bulge of orbital fat.Once the lower (and, if being performed, upper) blepharoplasty is completed, the skin of thelower eyelids and lateral orbital region is adequately degreased with acetone. This is animportant step to ensure even penetration of the phenol. The Litton formula is applied to thedegreased skin using 2 cotton-tipped applicators (Figure 2). LItton Formula does not need to bemixed fresh, but can be prepared and stored for several months. A gentle wiping, applyingmotion is used, extending laterally approximately 10 mm beyond the natural borderlines of thelateral and inferior orbital rims, and within 2 mm of the lower eyelashes. Caution must be takento avoid contact with the globe or with any tears that may develop that can draw the more dilute(and therefore more potent) phenol into the globe. A deep white frost should develop within 45seconds, after which ice water gauzes can be applied. Once the white frost fades and ruddyerythema appears, antibiotic or other type of ointment, such as Aquaphor (Beiersdorf Inc.,Norwalk, Conn), can be applied. If indicated, other areas of the face can be treated with phenol,or a medium-depth peel, such as Jessner solution followed by 35% trichloroacetic acid.Figure 2. Phenol peel solution being applied to the lower-lid anotomical unit. Using two cotton-tipped applicators, the phenol is applied laterally, approximately 10 mm beyond the lateral andinferior orbital rims and to within 2 mm of the lower eyelashes.The major intraoperative risk of phenol is cardiotoxicity. This is a dose-dependent event, thedose of which is not reached when peeling just the eyelids. However, for proper precaution, it isrecommended that there be proper cardiac monitoring, and that the patient be adequatelyhydrated. Phenol must be used cautiously on patients with kidney abnormalities in whom therecan be impaired phenol excretion. When peeling more than just the eyelids, the phenol should beapplied incrementally, with sufficient intervals between anatomical areas.Postprocedure Care and Expected CourseFor the first 48 hours, patients are to keep the head elevated and the eyelids icedto reduce swelling. Antibiotic drops are applied for the first 3 days, and oralantibiotics are taken for the first week. Care of the peeled skin consists ofcontinual reapplication of Aquaphor for the first 7 to 10 days, with rinsing of theskin 3 times a day before reapplication of the ointment, using a slightly aceticacid containing a mixture of water and white vinegar. At 7 days, there is usuallyfull reepithelialization, after which light makeups can be applied. To acceleratethe resolution of erythema, a low-strength steroid ointment can be appliedjudiciously.In addition to strict avoidance of sun for 2 months, patients are instructed to
avoid taking exogenous estrogens or other hormones that increase the risk ofpigment deposition. The postoperative monitoring for and management ofrecurrent hyperpigmentation is as important a step as the procedure itself.Prophylactically, patients are usually given a 4% to 10% formulation ofhydroquinone, mixed with hydrocortisone to help resolve residual erythema. Attimes, salicea gel is also used. Patients can expect erythema to last for up to 6months, but usually by 2 months this erythema can be classified as "mild," andpatients can resume their regular activities.Results of Simultaneous TCB With Phenol Peel for Infraorbital Dark CirclesI have used this approach on 8 patients, 5 women and 3 men, ranging from 28 to66 years of age. All patients were white, 4 of Hispanic origin, 2 orMediterranean origin, and 2 of European origin. This corresponds to thebreakdown of Fitzgerald skin types: type 2, 2 patients; type 3, 3 patients; type 4,2 patients; and type 5, 1 patient. In all cases, significant improvement inappearance was obtained (Figures 3, 4 and 5).Figure 3. A 48-year-old man, Fitzpatrick skin classification 5. Photo before thesurgery (top) and 18 months after surgery (bottom), with complete absence ofinfraorbital dark circles. At 3 years, there has been no return of dark circles.The time for maximum improvement was on average 5 months postoperatively,corresponding to the time for the resolution of erythema. Long-term results at upto 30 months have been consistent and satisfactory, with no recurrence of darkorbital circles. While the procedure produced significant lightening of the lower-eyelid skin, in no cases did this result in obvious demarcation between the lightereyelid skin and the darker surrounding skin. This good result can be attributed tothe fat that those patients with darker skin had such significant lower-eyeliddarkness that the lightening merely resulted in making the lower-eyelid skin lookeither the same or only slightly lighter than the surrounding cheek and temporalskin. Demarcation of the lower eyelids and the surrounding skin as a result ofalterations in skin texture, luster and rhytidosis was prevented by peeling theremainder of the face with Jessner-35% trichloroacetic acid in 3 patients.Figure 4. A 44-year-old woman, Fitzpatrick skin classification 2. Photographbefore the surgery (top) and 12 months after surgery (bottom), with completeabsence of infraorbital dark circles, associated with a minimal amount oferythema.Complications have been few, with 1 case of postoperative granuloma along the(nonsutured) conjunctival incision and treated with simple excision, and 2 casesof prolonged erythema lasting beyond 6 months. In 1 of these cases, theerythema was significantly contributed to by an allergic reaction from an over-the-counter hydrocortisone formulation; patients are now treated withprescription steroid formulations. The most common reason for failure in TCB,incomplete removal of fat, was not present in any patients. In addition, there
were no cases of lid retraction, dry eye syndrome, lateral rounding, increasedskin wrinkling, hematomas, or inferior oblique palsy.Figure 5. A 52-year-old man, Fitzpatrick skin classification 3. Photograph beforethe surgery (top) and 3 months after surgery (bottom), illustrating significantresidual erythema without evidence of infraorbital dark circles. At 15 months,the erythema resolved with no return of pigmentation.ConclusionsSimultaneous TCB and phenol peeling is an effective treatment for infraorbitaldark circles that are due to a combination of hyperpigmentation and some degreeof lower-eyelid orbital fat pseudoherniation. Proper diagnosis of the cause(s) ofthe dark circles is critical for patient selection.A number of therapies are available for reducing pigmentation. Several topicalbleaching agents use different mechanisms to reduce melanin. These agents,which include hydroquinone, kojic acid, and salicea gel are effective, to somedegree, on certain mild cases of hyperpigmentation. Lasers can be effective oncertain conditions of dark skin due to both hyperpigmentation and increasedvascularity. These lasers, which include the copper vapor, the pulsed dye, the Q-switched, and the argon, have their individual indications and parameters;however, this subject is beyond the scope of this article.Dermabrasion, cryosurgery, and chemical peeling smooth facial skin by peelingto some depth, usually within the dermis. The usual adverse effect ofdermabrasion and cryosurgery, and some forms of chemical peeling, notablyphenol, is hypopigmenting of the skin. Phenol decreases skin pigmentation byreducing the ability of melanocytes to produce melanin.Convention dictates that phenol peeling be limited to individuals with Fitzpatrickskin types 1 to 3. Use of phenol on skin types 4 to 6 can produce significantpigment irregularities. However, when phenol is used for reducing infraorbitaldark circles, the precise goal is to "harness" these pigment irregularities (i.e.,hypopigmentation) to create the desired result. The approach described in thisarticle has been used effectively most commonly on individuals with Fitzpatrickskin types 3 and 4, and occasionally types 2 and 5.Dark circles that are a result of lower-lid hypervascularity must not be treatedwith chemical peeling agents. Peeling risks exacerbating the appearance of thehypervascularity, due to the potential reduction of pigmentation in and thethinning of the skin that only makes the underlying vessels more prominent.Furthermore, hypervascularity can increase from the inflammatory response tothe chemical peeling. The approach to these patients is not clearly defined;fortunately, they constitute a small percentage of those patients with infraorbitaldark circles.While patients often do not express concern with lower lid dark circles, once it ispointed out as something that can be treated, there is high patient acceptance toundergo the described procedure. Advantages of this procedure are that it isreliable, safe, able to be performed in an ambulatory setting, and not onlylightens dark circles but also reverses the sequelae of photoaging and intrinsic
aging, resulting in more youthful-appearing skin.Any treatment designed to reduce hyperpigmentation will be most effectivewithin used in conjunction with steps taken to reduce exposure to factors thatcontribute to hyperpigmentation. Limiting sun exposure and avoiding thecombination of certain levels of hormones, notably estrogen, can reduce theamount of irregular melanin deposition. Altered levels of estrogen andprogesterone can occur with exogenous administration (e.g., hormonereplacement therapy and oral contraception) and with endogenous productionthat occurs with pregnancy and breastfeeding.The major downside of the TCB-phenol peel procedure is prolonged erythemathat can last for up to 6 months. Patients need to be counseled that this erythemawill eventually resolve and that the erythema is an improvement in appearanceover dark circles. As far as the concern about the potential appearance of a lineof demarcation between the area peeled with phenol and the surrounding skin,this has been unrealized. The surgeon must be prepared to treat demarcation thatis a result of differences in pigmentation with a remaining full-face phenol peel.Demarcation that is a result of differences in skin texture, luster, and rhytidosismust likewise often be treated with a remaining full-face medium-depthchemical peel, such as Jessner solution followed by 35% trichloroacetic acid.Long-term success has been dependent on judicious postoperative monitoringand treatment to prevent the recurrence of hyperpigmentation.- - - - - -Accepted for publication June 30, 1999Presented at the Foundation for Facial Plastic Surgery Eleventh AnnualSymposium on Cosmetic Surgery of the Face, Newport Beach, Calif, August 6,1997.Reprints: Jeffrey S. Epstein, MD, 6280 Sunset Drive, Suite 504, Miami, FL33143 (e-mail: JSEMD@dr-epstein.com)References:1. Lowe NJ, Wieder JM, Shorr N, et al. Infraorbital pigmented skin; preliminaryobservations of laser therapy. Dermatol Surg. 1995; 21:767-7702. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower lidblepharoplasty. Plast Reconst Surg. 1991; 88:215-220.3. Garcia A, Fulton JE. The combination of glycolic acid and hydroquinone orkojic acid for the treatment of melasma and related conditions. Dermatol Surg.1996; 22:443-4474. Newcomer VD, Lindbert MC, Stenbert TH. A melanosis of the face(chloasma). Arch Dermatol.1961; 83:284-297.5. Bourquet J. Les hernies graisseuses de lorbite: notre traitement chirurgical.Bull Acad Natl Med. 1924, 3:1270-1272.6. Palmer FR, Rice DH, Churukian MM. Transconjunctival blepharoplasty:
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