Your doctor needs to know there anatomy.

Dear David:

Yes there are all sorts of important structures in this area. That is why your doctor really needs to know their anatomy. The absolute deepest part of the dark circle is actually just at or a little below the bony orbital rim. At the bony rim, there are essentially no important structures and no large vessels. There are three predominant lower eyelid filling methods:

DeepfillTM: This is the method I developed. The key is using the bony as the deep land mark. This places filler at the level just above the bone covering. There are no major vessels at this level just below the lip of the bony orbital rim. Filler can be placed along the anterior lacrimal crest to safely fill the inner corner of the dark circle without traumatizing the tear duct system or the large vessel that travel between the inner corner of the eyelid and the nose. Great method for placing larger filler volumes which is what you need.

Superficial threading: This method was developed by Michael Kane, a plastic surgeon in New York City. This method floats Restylane between the skin and the lower eyelid muscle. This is a painstaking approach which is difficult to master but I use it as a useful adjunct in certain patients.

Middle lamelllar filling: This method was developed by Robert Goldberg at UCLA. Restylane is theaded in the lower eyelid muscle, the orbicularis oculi. This method is a little more forgiving than the superficial threading method. This technique is very good for filling in the lower eyelid lines. This method really requires a very clear understanding of eyelid/midface anatomy.

In reality, it is often necessary to combine approaches. WIth you, I would think that the deepfillTM approach would be best. The bad news is that you need about 3 milliliters of filler on each side. Treatment will last about a year.

I think that the benefit of the arcus marginalis release will be very modest, perhaps disappointing and I would not recommend it to you. There are surgeries that place orbital rim or tear trough implants and these might help you but they are very big surgeries and have the risk of creating unwanted post-surgical changes that can be very difficult to correct. I would encourage you to find a cosmetic dermatologist who does a lot of dark circle filler treatment.

Hi David,

I would fill your hollow conservatively with Restylane initially, have you return to the clinic in about 10-14 days for a possible touch up. The entire lower and lateral periorbital area needs to be in balance, usually there may be some feathering injections around the main defect to blend the entire area.

Restylane lasts surprisingly long in this area as there is little movement. Patients vary, but one year to eighteen months is common. There is some new collagen laid down during this time, so that when you return for retreatment, the hollow is not as deep, and usually less Restylane is required to fill the defect.

Good luck and be well.

Dr. P

Our preferred option for your situation might be to do a transconjunctival blepahroplasty with fat repositioning and slight fat reduction, followed by fillers (usually Restylane or Prevelle). Pure fat transposition procedures can be prone to relapse of lower eyelid fat bulges as the attached fat contracts with healing, visibility of the transposed fat, or lumpiness in this very thin skinned area.

Extensive deep use of fillers are also possible around the eyes and may be the least invasive, most predictable method.

There is a single large vessel at the bony orbital rim which of course must be avoided or bruising can be significant, so knowledge of the anatomy is important.

It is also possible to place fat injection, with its usual pluses and minuses, or LiveFill, nontraumatized fat-fascial grafts, precisely in the tear trough. Any graft must go through an incorporation stage, so will be somewhat firm and may need to be nursed along.

All these advanced lower eyelid procedures are technically complex and warrant a thorough knowledge of procedures of the lower eyelid and midface.