Recording: I have dark circles (hereditary) which is fine, I can live with that. How do I get rid of indentations? These indentations left after makeup application are killing me! I look old and tired when I'm not. What can I do about them?

Dr. Aiya Prasad: Thank you for your question. You've submitted three photos and a straightforward question about dark circles under the eyes, which you are clear is hereditary, and your concerned about what you described as indentations. In the different angles of the photos, I believe, basically, you're concerned about the area we refer to as the tear trough.

I think that most people who work in this area will agree that you are probably a good candidate for some type of filler that is a hyaluronic acid filler. I'll let you know a little bit about what we do in our practice. I'm a cosmetic oculofacial plastic surgeon. We actually combine the hyaluronic acid filler with something called platelet rich plasma. This was a kind of serendipitous discovery a few years ago when patients of ours who had aged appearance to their skin, who also had the dark circles, actually saw an improvement in the skin quality of the dark circles, even if they were genetic. That is because when eyelid skin is affected by aging or environmental changes, or, for someone who wears makeup, and then aggressively takes off their makeup, the chemicals used to wipe off the makeup can often dry out the skin and actually accelerate some of that aging appearance to the skin.

What we have been doing is we've actually been doing a combination approach of hyaluronic acid filler, such as Restylane, to provide some volume to fill that area in the tear trough, and, as well as the area of the orbital rim, or the rim between the eyelid and the cheek we call the eyelid-cheek junction. That typically will provide some volume, and then we combine that with platelet rich plasma which helps skin quality.

There have been studies done on wound healing where the combination of hyaluronic acid with platelet rich plasma actually resulted in an improvement in wound healing, and it's been our observation that we actually are very pleased with the qualitative improvement in the skin and the area.

I think that a challenge that you're going to face when you do decide to try this is that hyaluronic acid can be a little bit challenging technically for both the physician performing the procedure as well as for the patient who's undergoing the procedure in that very often the correction can be too little, too much, or create some irregularities and bumps. You just have to be committed to work through whatever challenges there are.

Once the material is placed and it looks good. . . The way I approach it is that I spend a lot of time on every patient where I'll put a little bit, I'll mould it, and I'll come back to the patient after a few minutes to see how it looks. But once it's done and it looks good, it can really look very, very nice, and it can make a real improvement. It does require maintenance, however. There's no ideal permanent solution. Although there are some doctors who recommend fat transfer, and other things that are involved, surgery or grafting of tissue, it's been my experience that eyelid skin is very thin and does not do well with fat grafting. I think it just very often results in irregularities and bumps. We have patients who come from all over the world for me to address fat that did not work out so well, and they actually need more extensive surgery to actually remove and reconstruct the tissue.

As far as hyaluronic acid is concerned, in addition there is a safety mechanism associated. It turns out that we actually have an enzyme called hyaluronidase which can actually melt the hyaluronic acid. I'm stating that because we also get referrals for patients who have excess hyaluronic acid under their eyes. They often come to us to start clean, and we end up actually dissolving it.

Just be aware when you are doing your consultations. Meet with doctors who have a lot of experience with dealing with dark circles and hollowed areas and with hyaluronic acid. There are some doctors who also use platelet rich plasma for this area, as well. Learn more about these options and start meeting some doctors to find one that you're comfortable with.

I hope that was helpful. I wish you the best of luck, and thank you for your question.


Correcting Under-Eye Indentations: Injectable Fillers and Platelet Rich Plasma (PRP)

Dr. Amiya Prasad details how under-eye hollowing and the accompanying dark circles can be treated non-surgically with regenerative medicine in the form of platelet rich plasma and volume addition through fillers.