Lower Eyelid Dark Circles (Tear Trough and Lid-Cheek Junction): A Stepwise Assessment Framework

Abstract

Background: Despite increasing popularity, the use of hyaluronic acid (HA) fillers for the correction of dark under-eye shadows remains challenging. Specific guidance on patient assessment is limited.

Objectives: The aim of this study was to develop a stepwise assessment framework for lower eyelid dark shadows to help practitioners classify patients based on their underlying problems and facilitate a more strategic approach to treatment.

Methods: Literature review and peer collaboration informed the current availability of educational material for use by experienced injectors when assessing patients presenting with dark circles. A practitioner survey provided insight into current practices. A focus group convened to review the survey results and discuss best practice approaches to patient assessment.

Results: Surveyed practitioners (n = 39) reported patient concern about under-eye hollows (91%), dark eye circles (80%), and looking tired (60%). All (100%) agreed that midcheek volume was critical when treating tear-trough depression, and only 26% reported use of a tear-trough classification system. The focus group developed a framework for assessing tear-trough depression and the lid-cheek junction in patients presenting with dark circles. Key factors within this framework included the importance of appropriate lighting when conducting a visual inspection, regional inspection of the cheek and tear trough, palpation of the orbital rim and soft tissues, determination of the orbital vector, and assessment of lower eyelid pigmentation and skin quality.

Conclusions: Careful step-by-step assessment can reduce the challenges of treating dark circles by identifying patients in whom dark eye circles may be improved without the need to directly inject filler into the tear trough.

Figure 1.

Lower eyelid dark circles: stepwise assessment framework.

Figure 2.

Inspection of the lid-cheek junction. Patient images reproduced from Liew and DeSilva (with permission from Georg Thieme Verlag KG).

Figure 3.

Assess midface and lower eyelid skin quality. Patient images reproduced from Liew and DeSilva (with permission from Georg Thieme Verlag KG).

Figure 4.

Palpation of the orbital rim and lid-cheek junction. Underlying bone tissue image, sourced from Mendelson and Wong. *Finger on midface pushing cephalad toward the lid-cheek junction, simulating the effect on volumizing the medial SOOF on lid-cheek junction. DMCF, deep medial cheek fat; SOOF, suborbicularis oculi fat; TTL, tear trough ligament.

Figure 5.

Classification Group 1b. A 25-year-old female displaying typical features including a negative orbital vector (A) and pseudo eye bags (B, arrow).

Figure 6.

Patient characteristics and treatment planning. DMCF, deep medial cheek fat; SOOF, suborbicularis oculi fat.

Figure 7.

(A) The same Group 1b 25-year-old female shown in Figure 5 presented with dark lower lid circles. (B) The lower eyelid dark circle is due to structural retrusion of the maxilla. The triangle shows the position of the underlying structural bony deficit and indicates the optimal placement of filler in the medial suborbicularis oculi fat pad and deep medial cheek fat pad to achieve correction. (C) Three months post injection with a small volume of soft hyaluronic acid filler, showing an elevation and effacement of the lid-cheek junction and improved appearance of dark circles without actual treatment of the lower eyelid region.

Figure 8.

Classification Group 2a. (A) A 54-year-old female exhibiting depression across all segments of the lid-cheek junction. (B) The same patient immediately following filling of the medial suborbicularis oculi fat pad and deep medial cheek fat pad with filler, showing elevation and effacement of the central lid-cheek junction. Image reproduced from Liew and DeSilva, with permission from Georg Thieme Verlag KG.