Under-Eye Circles Treatment
Eliminating dark circles under the eyes and filling tear troughs are often expressed desires of my patients. This is because dark circles, which appear as shadows under the eyes, can make one’s gaze appear tired. They often give the impression of fatigue. Especially middle-aged men in my practice in Munich regularly get injections to address their dark circles. For those who want to get rid of their dark circles without going under the surgeon’s knife, there are several options. The injection of hyaluronic acid and Platelet Rich Plasma (PRP) are two of them, which I would like to introduce in this article.
These are the topics:
Dark Circles Under the Eyes – Causes
Loss of fat tissue
Dark circles under the eyes usually have a specific cause, namely the loss of volume in the tissue below the eye. This loss leaves a void where the so-called “tear trough” forms, and over time, increasingly distinct dark circles become apparent. Therefore, when injecting dark circles, the primary aim is to compensate for the missing volume. With the correct technique, minor wrinkles can be removed in addition to plumping the tear trough.
The eye area is one of the central focal points in facial aging. The skin around the eyes is thin and sensitive, and it lacks a supportive layer of fat embedded in the connective tissue. Therefore, age-related changes in the tissue become apparent on the surface early and distinctly.
Just think of the typical fine wrinkles under the eyes that can appear at a young age, or the dark circles under the eyes, or the formation of a tear trough. Such changes can be very disruptive, which is why many affected individuals wish to have their tear troughs filled and dark circles removed.
Only Experts Should Treat Tear Troughs
This is possible today. Injecting dark circles and the tear trough can be done rather quickly. However, the procedure is not simple. It requires extensive practical experience and detailed anatomical knowledge to ensure the treatment is successful and complication-free. This is because the area beneath the eyes is not only thin and sensitive, but many blood vessels also permeate it. Moreover, an important nerve emerges from the skull bone in this region.
Adding to the complexity, the eye area here transitions directly into the cheek area, whose tissue structure is quite different. This can also become a challenge during treatment. Even a simple lymphatic congestion, which can present as swelling under the eye, at the level of the cheekbone, after the treatment, can blur the results. So, it’s highly recommended to entrust this procedure to experienced hands. The injection into the tear trough is truly only for professionals.
Lack of Fat Promotes Tear Trough Formation
The development of tear troughs and dark circles is, according to recent findings, due to the age-related loss of fatty tissue, specifically, the shrinkage of the deep suborbicularis oculi fat (SOOF). This pad of fat, located beneath the orbicularis oculi muscle, significantly contributes to facial volume and firmness.
Over the years, it diminishes, a decline thought to be due to worsening blood circulation, and consequently, undernourishment. This process is facilitated by illness, poor nutrition, lack of sleep, and stress, as well as environmental factors like cold, wind, or nicotine.
The shrinkage of the lower eyelid fat leads to the formation of a tear trough. It starts below the inner corner of the eye and runs along the eye socket. Its exact path varies from person to person. In the appearance of a typical “dark circle,” it covers a third to half the distance on the arc from the inner to the outer corner of the eye.
The tear trough casts a noticeable shadow between the lower eyelid and the nose, making the gaze appear tired. The loss of lower eyelid fat also makes the bony edge of the eye socket more prominent.
Ligaments running along the eye socket become visible as well, both of which enhance the impression of dark circles. (Note: Ligaments are dense, connective-tissue-like structures that connect the skin like holding bands to the underlying soft tissue or bones.)
The fat-poor region under the eyes borders a cheek area rich in fat. This structural difference can make dark circles more prominent during certain facial expressions. For instance, when laughing, the cheek lifts, emphasizing the transition between the cheek and the edge of the eye socket. Consequently, dark circles appear more pronounced. Such disharmony can be age-related or congenital. If congenital, it is further accentuated by the shrinking of the lower eyelid fat with increasing age.
Dark Circles Due to Translucent Veins
If the skin in this area also appears dark or bluish, this is mostly due to the underlying venous blood vessels showing through. The skin in the infra-orbital region is already thin, and it gets even thinner with age. Blood vessels can now be especially visible and appear as dark circles under the eyes. This is particularly noticeable in the morning when the tissue fluid, which was not sufficiently transported away during sleep and collected under the eyes, is drained. The dilated blood vessels then show up as dark spots under the skin.
Diseases and genetically determined hyperpigmentation can also contribute to dark circles under the eyes. Illnesses, especially heart, liver, and kidney conditions, as well as vascular damage, are significant contributors.
Hyperpigmentation can also occur after inflammation or as a result of constant eye-rubbing due to irritation. If these causes are present, augmenting the tear trough rarely leads to success, and dark circles are therapeutically difficult to remove.
In advanced age, the formation of “eye bags” may occur. While it was previously thought that these were due to a prolapse of a fat pad located in the eye socket, it is now believed to be due to lymphatic congestion resulting from impaired tissue drainage.
Eye bags become increasingly noticeable as the surrounding tissue slackens and sinks. Indirectly, they too are visually “softened” when lost volume in the infraorbital region is compensated for by filler augmentation.
Treating Dark Circles with Hyaluronic Acid
Augmenting the infraorbital region with hyaluronic acid filler is a very effective, non-surgical method of reducing tear troughs and dark circles. By padding the sunken areas of skin and directly injecting the tear trough, the region from the lower eyelid to the cheekbone can be visually harmonized and dark circles can be removed.
Hyaluronic Acid – A Natural Filler Material
Hyaluronic acid is a substance also found in the human body that is capable of binding large amounts of fluid. This property makes it not only an ideal filling material, but also a source of Hyaluronic acid is a substance also found in the human body that can bind large amounts of fluid. This property makes it not only an ideal filler but also a source of additional skin moisture.
Therefore, the treatment also improves skin texture. To prevent the body from immediately breaking down the injected hyaluronic acid, native hyaluronic acid is “cross-linked” in a chemical process. On the one hand, this gives it shape stability, and on the other hand, the effect of the augmentation is maintained for several months.
Treatment Goal and Process
The goal of the augmentation with hyaluronic acid is to compensate for age-related volume loss and to restore a more congruent, fresher overall impression of the eye area. Beyond removing dark circles, fine lines can be smoothed out and the transition between the fat-poor eye area and the fat-rich cheek region can be harmonized as part of the treatment. As the cheeks also have their signs of aging, an optimal overall result often requires additional injection in the cheekbone region.
The treatment process first involves a thorough cleaning and disinfection of the eye area. Local anesthesia is usually not administered, unless the patient requests it. The tear trough is injected with a sharp or blunt cannula, drop by drop, along the edge of the eye socket.
Blunt vs. Sharp Cannula
In my practice in Munich, I prefer to inject under-eye circles primarily with a blunt cannula. On one hand, this method allows for a very gentle injection in a sensitive region such as the tear trough.
The disadvantage is that blunt cannulas create a channel in the skin through which injected filler droplets can “slip back” and accumulate at one point. The resulting hyaluronic acid depot could bind an excessive amount of water and lead to unsightly swelling. Therefore, the choice of cannula type and injection technique is a decision made on a case-by-case basis.
Since the area beneath the eyes is densely laced with blood vessels, injections are made directly onto the bone to prevent accidental injection into a blood vessel. This also prevents a blueish hue of the injected hyaluronic acid showing through the skin, which would be an undesirable consequence of the treatment, known as the “Tyndall effect.”
Equally, any contact with the infraorbital nerve, which emerges from the skull in this zone, must be avoided, as this would be painful for the patient.
Typically, 0.5ml of hyaluronic filler per side is sufficient for a satisfying result. Following the injection, the filler is modeled with the fingertips and the treatment area is cooled with a cooling pad. To finish, a quick joint look in the mirror – and done!
Possible Complications
Removing dark circles with hyaluron is basically a low-risk treatment. In addition to hematomas and temporary redness, it is particularly swelling that can occur in the sensitive eye region after injections with hyaluronic acid. They may last for several days, but should disappear after 14 days at the latest. If not, then the injected hyaluron probably permanently draws too much water and partial or complete dissolution with Hylase should be considered.
The problem specifically affects individuals who are prone to water and fat congestion in the zygomatic region (so-called “malar bags“). Injecting under eye circles is often contraindicated in such cases, as it may even worsen the undesirable appearance. In general, the maxim “Less is more!” applies in this region, and as a physician one would rather undercorrect at first and later redose if necessary, instead of provoking unsightly swellings with an overcorrection. Another critical factor is the choice of the right filler, which should have a low viscosity and not be too hydrophilic.
Inflammation after under eye circles injection
A rarer but all the more unpleasant late effect is the delayed allergic reaction to the filler. This is an immune reaction of the body, which can also take weeks or months to set in, and leads to inflammatory swelling. During the Corona pandemic, its occurrence was reported more frequently, both in connection with infections and vaccination against it. The relationship between filler injection and corona-specific immune response is not yet clear.
In my medical practice, I have encountered several such cases, almost all of them after injecting the tear trough. Therapy initially consists of the administration of corticosteroids and, if unsuccessful, dissolution of the injected hyaluronic acid with Hylase.
In such a case, the question arises whether another attempt should be made later with another type of filler to remove dark circles without complications. This must be decided on a case-by-case basis. This is supported by the fact that the immune reaction is not suspected to be triggered by the hyaluronic acid itself, but by residues of bacterial protein in individual filler products or production batches.
Treating Dark Circles with PRP
If the primary aim of injecting hyaluronic acid into dark circles is to compensate for age-related volume loss, the focus of treatment with PRP is tissue regeneration and supplying the body’s own growth factors.
Removing dark circles with PRP follows a therapy principle proven in aesthetic medicine, which awakens the body’s self-renewal forces to initiate the repair of damaged tissue. PRP has been used for years in orthopedics, sports medicine, and oral and maxillofacial surgery.
PRP – An Autologous Blood Therapy
PRP, or Platelet Rich Plasma, is a substance derived from the patient’s own blood that contains a concentrated form of platelets, also known as thrombocytes. These platelets contain numerous growth factors and proteins essential for the wound healing process. When injected, the platelets release these growth factors, which have regenerative effects on the tissue. Their effects also occur indirectly by stimulating fibroblasts to proliferate in the treated area.
PRP can have a positive impact on the thickness, texture, hydration, and elasticity of the skin. It can also provide a temporary volumizing effect. PRP is suitable for treating lines and wrinkles, early nasolabial folds, or crow’s feet. It can also be used to remove dark circles under the eyes. However, PRP does not deliver immediate results like hyaluronic acid injections and requires multiple sessions for visible effects to be achieved.
Treatment Goal and Process
The primary goal of PRP treatment in the infraorbital region is the regenerative thickening and restructuring of the skin. The growth factors in PRP promote the proliferation of fibroblasts, leading to the production of new collagen fibers and additional blood vessels. The regenerated skin becomes healthier, firmer, and more elastic. Moreover, a thickened dermis and epidermis reduce the visibility of underlying blood vessels. According to some studies, specific growth factors released by PRP may also help reduce hyperpigmentation. As a result, dark circles can be removed or at least appear less prominent with regular PRP treatments.
The treatment process begins by collecting approximately 10-20ml of blood from the arm vein. The blood is then centrifuged to obtain PRP. The PRP is drawn into finely dosed syringes for the treatment. If local anesthesia is used, the time required for PRP preparation can be used to allow the numbing cream to take effect. I always recommend local anesthesia when injecting dark circles with PRP since the treatment involves multiple punctures.
Injecting PRP Into the Dark Circles Under the Eyes.
There are two main options for introducing PRP into the thoroughly cleansed and disinfected infraorbital region: one option is to directly inject PRP into the dark circles; another option is to apply PRP onto the skin and perform microneedling.
With microneedling, numerous needle punctures create temporary microchannels in the skin, allowing the PRP to penetrate from the surface into the deep dermis. The channels close after approximately 30 minutes, and the platelets begin to take effect within the depth of the skin.
Combining PRP with Microneedling
In terms of the treatment goal of skin regeneration and thickening through new collagen production, the second method has the advantage that microneedling itself already has a strong effect in this direction. This is why microneedling is also referred to as “percutaneous collagen induction therapy” in medical circles. The combination of PRP treatment and microneedling promises a particularly noticeable effect.
The main disadvantage of microneedling is the significant skin redness caused by the needle punctures, which can last for 2–3 days. However, the temporary bleeding that occurs is generally not problematic and, although it may look spectacular in photos, usually leaves no traces shortly after the treatment. The skin is not superficially injured by microneedling; instead, the needles essentially push the cells of the epidermis apart.
In my practice in Munich, I frequently combine both methods, as shown in the photo. During the microneedling procedure, PRP is applied and needled into the skin. And afterwards, I inject it with a fine needle at specific locations for additional enhancement.
Possible Complications
Since PRP is derived from the patient’s own blood and does not contain foreign substances, the risks associated with the treatment are minimal. Of course, with any procedure involving needles and injections, there is always a slight risk of infection. Additionally, when puncturing a region densely populated with blood vessels, bruising, or hematoma may occur. However, apart from these risks, PRP treatment offers limited room for complications, and allergic reactions are nearly non-existent.
The excellent tolerability and high safety of PRP treatment distinguish it from the aforementioned hyaluronic acid injections for under-eye circles. While hyaluronic acid injections can also be considered “safe,” the risks associated with them are higher compared to PRP treatment. If volume loss is not extensive and the patient is willing to accept gradual improvement instead of immediate results, overall, PRP treatment may be a better option for removing dark circles.
What is The cost of Treating Dark Circles?
Treating the tear trough and dark circles costs between $550 and $600 in my practice in Munich. This price is based on using a premium filler such as Juvederm Volbella, with a total filler volume of 1ml. It is crucial not to compromise on using high-quality fillers with the right viscosity to remove dark circles without complications. Cutting corners in this area should be avoided.
Treatment of the lower eye area with PRP costs 360-400€ in the variant without microneedling. If the PRP is administered as part of a microneedling on the (entire) face, then the cost is about 450-500€. Please note that all price quotations are approximate values and the actual billing of a treatment is done according to the German Medical Fee Schedule (GOÄ).
Please also keep in mind that treatment with PRP must be repeated for optimal results. Initially 2-3 times at intervals of 4-6 weeks. Every 6 months or more thereafter. I myself do the treatment on average every two months. The frequency that patients choose ultimately depends on how much they want the dark circles under the eyes to cost.
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About the author:
Dr. med. univ. Eva Maria Strobl is the owner of LIPS and SKIN Aesthetic Medicine practice in Munich. She is a trained specialist in general medicine (MedUni Vienna) and has over 10 years of specialization in non-surgical aesthetic procedures. Dr. Strobl is a member of the German Society for Aesthetic Botulinum Therapy e.V. (DGBT), the German Society of Anti-Aging Medicine e.V. (GSAAM) and of Network Global Health. She publishes regularly on her blog and on DocCheck.
Sources of this article:
Sattler et al, Fillers in Aesthetic Medicine, KVM Publishers.
De Maio, MD Codes™: A Methodological Approach to Facial Aesthetic Treatment with Injectable Hyaluronic Acid Fillers, Link.
Seo, Facial Volumization with Fillers, Springer
Ozer et al, Evaluation of platelet-rich plasma on infraorbital dark circles by using the FACE-Q scales, Link.
