CRAFT OF FACIAL PLASTIC SURGERY
Management of Infraorbital Dark Circles
A Significant Cosmetic Concern
Jeffrey S. Epstein, MD
Despite the frequency with which it occurs, little has been written in the scientific literature on the treatment of infraorbital dark circles. I have developed a technique that simultaneously treats the 2 contributing causes of these circles: hyperpigmentation of skin and pseudoherniation of orbital fat. The technique involves simultaneous transconjunctival blepharoplasty an deep-depth phenol chemical peel. Successful outcomes have been obtained in patients with Fitzpatrick classification skin types 1 to 5, with a low incidence of complications. Adequate preoperative counseling regarding prolonged erythema and careful postoperative monitoring with, if necessary, medical intervention are essential if both surgeon and patient are to be satisfied with the outcomes. Despite the lack of attention received in the plastic surgery literature, infraorbital dark circles can be a significant cosmetic problem. While there are no statistics giving the frequency of its occurrence, judging from the amount of advertising of cosmetics marketed to treat it, dark circles under the eyelid are a cosmetic concern for a large number of individuals. In my practice, while patients in consultation may not mention infraorbital discoloration, many are interested in having it treated once they are informed that it is a treatable condition.
CAUSE OF INFRAORBITAL DARK CIRCLES
There are several causes for the appearance of dark circles under the eyelids. The most common primary cause is excessive pigmentation, which is seen in such conditions as dermal melanosystosis and postinflammatory hyperpigmentation. Dermal melanosystosis is due to both congenital as well as environmental causes, including excessive sun exposure and occasionally the taking of exogenous estrogens. Postinflammatory hyperpigmentation usually has allergic or atopic components.
Infraorbital dark circles due to hyperpigmentation usually appear as a slightly curved band of brownish skin approximating the shape of the underlying inferior orbital rim. These circles appear even darker when present below the bulging of the lower eyelids that is due to pseudoherniation of orbital fat. In effect, the bulging lower eyelids are casting a shadow on the skin below. When the lower-eyelid skin is manually stretched, the area of pigmentation is spread out, without any blanching or significant lightening.
Blanching of this area with skin stretching would be consistent with the second common primary of infraorbital discoloration, the visible prominence of the subcutaneous blood vessel plexus. This hypervascular appearance is due to some combination of exceptional transparency of the overlying skin and excessive subcutaneous vascularity. In these cases, the entire lower eyelid has a purplish appearance that on closer examination is revealed to consist of prominent blood vessels, covered by a thin layer of skin. While involving the entire lower lid, the vascularity of usually concentrated along the lower aspect of the eyelid, occurring (similar as with primary hyperpigmentation) usually just beneath any pseudoherniated orbital fat.
It can be deduced that lower-eyelid ballooning due to pseudoherniated orbital fat is commonly associated with, and usually exacerbates, the appearance of infraorbital dark circles. Further, it has 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 orbital fat, thus, is usually intimately related to the presence of infraorbital dark circles.
TREATING INFRAORBITAL DARK CIRCLES
As described above, the cause of dark infraorbital circles is most commonly due to a combination of hyperpigmentation and some degree of lower-lid bulging due to fat pseudoherniation. 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 an important 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, 1 ml; creating a phenol concentration of 48%). The TCB is an effective surgical procedure for reducing excess lower-lid fat, first described in 1924 by Bourquet.5 Contemporary proponents of TCB have popularized this approach, so that in 1999, it has widespread acceptance. When performed properly, TCB has a low incidence of complications and is effective for treating almost all cases of lower-lid fat pseudoherniation. In most cases, skin does not need to be excised, and, when performed through a retroseptal approach (which is my approach) simultaneous lower-lid skin peeling can be performed, permitting the reversal of dermatochalasis and rhytidosis, and, as in my approach, the reversal of skin hyperpigmentation.
There are several types of phenol peel formulations, all with effective phenol concentrations between 40% and 48%. At these concentrations, the phenol penetrates down to the reticular dermis, thus repairing damaged elastotic skin. Similarly, at this concentration the usual adverse effect of phenol peeling is hypopigmentation. Phenol decreases skin pigmentation by reducing the ability of melanocytes to produce melanin. While the Baker and Gordon phenol peel is the most common of the phenol chemical peel formulas, I prefer to use the Litton phenol peel.
The goal of pretreatment care is to prepare the skin for the peeling procedure, and to minimize its ability to produce pigmentation. In addition to the strict avoidance of sun for the preceding 7 days, 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 results obtained with this topical agent, in the hopes that significant improvement is obtained, so the phenol peel process then is not necessary. In the majority of cases, however, while there is some improvement in the dark circles and rhytidosis, in most cases it is insufficient for the patient.
The procedure is usually performed under light intravenous sedation. Before the surgery, with the patient in a sitting position, the areas of lower-lid orbital fat pseudoherniation are marked. In those 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 skin with 2 to 3 ml. of 2% lidocaine with 1:100 000 epinephrine. Under sterile conditions, a transconjunctival 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 retroseptal approach that has been well described in the literature, the excess fat is excised using a hand-held high temperature cautery unit. Once the surgeon is satisfied that the appropriate amount of fat has been removed, such that the minimal pressure on the globe there is no fat ballotting above the 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 a retroseptal 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 the lower eyelids and lateral orbital region is adequately degreased with acetone. This is an important step to ensure even penetration of the phenol. The Litton formula is applied to the degreased skin using 2 cotton-tipped applicators (Figure 2). LItton Formula does not need to be mixed fresh, but can be prepared and stored for several months. A gentle wiping, applying motion is used, extending laterally approximately 10 mm beyond the natural borderlines of the lateral and inferior orbital rims, and within 2 mm of the lower eyelashes. Caution must be taken to 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 45 seconds, after which ice water gauzes can be applied. Once the white frost fades and ruddy erythema 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 and inferior 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, the dose of which is not reached when peeling just the eyelids. However, for proper precaution, it is recommended that there be proper cardiac monitoring, and that the patient be adequately hydrated. Phenol must be used cautiously on patients with kidney abnormalities in whom there can be impaired phenol excretion. When peeling more than just the eyelids, the phenol should be applied incrementally, with sufficient intervals between anatomical areas.
Postprocedure Care and Expected Course
For the first 48 hours, patients are to keep the head elevated and the eyelids iced to reduce swelling. Antibiotic drops are applied for the first 3 days, and oral antibiotics are taken for the first week. Care of the peeled skin consists of continual reapplication of Aquaphor for the first 7 to 10 days, with rinsing of the skin 3 times a day before reapplication of the ointment, using a slightly acetic acid containing a mixture of water and white vinegar. At 7 days, there is usually full reepithelialization, after which light makeups can be applied. To accelerate the resolution of erythema, a low-strength steroid ointment can be applied judiciously.
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 of pigment deposition. The postoperative monitoring for and management of recurrent hyperpigmentation is as important a step as the procedure itself. Prophylactically, patients are usually given a 4% to 10% formulation of hydroquinone, mixed with hydrocortisone to help resolve residual erythema. At times, salicea gel is also used. Patients can expect erythema to last for up to 6 months, but usually by 2 months this erythema can be classified as “mild,” and patients can resume their regular activities.
Results of Simultaneous TCB With Phenol Peel for Infraorbital Dark Circles
I have used this approach on 8 patients, 5 women and 3 men, ranging from 28 to 66 years of age. All patients were white, 4 of Hispanic origin, 2 or Mediterranean origin, and 2 of European origin. This corresponds to the breakdown 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 in appearance was obtained (Figures 3, 4 and 5).
Figure 3. A 48-year-old man, Fitzpatrick skin classification 5. Photo before the surgery (top) and 18 months after surgery (bottom), with complete absence of infraorbital 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 up to 30 months have been consistent and satisfactory, with no recurrence of dark orbital circles. While the procedure produced significant lightening of the lower-eyelid skin, in no cases did this result in obvious demarcation between the lighter eyelid skin and the darker surrounding skin. This good result can be attributed to the fat that those patients with darker skin had such significant lower-eyelid darkness that the lightening merely resulted in making the lower-eyelid skin look either the same or only slightly lighter than the surrounding cheek and temporal skin. Demarcation of the lower eyelids and the surrounding skin as a result of alterations in skin texture, luster and rhytidosis was prevented by peeling the remainder of the face with Jessner-35% trichloroacetic acid in 3 patients.
Figure 4. A 44-year-old woman, Fitzpatrick skin classification 2. Photograph before the surgery (top) and 12 months after surgery (bottom), with complete absence of infraorbital dark circles, associated with a minimal amount of erythema.
Complications have been few, with 1 case of postoperative granuloma along the (nonsutured) conjunctival incision and treated with simple excision, and 2 cases of prolonged erythema lasting beyond 6 months. In 1 of these cases, the erythema was significantly contributed to by an allergic reaction from an over-the-counter hydrocortisone formulation; patients are now treated with prescription 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, increased skin wrinkling, hematomas, or inferior oblique palsy.
Figure 5. A 52-year-old man, Fitzpatrick skin classification 3. Photograph before the surgery (top) and 3 months after surgery (bottom), illustrating significant residual erythema without evidence of infraorbital dark circles. At 15 months, the erythema resolved with no return of pigmentation.
Simultaneous TCB and phenol peeling is an effective treatment for infraorbital dark circles that are due to a combination of hyperpigmentation and some degree of lower-eyelid orbital fat pseudoherniation. Proper diagnosis of the cause(s) of the dark circles is critical for patient selection.
A number of therapies are available for reducing pigmentation. Several topical bleaching agents use different mechanisms to reduce melanin. These agents, which include hydroquinone, kojic acid, and salicea gel are effective, to some degree, on certain mild cases of hyperpigmentation. Lasers can be effective on certain conditions of dark skin due to both hyperpigmentation and increased vascularity. 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 peeling to some depth, usually within the dermis. The usual adverse effect of dermabrasion and cryosurgery, and some forms of chemical peeling, notably phenol, is hypopigmenting of the skin. Phenol decreases skin pigmentation by reducing the ability of melanocytes to produce melanin.
Convention dictates that phenol peeling be limited to individuals with Fitzpatrick skin types 1 to 3. Use of phenol on skin types 4 to 6 can produce significant pigment irregularities. However, when phenol is used for reducing infraorbital dark circles, the precise goal is to “harness” these pigment irregularities (i.e., hypopigmentation) to create the desired result. The approach described in this article has been used effectively most commonly on individuals with Fitzpatrick skin types 3 and 4, and occasionally types 2 and 5.
Dark circles that are a result of lower-lid hypervascularity must not be treated with chemical peeling agents. Peeling risks exacerbating the appearance of the hypervascularity, due to the potential reduction of pigmentation in and the thinning of the skin that only makes the underlying vessels more prominent. Furthermore, hypervascularity can increase from the inflammatory response to the chemical peeling. The approach to these patients is not clearly defined; fortunately, they constitute a small percentage of those patients with infraorbital dark circles.
While patients often do not express concern with lower lid dark circles, once it is pointed out as something that can be treated, there is high patient acceptance to undergo the described procedure. Advantages of this procedure are that it is reliable, safe, able to be performed in an ambulatory setting, and not only lightens 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 effective within used in conjunction with steps taken to reduce exposure to factors that contribute to hyperpigmentation. Limiting sun exposure and avoiding the combination of certain levels of hormones, notably estrogen, can reduce the amount of irregular melanin deposition. Altered levels of estrogen and progesterone can occur with exogenous administration (e.g., hormone replacement therapy and oral contraception) and with endogenous production that occurs with pregnancy and breastfeeding.
The major downside of the TCB-phenol peel procedure is prolonged erythema that can last for up to 6 months. Patients need to be counseled that this erythema will eventually resolve and that the erythema is an improvement in appearance over dark circles. As far as the concern about the potential appearance of a line of demarcation between the area peeled with phenol and the surrounding skin, this has been unrealized. The surgeon must be prepared to treat demarcation that is 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 rhytidosis must likewise often be treated with a remaining full-face medium-depth chemical peel, such as Jessner solution followed by 35% trichloroacetic acid. Long-term success has been dependent on judicious postoperative monitoring and treatment to prevent the recurrence of hyperpigmentation.
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Accepted for publication June 30, 1999
Presented at the Foundation for Facial Plastic Surgery Eleventh Annual Symposium on Cosmetic Surgery of the Face, Newport Beach, Calif, August 6, 1997.
Reprints: Jeffrey S. Epstein, MD, 6280 Sunset Drive, Suite 509, Miami, FL 33143 (e-mail: [email protected])
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