Periorbital anatomy: The skin around the eyes is thinnest in the body with minimal subcutaneous fat. A thorough knowledge of anatomy is required for performing procedures on this sensitive area so as to avoid complications.

Causes of dark circles:

There are several factors:-

a.Heredity : Dark circles are inherited trait.The skin around the eyes is very thin so when blood passes through the veins close to the surface of thin skin it gives bluish tint.

b.Excessive exposure to sun : Causes the thin skin around the eyes to become more thinner and fastens the wrinkle formation. Sun exposure also increases production of melanin and increases the dilatation of blood vessels.

c.Lack of sleep and stress: Causes accumulation of hemoglobin and hemosiderin induced pigmentation

d.Anaemia and lack of balance diet: Contributes to the discoloration of area around the eyes.

e.Age : Loss of collagen leads to thinning of skin around the eyes

f. Extension of pigmentary demarcation lines.

g . Other factors : Smoking , Alcohol, Atopic dermatitis, Acute illness can lead to dark circles.

Causes of Puffiness:

a.Heredity

b.Lack of sleep which leads to poor blood circulation

c.Fluid retention :Occurs due to increase of sodium and caffeine intake and less of water intake

d.Ageing

e.Illness : Thyroid disorders, nephropathies, cardiopathies and pnemopathies

Effects of Ageing:

q Pseudo herniation of post septal fat

q Increase in height and width of bony orbit

q Crows feet

q Increase in height and width of bony orbit

q Tear Trough

Medical Therapy

Topical Agents to reduce periorbital hyperpigmentation:

·       Hydroquinone

·       Retinoic acid – 0.01% to 0.1 %

·        Vitamin C, E, K

·       Hydroxy acids

·       Azelaic acid

·       Kojic Acid

·       Arbutin

·       Licorice

·       Sabi white

·       Cosmetic Concealers

Oral Treatment

·       Iron supplements

·       Antioxidants

·       Tranexemic acid

·       Retinoids

·       Multivitamins

Procedural Therapy:

Chemical Peels :

Involve the application of a chemical exfoliating agent to the skin resulting in controlled destruction of the superficial layers of the skin to the required depth , followed by subsequent repair and regeneration .

Various Peeling agents which are available to reduce periorbital melanosis:

Glycolic acid: It is keratolytic and stimulates collagen production

Lactic acid: It is keratolytic and has moisturising effect

Kojic acid : Suppreses the tyrosinase activity

Arginine peels: It increases the elasticity of skin

Ferulic acid : It has antioxidant action

Combination peels: Multiple peeling agents complement their synergistic activity.

6 to 8 sittings of peeling can be done with a gap 15 days

Microneedling : Dermarollers of 0.25 and 0.5mm are available for under eye area

Mechanism of action: Needles create microchannels which increases the delivery of the drug . These substances have antioxidant, anti-inflammatory,depigmenting and vasoprotective effect. It also stimulates the collagen production and also increases the blood supply to the skin.

Drugs which can be used :

·       Glutathione

·       Kojic acid

·       Lactic acid

·       Ascorbic acid

·       Tranexemic acid

·       Hyaluronic acid

Treatment protocol : 4 to 6 sessions one month apart can be done

Lasers : Pigment specific lasers and pigment non-specific lasers can be used for periorbital rejuvenation. Nowadays Q-switched Nd:YAG laser is   safely used  to lighten the pigmentation around the eyes, it is popoularly used in treatment of facial pigmentation.The laser light disperse the pigment cells within the skin ,which leads to reduction of dark circles.

Things to consider :

·       Proper protection of eyes.

·       Internal metal  eye shield mandatory.

·       There may be downtime

·       Use of sunscreen post laser

·       Repeated sessions and maintainence for best results

Jet Peel Technology:The area around the eyes is treated with normal saline under pressure through fine nozzles. It enhances the lymphatic drainage which helps in reduction of puffiness . Lightening agents,vitamins and antiaging agents can be infused with this technology. Chemical peels done after jet peel have much better results than used alone.

PRP( Platelet Rich Plasma therapy): Doing PRP around the eyes helps in collagen and elastin generation which leads helps in wrinkle reduction and also increases the taughtness of the skin.

Neurotoxins: Botulinum toxin  is a protein produced by the anaerobic bacterium Clostridium Botulinum which helps in reduction of wrinkles around the eyes and for brow lift.

When injected intramuscularly at therapeutic dose it leads to partial chemical denervation of muscle resulting in localised reduction in muscular activity.The anatomy of the muscles of facial expression is complex, overlapping , interdigitating and variable hence a thorough knowledge of the muscles of facial expression is important.

Hyaluronic acid fillers: It helps in reduction of tear trough.Product  is placed pre periosteally, anterior to inferior orbital rim . After injecting the hyaluronic acid gel binds water and adds to the volume of tissue . As it hydrates the skin the eyes look fresher post procedure hence it is becoming a popular procedure . Thorough knowledge of periorbital anatomy  and proper technique of injection is required to avoid complications.

Radiofrequency Skin tightening treatment: Radiofrequency does not use laser or light technology hence it overcomes light based disadvantages . It offers enhanced tissue penetration independent of skin colour, causing no or minimal damage to epidermis. Radiofrequency delivers non-specific heat to its target tissues, which results in collagen production .

Thread Lift: PDO threads are gently inserted under the skin with fine needle.The threads create a supportive mesh to deliver a lifting effect and while also smoothing away fine lines and wrinkles. Threads also encourage the skin to produce new collagen and elastin.

Treatment options available depending on symptoms:

Conclusion:It is evident that many treatment options are available for rejuvenation of eyes. Proper patient selection and severity of symptoms is important to determine the best therapeutic option. The most frustating aspect of this concern is limited response to treatments. The key to successful treatment is to target the primary cause and maintenance  of newly rejuvenated skin through sun protection ,a good skin care regime are important to prolong clinical results  .

Refrences:

Malakar S , Lahiri K , Banerjee U , Mondal S , sarangi S ,. Periorbital melanosis is an extension of pigmentary demarcation line – F on face . Indian J Dermatol Venereol leprol . 2007 Sep- Oct ; 73( 5 ) : 3235.

Hirmand H . Anatomy and non surgical correction of the tear trough deformity . Plast Reconstr Surg . 2010 Feb ; 125 ( 2 ):699-708 .

Roh MR , Chung KY . Infraorbital dark circles : definition , causes , and treatment options . Dermatol surg 2009 Aug ; 35 (8) : 1163-7 .

Elsaie ML. Cutaneous remodeling and photorejuvenation using radiofrequency devices. Indian J Dermatol 2009; 54(3): 201–5

Friedman DJ, Gilead LT. The use of hybrid radiofrequency device for the treatment of rhytides and lax skin. Dermatol Surg 2007; 33(5): 543– 1

Doddaballapur S . Microneedling with dermaroller . J Cutan Aesthet Surg . 2009 ; 2 : 110-1 .