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Enhancement of the Eye Area: Treating Tear Troughs, Dark Circles and Eye Bags enhance

Tear troughs are grooves that occur at the junction between the lower eyelids and the upper cheek. Although mild tear troughs can develop from even a young age due to genetic predisposition, they are also a common sign of ageing. In some individuals, tear troughs can develop into a more extensive area of hollowing, with a loss of the smooth transition between the lower eyelids and the cheeks creating under-eye shadows. In addition, thinning of the under-eye area allows the underlying blood vessels to show more, resulting in dark circles. Some individuals can also develop increased skin pigmentation in the eyelids and the surrounding area, that can also contribute to dark circles. Thinning and weakening of the soft tissue in the under-eye area can allow eye bags to form. All of these genetic and ageing-related changes can result in a tired, sad or even angry look, and have a significant impact on facial attractiveness.

Cosmetic hyaluronic acid (HA) fillers can be used to substantially improve the appearance of tear troughs, under-eye hollows, and dark circles restoring a more youthful, rested and brighter look. HA fillers can also be used to ‘hide’ mild to moderate eyebags without the need for surgery. The results can be transformative and long-lasting, yet remain very natural-looking with minimal downtime. Furthermore, these treatments can be combined with BOTOX®️ to reduce wrinkles around the eyes.

Sloave Clinic London

Overview of the Treatment

icon-clock How long is the procedure?

An initial appointment with Dr Rhobaye usually involves a detailed consultation for a tailored treatment strategy of around 20 to 30 minutes. The actual injection stage takes only 10-20 minutes, depending on the area(s) being treated. Overall, the treatment planning, preparation and injections take 30-45 minutes but can be significantly longer if combined with other treatment areas. A skin analysis is also performed to address any dark circles caused by increased pigmentation in the skin around the eyes, and a suitable evidence-based skincare regime is prescribed.

icon-needle How comfortable is the treatment?

The vast majority of our patients tolerate the treatments very well. The premium cosmetic fillers that we use for eye area contain a local anaesthetic, and a separate anaesthetic is not usually required for most procedures. Nevertheless, an additional topical anaesthetic can be applied before the treatment for even greater comfort if needed. There may be some mild tenderness after the procedure, but this usually is easily controlled with regular painkillers such as paracetamol.

icon-heart How long is the recovery time?

Non-surgical eye area rejuvenation is a minimally invasive technique with significantly less risk of complications and downtime compared to surgery. You can return to work or your usual routine immediately or very soon after treatment.

You may experience some very mild swelling and occasionally bruising, which can take a few days to settle. Should bruising occur, they can be effectively covered up with makeup.

You will be advised by Dr Rhobaye on the expected recovery time so that you can plan a suitable procedure date. If requiring treatment before an important event, please book ahead allowing time for both the treatment and a 2-3 week follow-up review.

icon-eye When will I see results?

The results from hyaluronic acid filler treatments are immediate, and you should expect a noticeable improvement straight away. However, these results will develop further as the fillers undergo a process of hydration (water absorption), bio-integration and eventually compaction, which can take some time to complete. There will also be a degree of minor swelling which needs to resolve to assess the treatment outcome. Consequently, the final stable results can take several weeks to appear, typically 4-6 weeks.

If you have dark circles, treating any tear troughs or under-eye hollowing will immediately help to improve the dark circles by increasing the thickness of the area and reducing the appearance of shadows. However, dark circles can also be caused by a pigment problem with the skin, and you will also need a bespoke professional skincare regime to reduce the pigmentation. Consequently, you will see an instant improvement in the shadowing from the fillers, but it can take several weeks to a few months to improve the pigment issue. 

results How long do results last?

The results may last between 12-24 months or even longer, with some individuals having stable results for years. Although HA fillers are classified as temporary, results can persist for a long time such that the baseline is improved with each treatment. This, in turn, means that you need less filler to maintain the same results and that the results can last incrementally longer with each treatment, especially if undertaken as part of a maintenance programme.

icon-calendar How many sessions will I need?

This will be discussed during your consultation as it varies from patient to patient and on the treatment area and desired result. Treating the under-eye area may involve first treating other parts of the face first to optimise the structural support in those areas so that less filler is needed in the delicate eye area.  Therefore, for certain patients, only one session is necessary, whereas others may require several staged procedures over some time. We usually recommend that patients seeking further treatment allow at least 2 weeks (preferably 4 to 6 weeks) before undergoing additional filler procedures within the same area. After the optimal result is achieved, then only occasional maintenance treatments are needed perhaps once every 12-24 months.

natural-icon Will it look natural?

A fundamental principle in our treatment philosophy is that the results have to look natural. We take great care and skill in achieving this through a carefully planned treatment strategy that is highly individualised to each patient’s specific facial anatomical features. Dr Rhobaye is a highly experienced specialist and leading authority in non-surgical and minimally-invasive facial aesthetics. He uses advanced techniques that enhance the face in an aesthetically harmonious and balanced manner, avoiding issues such as overfilling or creating distracting and disproportionate features. Please look at our photo gallery for examples of our work.    

reverse Can the treatment results be reversed?

Our experience with eye-area enhancement is that the patient satisfaction rate of this procedure is extremely high. Nevertheless, one of the main advantages of using hyaluronic acid (HA) fillers is that the procedure is reversible. If a patient wishes to reverse the changes for any reason, a particular enzyme (hyaluronidase) can be injected into the treatment area to dissolve the HA filler.

Disclaimer: Individual results and reactions may vary and can be affected by factors such as anatomy, physiology, metabolism, physical as well as environmental stresses, and fluctuations in body weight.

Sloave Clinic London
  • Challenges in treating Tear Troughs and under-eye hollows with Cosmetic Fillers

    Treating the under-eye area with cosmetic fillers, as with surgery, is a highly specialist technique. This area and can be challenging to treat due to the many anatomical changes that contribute to ageing around the eyes.  The under-eye area is thin with a delicate lymphatic system that is responsible for removing tissue fluid. Increased pressure or compression can, therefore, result in compromised lymphatic drainage leading to fluid retention and swelling, as people often notice in the mornings when they first wake up. Hyaluronic acid fillers are hydrophilic and therefore attract water molecules. Indeed, injecting too much filler, as is commonly done by non-specialists, can increase the pressure within those tissue compartments, thereby compromising the lymphatic drainage leading to swelling. This effect may not necessarily occur straight away but can build up slowly over time. It is essential, therefore, that minimal volumes are injected directly into the under-eye area using a less hydrophilic filler to reduce compression of the lymphatic system. This can be done by using advanced filler techniques, which also treat neighbouring areas that indirectly enhance the under-eye area, reducing the amount of filler needed to be injected directly. With these specialist techniques, excellent results can be achieved with cosmetic fillers that also minimise the risk of swelling or complications.

  • Direct versus Indirect Correction of Tear troughs and Under-eye hollows

    Direct versus indirect correction is a key principle in filler treatments and applies to nearly all facial areas. Direct correction is when an area is treated by injecting filler specifically into that area (i.e. filling a tear trough or hollow in the case of under-eyes). Indirect correction is an important filler technique where one area of the face can be improved indirectly by treating a neighbouring or even more distant region of the face. In the case of tear troughs and under-eye hollows, this may involve first treating the mid-cheek area to provide foundation and support for the under-eye soft tissue. More distant indirect correction may involve treating both the temples and outer cheeks, both of which can improve tear troughs and hollows by tightening the orbicularis oculi muscle that circles the eye, which in turn can stretch the overlying skin and reduce muscle resting hypertonicity, which improves the appearance of the hollows. This process is called myomodulation, which essentially describes the technique where fillers can be used to either enhance or inhibit muscle action depending on how and where the filler is injected. To read more about indirect versus direct correction and myomodulation, please refer to the Advanced Information Section of the Full Face treatments.

  • Importance of Facial Skeleton Assessment in Periorbital Aesthetics

    Careful facial assessment is crucial in all filler treatments and in particular, the eye region. This includes an assessment of the facial skeleton, which provides structure and support for the overlying soft tissue. Consequently, patients with a deficiency in cheek projection (maxillary hypoplasia with a negative vector), whether genetic or through ageing, are more likely to develop tear troughs as they lack bony support. It is important, therefore, that in those patients, structural support is created by injected a higher density filler deep onto the bone, providing better projection of the mid-face and an improved platform for the overlying soft tissue.

  • Assessing the canthal tilt

    The canthal tilt is also an important part of the assessment in periorbital aesthetics. The canthal axis is an imaginary line between the outer corner (lateral canthus) and inner corner (medial canthus) of the eye. The canthal tilt is the angle this axis makes with a horizontal line. It essentially describes the degree to which the eyes appear to slant in an individual. A neutral canthal tilt means that both corners of the eyes are at the same level and there is no slant. A positive canthal tilt is where the outer corner of the eyes are at a higher position than the inner corner, such that the eyes appear to slant upwards. Females ideally have a degree of positive tilt of between 5-10 degrees as this is perceived as being more feminine. Too much tilt, however, can make the eyes look ‘cat-like. Men ideally have a neutral to small degree of tilt as this is perceived as being more masculine and attractive. Consequently, an exaggerated positive tilt in a male can feminise the eyes. A neutral tilt in a female or negative tilt (where the eyes slant downwards laterally) in both females and males is associated with facial ageing. As part of peri-orbital or eye-area enhancement, cosmetic fillers can be injected using advanced techniques to subtlety modify the ‘apparent’ canthal tilt in selective individuals to optimise the appearance of the eye area further. These techniques involve very careful and intricate micro-injections onto the bone of the outer orbital ridge (lateral canthal region), in combination with using an indirect myomodulatory action to rebalance the eye muscle and modify the pull on the eyelids and outer eye corner. These techniques should only be done by specialists with extensive experience of treating the eye-area. More profound changes, however, require surgical intervention. 

  • Defining tear troughs and peri-orbital grooves

    A tear trough is a groove or furrow located at the junction between the lower eyelid and the upper cheek, beginning at the inner corner of the eye (medial canthus), ending at an approximate point below the pupil (corresponding roughly to the mid-pupillary line).  Anatomically, it corresponds to the boundary between the inner (palpebral) and outer (orbital) portion of the circular sphincter muscle of the eye (orbicularis oculi). They can develop from a young age due to a genetic predisposition, where they tend to be relatively mild. They are, however, also a common feature of the ageing face. In some individuals, particularly with advancing age, the tear trough can become continuous with another indentation called the palpebromalar groove that starts from the outer corner of the eye (lateral canthus) and also runs downwards along the lid-cheek junction meeting the tear trough towards the middle. Although the two grooves appear to be continuous, studies suggest that they may have somewhat different underlying anatomical structures. There is also an important distinction between the tear trough and a third more diffuse and less defined indentation called the nasojugal groove, which like the tear trough starts at the inner corner of the eye but continues more obliquely downwards (corresponding to the space between the lower border of orbicularis oculi muscle and the levator labii superioris alaeque nasi muscle). The nasojugal groove can also appear to communicate with, yet another, fourth indentation called the mediojugal (mid-cheek) groove that, as its name suggests, runs obliquely downwards and outwards across the middle of the cheek. The nasojugal groove is often mistakenly referred to as the tear trough, and in some individuals differentiating between a nasojugal groove and true tear trough can be difficult especially as they run very close to each other towards the inner corner of the eye. While the difference may seem academic and of anatomical interest only, the importance is that branches of the facial artery can run in the base of the nasojugal groove as they pass up the face towards the inner corner of the eye. This region should only be treated, therefore, by highly skilled specialists with considerable treatment experience and anatomical understanding.

  • Dark circles and their causes

    Some individuals can develop a diffuse depression or concavity under the eyes commonly referred to as an ‘under-eye hollow’ (essentially where a tear trough and nasojugal groove appear as one). These hollows can affect the way light reflects from the surface of the skin, creating under-eye shadows. They also often have dark circles due to the skin being thinner and more translucent, which allows the underlying veins carrying purplish-blue blood to show more as they are closer to the surface (a ‘Tyndall Effect’). The blood vessels themselves also tend to be more dilated with sluggish circulation leading to a degree of pooling of the dark venous blood. Dark circles can also be caused by having increased melanin pigment in the skin around the eye (periorbital hyperpigmentation), either through a genetic predisposition (familial or ethnic) or due to prolonged sun exposure. Certain medical conditions such as iron-deficiency anaemia and under-active thyroid can also be associated with developing dark circles, as are a lack of sleep and dehydration, which can cause a thinning of the delicate under-eye skin.

  • Treating Dark Circles with Cosmetic Fillers and Professional Skincare

    Cosmetic filler injections can greatly improve dark circles caused by shadows from tear troughs and under-eye hollows by indirectly repositioning the cheek fat pads upwards and directly filling out the depressions recreating a smooth contour transition between eyelids and cheek and reducing the under-eye shadows. Furthermore, by increasing the volume and therefore, the distance between the skin and underlying blood vessels, fillers can also reduce the visibility of the dark venous blood and hence also reduce the dark circles. Patients with dark circles caused by increased pigmentation often require additional treatment with professional medical-grade skincare. These include tyrosinase inhibitors, which block a key enzyme involved in the production of the melanin pigment, as well as antioxidants and broad-spectrum sunscreen that help protect against sun and other environmental exposure (which can damage the skin and stimulate overproduction of the pigment). These skincare products often also contain ingredients such as caffeine that help to improve the circulation of the blood in the under-eye area and reduce the contribution of the venous blood to the dark circles. 

  • Lower Eyebags and their causes

    The eyeballs are surrounded and protected by pockets of fat that act as cushions against the hard bony surface of the inner eye sockets. These fat pockets are separated into discrete compartments behind the upper and lower eyelids, where they are held in place inside the eye sockets by overlying skin, muscle and connective tissue (orbital septum). In some patients, this skin and soft tissue barrier that holds the fat compartments in place can begin to weaken allowing the fat to bulge forwards (pseudo-herniate) and form lower eyelid eyebags (palpebral bags). These patients often have generalised thinning and volume loss with under-eye hollowing as well as dark circles, which can make the eyebags appear even more prominent and unsightly. Surgical correction of the eyebags is called a lower blepharoplasty where the protruding fat pockets are either cut out or repositioned, and the overlying skin and soft tissue is tightened with sutures to push back the remaining fat and prevent further bulging. This may also be combined with fat grafting for volume correction and additional treatments such as laser resurfacing procedures to improve the skin envelope.

  • Treating eyebags non-surgically with Cosmetic Fillers

    Cosmetic fillers based on hyaluronic acid gel can be used to improve the appearance of mild to moderate eye bags without the need for surgery with potentially remarkable results. The basic concept of filler treatment is fundamentally different from a surgical lower blepharoplasty in that it is the area around the eye bags that is being treated rather than the eyebags themselves. By improving the structural support in the mid-cheek area and correcting under-eye hollows through volume replacement, the projection of the soft tissue surrounding the eyebags can be improved, in effect concealing or hiding the eyebags.  The results from modern cosmetic fillers in this area can last for a considerable period of time, and progressively less filler is needed with each repeat treatment. Furthermore, there is substantially less downtime and risk of significant complications than with surgery.

    Nevertheless, this is a highly specialist procedure, and correct patient selection is crucial as patients with severe eyebags, considerable skin and muscle laxity or a degree of localised tissue oedema (swelling) can have poorer treatment outcomes and are therefore not suitable. Furthermore, unlike surgery, the bags themselves are not directly treated but rather are hidden by treating the surrounding areas and therefore, they may continue to deteriorate with time in some individuals. Nevertheless, the ability to treat eye bags without the need for surgery but with potentially excellent results represents a significant advancement in periorbital aesthetics and a great alternative for many patients.

  • Treating upper eyelid hollowing (A-Frame deformity)

    Volume loss in the upper eyelids at the junction with the brow can lead to ‘infra-brow hollowing’ with increased visibility of the bony border of the upper eye socket (orbital rim) and deepening of the sulcus.  These changes lead to the loss of the curved smooth, soft tissue contour normally associated with youthfulness, which is sometimes referred to as an “A-frame” deformity due to the slightly acute angle that forms in the soft tissue towards the middle of the orbital rim. The eyes can begin to appear sunken or recessed, and give the impression that the eyes are rounder and narrower, all of which are classic signs of ageing in the eye area. However, these changes can also result from a surgical upper eyelid blepharoplasty, where an excess amount of fat has been removed leading to increased visibility of the bony orbit.

    Cosmetic fillers can be used to replace lost volume in the upper eyelid hollowing and re-establish a more youthful smooth curved contour by injecting a low density filler along the superior orbital rim using a cannula. This treatment can result in quite a significant improvement in the periorbital aesthetic appearance. Furthermore, the results can be long lasting, with some patients noticing continuous improvement even after two to three years.

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