British Journal of Dermatology
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Volume 160, Issue 5, Pages 1022-1025
Published Online: 13 Mar 2009
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DERMATOLOGICAL SURGERY AND LASERS
Treatment of infraorbital dark circles by autologous fat transplantation: a
pilot study
M.R. Roh, T-K. Kim and K.Y. Chung
Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of
Medicine, 134 Shinchon-Dong, Seodaemoon-Gu, Seoul 120-752, Korea
Correspondence to Kee Yang Chung.
E-mail: kychung@yuhs.ac
Conflicts of interest
None declared.
Copyright Journal Compilation © 2009 British Association of Dermatologists
KEYWORDS
autologous fat transplantation • infraorbital dark circles • pilot study
ABSTRACT
Background Infraorbital dark circles are a cosmetic concern for a large number of individuals. However, the
exact definition and precise cause has not been elucidated clearly. In our experience infraorbital dark circles
due to thin and translucent lower eyelid skin overlying the orbicularis oculi muscle can be treated
successfully with autologous fat transplantation.
Objectives This study was conducted to clarify the nature of dark circles under the eyes and determine the
efficacy of autologous fat transplantation.
Patients and methods Ten patients with dark circles due to increased vascularity and translucency of the
skin were included. They received at least one autologous fat transplantation and follow-up evaluations
were conducted at least 3 months after the last treatment.
Results An average of 1·6 autologous fat transplantations were done in both infraorbital areas. Patients
showed an average of 78% improvement (average grading scale: 2·6 out of 4). Most of the patients showed
improvement in the infraorbital darkening and contour of the lower eyelids.
Conclusions Autologous fat transplantation is an effective method for the treatment of infraorbital dark
circles due to thin and translucent lower eyelid skin overlying the orbicularis oculi muscle.
Accepted for publication 16 December 2008
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2133.2009.09066.x About DOI
ARTICLE TEXT
'Infraorbital dark circle' refers to conditions that present with darkness of infraorbital eyelids. It can be a
significant cosmetic problem, and many individuals seek treatment for this condition. Possible causative
factors of the dark circles include excessive pigmentation, thin and translucent lower eyelid skin overlying
the orbicularis oculi muscle and shadowing due to skin laxity and tear trough. 1 The therapeutic approach
must vary with cause as infraorbital dark circles are due to multiple factors. In cases of infraorbital dark
circles due to excessive pigmentation, different treatment options such as topical agents, chemical peeling
and lasers are currently available. For infraorbital dark circles due to thin and translucent lower eyelid skin
overlying the orbicularis oculi muscle, the therapeutic modality is to restore the volume underneath the
eyelid. One of the methods of restoration is autologous fat transplantation, which has long been used for
soft-tissue augmentation.2 Autologous fat is completely biocompatible, and is therefore usually the safest
choice for altering facial volume or contours. We present the results of our pilot study evaluating the
efficacy of autologous fat transplantation in the treatment of infraorbital dark circles due to thin and
translucent lower eyelid skin overlying the orbicularis oculi muscle.
Patients and methods
Patients who attended the Dermatology Department at Severance Hospital, Yonsei University, Seoul, Korea
for treatment of infraorbital dark circles were recruited to the study. Inclusion criteria were patients with
infraorbital dark circles primarily due to thin and translucent lower eyelid skin overlying the orbicularis
oculi muscle. Patients were thoroughly advised about the nature of the study, treatment options and possible
complications, after which informed consent was obtained.
Donor sites of the fat, usually at the buttocks or lower abdomen, were tumesced using Klein's technique.3
After a 20-min period for vasoconstriction, fat was aspirated using a 10-mL Luer lock syringe and a blunt
14-gauge cannula. Aspirated fat was drained of the fluid component including the oil layer and blood on a
lint-free autoclaved filter paper and the fatty tissue that includes the stromal cells was transferred to 1-mL
syringes for injection with an 18-gauge cannula. Nerve or field blocks were done using 1% lidocaine with
1 : 100 000 adrenaline before the injection. The adit for the cannula was made with an 18G needle in the
junction of the nasal ala with the cheek and small droplets of fat were injected under both eyes between the
skin and the muscle layer. If the tear trough was prominent, some fat was injected above the infraorbital
bony margin. A mean volume of 1–2 cm3 of fat, depending on the amount of depression, was placed in each
infraorbital area. Remaining fat was stored at 4 °C for 2 h, then slowly cooled down to −20 °C for 2 h
followed by long-term storage at −70 °C. Patients were examined 1 week postoperatively and further
injections were done at 3-month intervals using the frozen fat. At least one fat injection was done and the
patients were evaluated at least 3 months from the last treatment.
Results
Ten patients were treated with autologous fat transplantation for infraorbital dark circles due to thin skin
overlying the orbicularis oculi muscle. Relevant epidemiological and clinical features are listed in Table 1.
There were eight women and two men, with age range 20–56 (mean 37·1) years. The patients showed
Fitzpatrick skin types II and III. Four patients also showed tear troughs that exacerbated their looks. None of
the patients had received any previous treatment for their dark circles. Fat tissue donor sites were buttocks
and lower abdomen. An average of 1·6 autologous fat transplantations were done in both infraorbital areas.
Patients were evaluated clinically with serial photographs. A medical observer performed clinical
assessments using the following grading scale: 0, < 25% improvement (poor); 1, 26–50% improvement
(fair); 2, 51–75% improvement (good); 3, 75–90% improvement (excellent); and 4, 91–100% improvement
(complete). The patients were evaluated at least 3 months after the last treatment. Clinical results are shown
in Table 1. The patients showed an average of 78% improvement (average grading scale: 2·6). Most of the
patients showed improvement in the infraorbital darkening and contour of the lower eyelids (Fig. 1).
However, none of the patients showed 100% improvement of the lesion, which suggests multiple factors
contributing to the infraorbital dark circles and absorption of the injected fat. Postoperative complications
included minimal bruising, pain, oedema and erythema, but they rarely persisted for more than 72 h.
Table 1 Clinical baseline features and results of 10 patients with infraorbital dark circles treated
with autologous fat transplantation
Sex/age
Patient (years)
Donor
site
Number of
injections
Follow-up period
from the last
treatment (months)
Tear
trough
Improvement, %
(grading scale)
1
2
3
4
Buttock
Buttock
Buttock
Lower
2
3
2
2
12
18
8
14
No
Yes
No
No
70 (2)
80 (3)
60 (2)
60 (2)
M/36
M/56
F/32
F/26
5
6
F/27
F/50
7
8
9
10
F/20
F/23
F/49
F/52
abdomen
Buttock
Lower
abdomen
Buttock
Buttock
Buttock
Buttock
2
1
12
12
No
Yes
80 (3)
90 (3)
1
1
1
2
3
6
6
24
No
No
Yes
Yes
70 (3)
60 (2)
80 (3)
90 (3)
Grading scale: 0, < 25% improvement (poor); 1, 26–50% improvement (fair); 2, 51–75% improvement
(good); 3, 75–90% improvement (excellent); 4, 91–100% improvement (complete).
Fig 1. (a) Infraorbital dark circles prior to treatment
(patient 3). (b) Same patient (patient 3) 8 months after last
treatment. (c) Infraorbital dark circles prior to treatment
(patient 5). (d) Same patient (patient 5) 12 months after
last treatment. (e) Infraorbital dark circles prior to
treatment (patient 10). (f) Same patient (patient 10)
24 months after last treatment.
[Normal View ]
Discussion
Infraorbital dark circles are thought to have a multifactorial aetiology. One of the primary causes is
excessive pigmentation, which is seen in conditions such as dermal melanocytosis and postinflammatory
hyperpigmentation. Infraorbital dark circles are observed in dermal melanocytosis such as naevus of Ota
and acquired bilateral naevus of Ota-like macules (Hori's naevus).4 Postinflammatory hyperpigmentation
under the eyelids is usually caused by allergic or atopic dermatitis. This condition usually appears as a
slightly curved band of brownish skin approximating the shape of the underlying inferior orbital rim. The
pigmentation looks darker when it is present below the bulging of the lower eyelids induced by the
pseudoherniation of orbital fat. The bulging lower eyelids add a shadow effect and worsen the appearance.
When the lower eyelid skin is manually stretched, the area of pigmentation spreads out without any
blanching or significant lightening of the pigmentation.5
Another common cause of infraorbital darkening is due to thin and translucent lower eyelid skin overlying
the orbicularis oculi muscle. The orbicularis oculi muscle lies right beneath the skin with little or no
subcutaneous fat and the darkness may be due to the visible prominence of the subcutaneous vascular
plexus or vasculature contained within the muscle. This condition usually involves the medial half of the
lower eyelids with violaceous appearance, which is consistent with prominent blood vessels covered by a
thin layer of skin. The violaceous appearance is usually accentuated during menstruation. This
hypervascular appearance was suggested to be due to the combination of exceptional transparency of the
overlying skin and excessive subcutaneous vascularity.5
In some of these patients, as is shown in our cases, the darkening is aggravated by the association with a
tear trough, which is a depression centred over the medial inferior orbital rim. 6 The condition aggravates
with ageing due to the loss of subcutaneous fat with thinning of the skin over the orbital rim ligaments,
which confers a hollowness aspect to the orbital rim area. 7 Tear troughs were present in patients older than
45 years in our cases. The combination of the hollowness and the overlying pseudoherniation of the
infraorbital fat accentuates the shadow in the tear trough depending on the lighting conditions.8
Another cause of infraorbital dark circles is shadowing due to skin laxity. Dermatochalasia and periocular
rhytides are a common manifestation of ageing. Over time, collagen and elastin in the thin tissue of the
eyelids and periorbital skin undergo both ultraviolet-induced and age-related degeneration.9 In addition, the
damaged epidermis releases collagenases, which further contributes to collagen degeneration. Skin laxity
due to photoageing imparts a shadowing appearance on the lower eyelids, which results in infraoribital dark
circles. In the majority of patients, infraorbital dark circles are due to a combination of the previous causes.
Treatments for these conditions vary with the cause. For infraorbital hyperpigmentation, treatment such as
bleaching creams, topical retinoic acids, chemical peels and pigment-specific laser therapy have been used.
Lowe et al.1 reported that Q-switched ruby (694 nm) laser was effective in lightening the hyperpigmentation
after two treatments. High-energy, pulsed CO2 laser, which is a nonpigment specific laser system, also
showed successful results for the treatment of infraorbital dark circles. 10 In these cases, dark circles were
due to skin laxity and the beneficial effects were due to the ability to tighten dermal tissue and improve
surface texture by vaporizing intracellular water.11
Although treatments aimed at hyperpigmentation and skin laxity have been tried, there are no reports of
treating dark circles due to thin and translucent lower eyelid skin overlying the orbicularis oculi muscle. Our
study showed excellent improvement of infraorbital dark circles mainly due to these factors with autologous
fat transplantation. In some of our patients with accompanying tear trough, the condition was also
successfully corrected with autologous fat transplantation.
Fat transplantation has been used in a variety of conditions involving volume loss. It is widely used for
panfacial global subcutaneous atrophy secondary to intrinsic ageing or trauma. 12 Although controversy
exists regarding long-term survival of transplanted fat in the subcutaneous layer,13–15 clinical reports
continue to be optimistic because fat is readily available, safe, noncarcinogenic, easily acquired and
autologous, which decreases the host immune response. Pinski and Roenigk2 reported that the mobility of
the site being treated is one of the most important factors in determining graft longevity. The infraorbital
area is a relatively nonmobile area, which resulted in good survival of the transplanted fat. As infraorbital
dark circles are due to thin and translucent lower eyelid skin overlying the orbicularis oculi muscle in our
cases, transplanted fat allows the covering of the vascular areas and reduces the transparency of the skin.
Soft tissue fillers are also widely used for improving volume loss and facial contour. However, virtually
every filler available—whether resorbable, biodegradable or permanent—has been associated with cases of
granulomatous reactions.16–18 Given the relative thinness of the skin of the eyelid and cheek/eyelid junction,
soft-tissue filler that is injected too superficially in these areas is at high risk of resulting in visible or
palpable nodules or worsening of colour due to their transparency.
Fat transplantation is a relatively safe procedure with a low complication rate. Most sequelae, such as
ecchymosis, oedema, fat necrosis and contour irregularities, are temporary, lasting only a few weeks.
However, there are reports of vascular occlusion or the development of emboli, which are the most serious
complications with fat transplantation in the face.19,20 Therefore, injecting small aliquots of fat using low
injection pressures with a blunt cannula is recommended to decrease the risk of embolization and vascular
penetration.21 This study represents the successful use of autologous fat transplantation for the treatment of
infraorbital dark circles. It is important for clinicians to differentiate the main cause of the infraorbital dark
circle before treatment and choose appropriate methods corresponding to the cause. We suggest that, in the
cases of infraorbital dark circles due to thin and translucent lower eyelid skin overlying the orbicularis oculi
muscle, autologous fat transplantation can be an effective and safe treatment option.
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