Dark Circles Under Eyes: 5 deep tear trough treatments

We’ve talked before about dark circles under eyes. One of the most common causes is a deep tear trough.  The tear trough is that depression extending from the inner corner of your eye diagonally toward your cheek.  This depression occurs where the facial fat has thinned out and dropped down into the cheeks. The bone of the eye socket is now right below the skin and the two are fairly well attached to each other.  As the skin above and below age and change, this area becomes even more apparent. It can become dark and develop a noticeable shadow, which makes one appear tired and more aged.  There are many options to treat this, and the methods are changing as we better understand facial aging.

dark circles under eyes - Facial filler Juverderm

Juvederm treatment under eyes and around mouth.

1. Make-up:

Many women (and even some men) utilize concealer in this area to lighten the skin and diminish the shadow.  When the problem is subtle, make-up is a great, non-invasive and inexpensive treatment.  As the problem worsens, however, make-up cannot fully hide the changes and may begin to accentuate it.

2. Skin lightening creams:

In certain people and ethnic groups, the skin in this area darkens. This can be due to actual pigment changes in the skin or from very shallow blood vessels just below the thin skin. When it is pigment related, skin lightening creams, such as hydroquinone, can be effective.  When starting this type of treatment, it is helpful to consult a skin specialist or aesthetician highly experienced in its use. Start with a weaker concentration (no higher than 4%) and use it for a short time until you are sure you aren’t especially sensitive.  Slowly increase the use and concentration until the desired effect is achieved. Rarely will these types of creams completely fix the problem, but they can make a noticeable improvement.

dark circles under eyes - Hydroquinone skin cream

Hydroquinone skin cream

3. Phototherapy:

Intense pulsed light, and even some laser treatments, are used to lighten skin pigmentation and tighten skin in the under eye area. Often this is proceeded by use of a topical lightening cream and possibly a short course of Retin-A to maximize effect.  Again, this should be done by someone with a lot of experience in administering the whole treatment.  Different skin types react differently, so be sure your practitioner explains how they are tailoring your treatment to you personally.

4. Facial Filler:

Hyaluronic acid fillers such as Juvederm, Belotero, and Restylane are well suited to treating the tear trough area when the problem is loss of facial fat volume.  Filling this area back up with a substance that is similar to the building blocks of normal collagen can give a new youthful appearance to the mid-face. It is relatively inexpensive, costing around $500 for a treatment. In many cases it lasts 12-18 months.  Filler is injected with a small needle into the space directly above the bone and then massage around until it appears smooth.  In a few weeks, it softens up be hardly be felt.  It is a safe procedure with some occasional bruising taking place. When injected deep, the chances of it getting into a blood vessel and causing problems in uncommon, although this is the greatest risk. See Dr. Harris explain more about facial filler in a short video here.

dark circles under eyes - Belotero facial filler

Belotero facial filler

5. Lower eyelid fat repositioning and blepharoplasty:

When fat in the lower eye socket begins to come forward, it creates a bag in the lower eyelid. A crease forms at the bottom of the bag over the bone of the eye socket. Lower eyelid surgery (blepharoplasty) is performed to move fat from this bag into the upper cheek and tear trough, which fills in the depression and returns the fat to a normal location, where it was before it descended into the cheek.  In some people, a portion of the fat is also removed. In others we also remove a small amount of skin below the eyelashes. All of these techniques serve to smooth out the transition from the eyelid to the cheek, which is a hallmark of a youthful, rested appearance. See our gallery for eyelid before and after photos.

If under eye shadow or bags are a problem for you, give us a call for a free consultation at (801)264-4420, or email Dr. Harris directly at [email protected].

Think about the first image that crosses your mind when you hear the word Botox or facial filler. It is likely one of a plastic, frozen faced woman with evidence of one too many facial plastic surgery procedures, unnatural facial proportions, oversized lips and unnaturally tight skin.  These are the extremes that websites and the media have convinced us are common place.  For this reason, many of my patients are hesitant or scared about using these products as they don’t want that unnatural look.  But they are still in my office asking about what can be done.  So where is the happy medium?  Reverse aging changes in a way that doesn’t appear artificial.  Herein lies the art of facial plastic surgery.  Artfully using these medications can yield great improvements in facial appearance.  Misuse or overuse can do the opposite at great cost to you.

The key to Botox/Dysport is putting the right amount in the right place.  That seems intuitive, but results can vary greatly by the technique used and experience of the injector.  Botox is popular because it works and most people who are happy with their Botox treatment get a nice flattening of the lines between the brows, on the forehead and in the crow’s feet.  When improperly placed, brows drop or have a “Spock” appearance, lower eyelids can sag, and the face may look too inanimate to be real.  To get a natural effect, first start with an experienced injector, one that will study your facial expression and target the problem muscles, rather than just injecting in a standard pattern.  Then, expect to be invited back after the first week to ensure the proper result was attained.  Sometimes, I feel I’ve given my patients enough to relax the forehead evenly, but after a week I need to add a few more units to the outer forehead muscles.  This allows me to better map out the face and subsequent injections will be on target.  Where a few get into trouble is wanting to eliminate every facial wrinkle with Botox and convincing someone to inject them.  Your face needs expression, which is an underappreciated part of facial beauty.  An appropriate dose of Botox will allow for this movement and still soften the telltale signs of aging.  If your doctor takes his/her time and follows up, your results should end up exceeding your expectations.

In like fashion, the key to good filler is the right filler, in the right amount, in the right place.  Again, that seems intuitive, but many people get into trouble when they want either the wrong type of filler or too much filler placed.  An experienced injector will have a preference for certain brands and types of fillers in different areas of the face.  This is usually based on their experience and results. It is in your best interest to let the injector direct you on what filler they want to use.  If you have a strong preference, seek out a person who specifically advertises using that brand.  With regard to the amount of filler placed, many people think more is better.  This is where the unnatural appearance is most likely to enter the picture.  Overinflated lips, cheeks and tear troughs are dead giveaways that work has been done.  My advice is start slow and add as necessary. Fillers all come by the vial.  An injector can inject part or all of the vial and save the rest for a few days until the initial swelling has resolved.  This allows a metered approach and can give you a maximum improvement without overdoing it.  The flip side to this comes when patients expect a maximum improvement at a minimal cost.  Often two to three (or more) vials are necessary to get a significant improvement, especially in the smile lines and cheeks.  With one vial retailing for around $500-600, many people aren’t willing to spend that much on a non-permanent procedure.  This is where you need to have a frank discussion with your injector about what result you can expect and whether you’d be better off saving for a surgical procedure or maximizing other less invasive treatments.  Having appropriate expectations is key to your satisfaction.


Facial aging takes a toll on our lower face as skin thins, fat atrophies and descends, and wrinkles form. Three common problems people come in for are deep nasolabial folds (the crease from your nose to the edge of your mouth), vertical lip lines (sometimes called smoker’s lines, but not exclusive to smokers), and small or fading lips. All of these changes are tell-tale signs of aging, but there are products available that do a great job of reducing their appearance. Let’s look at each one.

Nasolabial folds:

nasolabial folds

Nasolabial folds (arrow)

These folds are present in everyone who ever smiled, but as your facial skin becomes less elastic and facial fat shrinks away, the cheeks descend and form permanent nasolabial folds. These can be accentuated by significant weight loss, sleeping on your side, and skin damage due to tanning. Preventing them is ideal, but aside from using sunscreen, which won’t guarantee they’ll stay away, you can’t do much to avoid them. There are three main ways they are treated. 1) facial fillers such as Juvederm, Restylane and Radiesse are used to fill in the lines, restoring some of the lost volume. These can be injected both directly beneath the crease, but also into the cheeks above creating some minor lifting. In both instances, dramatic reduction of the lines can result. With most of these products, some improvement from baseline can be seen for about a year (more or less varying by individual). There are some risks, such as rare severe reactions to the fillers as well as over-placement of product. Restylane and Juvederm can be dissolved in place with a second injection, but Radiesse has to be expressed or surgically removed. All will fade with time if left in place.

Radiesse to the nasolabial folds

Nasolabial folds and mental crease (chin line) treated with Radiesse.

Vertical lip lines:

vertical lip lines

Vertical lip lines

Loss of fat around the mouth along with facial movements can lead to formation of vertical lip lines. Many people find these objectionable because they are associated with smoking and they make the person appear tired or unhappy.  Other than using sunscreen and not using your lips, you can’t do much to avoid them.  Four different treatments are commonly utilized.  Botox can be injected in small amount in several places along the lips to relax the muscles causing the lines.  This can, however, cause your mouth to move differently and look irregular when you smile.  Fillers, most commonly the hyaluronic acid varieties such as Juvederm and Restylane, can be injected in various patterns to soften the lines’ appearance.  Some people also inject collagen, but this tends to last for a much shorter time. Laser skin resurfacing has also been shown to improve the appearance of these lines.  Finally, dermabrasion, which is essentially sanding down the skin to remove the wrinkle, can be done.  I prefer the injectable fillers as they are not permanent, can be reversed if too heavy handed, are very unlikely to cause inadvertent scarring, and won’t generally affect your mouth movements.


Fading (flat) lips:

Progressive addition of Juvederm to the lips

Thin lips with progressive addition of Juvederm for volume

Lip fullness can be something you lose with time, or something you just never had. The ideal proportion of the female lips are about 40/60, or if you look straight at the total height of the upper and lower lips closed, the upper lip should be 40% and the lower lip 60% of the height. Most commonly, the upper lip is more flat or rolls in and under as we age, making it appear thin. To regain that ideal shape, you must replace volume. Similar to above, dermal fillers work very well for this. They are injected along the vermillion border (junction of normal skin and pink lip skin) near the central portion of the lip, as well as within the body of the pink tissue of the lip. The outer edges near the corners of the mouth are avoided to prevent that fish mouth appearance. Maintaining the proper proportions and being conservative with volume changes will make the lips appear full and youthful, not inflated.

Call our office at (801)264-4420 for a consultation to discuss dermal fillers and your options.