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intensity of hyperpigmentation, the severity of the nasal fat pad prolapse and the degree of rhytidosis (or myocutaneous laxity) of the eyelid as well the amount of fluid retention or oedema.7,8
Tear trough deformity Tear trough deformity may be classified as follows:12,13
Managing Dark Circles in SOC Dr Stephen Humble discusses the aetiology and management of dark circles in skin of colour patients In aesthetic medicine, dark circles under the eyes are a common concern across all ethnicities, but they may be particularly prominent in the setting of skin of colour due to higher concentrations of melanin.1 Regardless of the Fitzpatrick scale,2 before determining the best way to manage dark circles under the eyes, it is always useful to assess what the specific contributing factors are. Specifically, within the setting of skin of colour (SOC), the universal causes of dark circles must be considered, such as tear trough deformity; however, the approach to treatment may be modified appropriately. For instance, higher baseline concentrations of melanin may significantly accentuate underlying hollowness and hyperpigmentation can cause dark circles even in the absence of tear trough hollowing, especially in SOC.1,3-6
Anatomy Perhaps the first thing to consider in dark circles is the underlying anatomy around the eye, including the nasojugal fold.1 The orbicularis oculi muscle and the levator palpebrae superioris control the opening and closing of the eyelid.7 The tear trough is a triangular depression below the lower
eyelid and within the orbicularis oculi muscle that runs diagonally from the medial canthus to the mid-pupillary line.7,8 It is comprised of a superficial and deep plane and is supported inferiorly by the orbicularis retaining ligament.8,9 The anatomical predisposition to the development of tear trough deformity is not known to be significantly different between differing ethnicities.8,10 However, the overlying skin varies significantly with regards to its thickness and its melanin concentration, and this can magnify the prominence of the tear trough deformity disproportionately.1,4 The angular artery is the most important vascular structure to consider (although there are others) and it emerges below the orbicularis oculi muscle to travel along the inner canthus of the eye, it is accompanied by the angular vein.7,8,11 The potentially catastrophic risk of intravascular injection to vision must be minimised by careful technique, aspiration and arguably the blunt cannula technique.11 The infraorbital nerve emerges from the infraorbital foramen inferior to the orbital rim within the mid-pupillary line.7 Dark circles under the eye area may be evaluated more generally by assessing the depth of the tear trough deformity, the
• Class I: Volume loss limited medially to the tear trough. May have mild flattening extending to the central cheek area. No bulging orbital fat • Class II: Volume loss in the lateral orbital area and the medial orbit, may have moderate volume deficiency and flattening of the middle and upper cheek. Mild to moderate orbital fat bulging • Class III: Full depression circumferentially along the orbital rim, from medial to lateral. Severe orbital fat bulging Tear trough deformity may be treated effectively with hyaluronic acid (HA) filler particularly well in Class I patients and may be improved in Class II patients, however HA filler will not improve orbicularis oculi hypertrophy, pigmentation, myocutaneous laxity or oedema.7 Patient selection is of vital importance as the most severe cases may not respond well to treatment with HA fillers and more invasive surgical techniques are indicated such as blepharoplasty or fat grafting.5,8,12,14 There are two main approaches for the administration of HA filler to the tear trough area: performance is with either a needle or a cannula.7 There is no proven advantage of one technique over the other for any given skin type, but my personal preference is for the cannula technique due to its better safety profile and less risk of bruising, which may appear particularly dark in SOC patients.
Hyperpigmentation Hyperpigmentation may be more prevalent and more noticeable in patients with SOC due to a number of exogenous and endogenous factors.1,3-6 Naturally, darker skin tones Fitzpatrick2 IV-VI tend not to experience sunburn and as such, especially during childhood, may not have necessarily had a natural prompt to wear SPF.3 Many people with SOC have connections with hot countries and may have spent time living in or visiting regularly, thus increasing their cumulative exposure to UV light, which is one if the principle exogenous causes of hyperpigmentation.4,5,15
Reproduced from Aesthetics | Volume 8/Issue 11 - October 2021
