Eyes that look tired have historically been difficult to treat. The reason is that the appearance of tired eyes is caused by several factors, some of which respond to treatment and some of which do not. There are usually four components that make up the appearance of puffy and tired looking eyes.
1. Dark pigmentation of the skin under the eyes. The predisposition to this is usually genetic. Some people get it early in life and some later. Pigmentation is also affected by ethnicity. Indians, for example, are more prone to having noticeably dark pigmentation under their eyes.
Treatment options: Not a lot that can be done about dark pigmentation. Bleaching creams with hydroquinone or kojic acid sometimes help.
2. Fine lines and wrinkles throughout the lower and upper lids – “crepey” skin. This comes to most people with age. Of course, there is some genetic variability as to when and how severe the wrinkles become. These fine lines are cause by the loss of elasticity and subcutaneous fat that comes with age. The other major factor that accelerates the development of these lines is sun damage.
Treatment option: Currently, the only solution to this issue is laser treatment. The only type of laser that I have seen that actually makes any difference in under eye wrinkles is the fractionated CO2 laser. Examples of this kind of laser include the Active Fx and the Fraxel re:pair. The laser treatment is relatively quick and easy, but there is about 7 days of downtime. Results are dramatic.
3. Bulging of the skin under the eyes caused by fat tissue that is “pooching” out. Again, this is a combination of age and genetic predisposition. This effect is caused by a weakening of the membrane that usually keeps orbital fat in check. The fat tissue bulges through the membrane and into the skin of the lower eyelid.
Treatment option: This is usually a surgical issue. If there is a large amount of bulging, only blepharoplasty with fat repositioning will really help. However, if there is only a small to moderate amount of bulge, the doctor can use hyaluronic acid (Juvederm or Restylane) under the bulge to camouflage the appearance. If you raise the skin under the bulge with a filler like Juvederm, filling in the valley between the cheek and the lower eyelid, the observer no longer sees the bulge.
4. “Tear trough” under eye area indentation – this is the situation that is most common in my practice. Age and genetic predisposition cause fat loss, leading to an indentation in the “naso-jugal groove” (the area underneath the lower eyelid, above the cheek), a shadow falls into the groove and the person’s eyes appear tired. This is easily corrected with injection of a hyaluronic acid filler. I prefer Juvederm because it is smooth and lasts for over 1.5 years in that area. This is a technically difficult procedure and should be done by experienced injectors only, so if you’re thinking of having this procedure done, you should certainly find out how many the doctor has performed.
Aside from filler there lasting 3 times as long as any other area, the other unique quality to the under-eye area is that it is pretty much painless. The skin doesn’t seem to have alot of pain nerve connections.
5. Loose upper eyelid tissue that overhangs the eyelid is another element in making the eyes look tired. This is exclusively a surgical issue. A conservative surgeon should be able to take off only a small amount of skin, leaving a natural appearance. The danger in being too aggressive is that the patient will have a hollow appearance to their upper eyelid area. Future fat loss with age should be taken account of and the surgeon should err on the conservative side. A good if slightly tight result now can become a hollow, terrible result in 15 years.
These procedures have been adoopted faster than I even expected back in the day (6 years ago) when it was all getting started.
Dr. Rivkin,
