The eyes play a central role in facial expression. Over time, they often become one of the first areas to show signs of fatigue or aging. During consultations, patients frequently mention dark circles and the tear trough. Although these two terms are often confused, they correspond to distinct anatomical and aesthetic realities.
Even if they can appear simultaneously, their origins differ and involve specific pathophysiological mechanisms. A thorough morphological evaluation is therefore essential to make an accurate diagnosis and guide the choice of the most appropriate treatment.
It is crucial to establish this differential diagnosis with precision, in order to offer a tailored management plan based on a coherent, personalized, and scientifically validated approach.
The valley of tears corresponds to a linear depression that extends from the lower and inner part of the lower eyelid toward the cheekbone, following the path of the orbito-malar ligament. This deep ligament marks the transition between the lower eyelid and the cheek. When this area loses its structural support, a hollow forms, often interpreted as a sign of fatigue or sadness.
Several mechanisms can be involved: bone resorption at the infraorbital rim, atrophy of the malar fat compartment, laxity of the suspensory ligament, and alteration of the deep dermal structures (notably collagen and elastin).
The result is a pronounced shadow under the eye, not related to pigmentation but to a disruption of continuity between the eyelid and the cheek.
The dark circle manifests as an alteration of the coloration under the eye, which can occur independently of a hollow. Several types can be distinguished :
The dark circle can exist without the valley of tears, and vice versa. Their coexistence is common, but it remains essential to distinguish them clearly, as their underlying mechanisms are distinct and require specific therapeutic approaches.
The valley of tears results from a deep anatomical aging process, marked by the progressive disorganization of the support structures of the midface. This hollow forms when the malar fat descends, the suspensory ligaments retract, the infraorbital bone resorbs, or, in some young subjects, in the case of hypoplasia of the cheekbone. It is not a simple surface defect, but a true issue of volume and structure, requiring precise morphological analysis for appropriate management.
Dark circles result from a set of well-identified pathophysiological mechanisms. Three main types of dark circles can be distinguished: pigmentary, vascular, and structural. Pigmentary dark circles are due to an excess of melanin in the epidermis or dermis, frequently observed in darker skin phototypes. Vascular dark circles, on the other hand, are linked to the increased transparency of the periocular skin — particularly thin (on average 0.33 mm) — revealing the underlying venous network, often exacerbated by venous stasis. Finally, hollow dark circles are secondary to the atrophy of the suborbital fat or resorption of the lower orbital rim, physiological processes related to aging. These three components can coexist and are often influenced by aggravating factors such as lack of sleep, oxidative stress, circulatory disorders, or certain dermatological conditions (atopic dermatitis, eczema, etc.). A precise clinical evaluation is essential to adapt the therapeutic strategy.
It is entirely possible to treat the valley of tears and dark circles simultaneously, provided a reasoned, progressive approach adapted to each patient’s anatomy is adopted. When these two issues coexist — which is common in clinical practice — a combined protocol can be considered, provided anatomical priorities are strictly respected.
The first step is to correct the suborbital hollow when it is pronounced. Filling the valley of tears with hyaluronic acid often alone reduces the shadow, thus significantly diminishing the visual perception of the dark circle.
A period of two to four weeks is then recommended to allow the product to stabilize and to evaluate the result precisely. If a hollow persists despite volume restoration, additional treatment may be proposed. This could include, for example, a vascular or pigment laser, a targeted peel, or medical care aimed at improving skin quality and local microcirculation.
This progressive approach, focused on analyzing the real causes of the dark circle and hollow, helps avoid excessive corrections and ensures a harmonious, discreet, and natural result.
Many patients, sometimes for several years, try to mask or correct the valley of tears using over-the-counter cosmetic products. Anti-dark circle creams, draining serums, decongestant patches, or so-called “illuminating” treatments are used in the hope of reducing the visible hollow under the eye. This approach, often driven by enticing marketing promises, remains ineffective when it comes to a true anatomical sagging.
Contrary to a widely held belief, the valley of tears does not result from a simple lack of hydration or superficial pigmentation excess. It is a structural phenomenon, linked to the loss of support from deep tissues. Over time — or sometimes constitutionally in young patients with delicate facial features — one observes atrophy of the malar fat compartments, bone resorption at the infraorbital rim, ligament laxity, and deterioration of skin quality. These anatomical changes create a pronounced groove between the lower eyelid and the cheek, which cosmetics, by definition, cannot correct. No topical product, however sophisticated, can restore lost volume or recreate the deep architecture of the midface.
Certain cosmetic products may temporarily improve the superficial appearance of the skin: they contribute to better epidermal hydration, slightly stimulate local microcirculation, or reduce visible signs of fatigue after a short night. But these effects are superficial, transient, and have no real impact on the underlying structure. When the valley of tears is established, only targeted medical treatment can achieve a visible and lasting result.
The reference treatment remains hyaluronic acid injection, specifically formulated to restore volume in this delicate area. When performed with precision, this procedure smooths the transition between the eyelid and the cheekbone while respecting the natural proportions of the face. In some cases of very pronounced hollows, additional techniques may be necessary, such as collagen stimulation through biorevitalization or photorejuvenation.
It is therefore essential, during consultation, to clarify these issues with the patient. Many patients come with expectations largely influenced by cosmetic marketing, hoping that a simple surface treatment will correct a problem that actually involves deep anatomical structures. The physician’s role is twofold: to deconstruct these unrealistic expectations while proposing a personalized therapeutic strategy, based on a detailed analysis of morphology, tissue quality, and facial dynamics. Only a rigorous medical approach, respectful of each patient’s anatomy, can achieve a result that is natural, harmonious, and lasting.
Certain morphologies, certain phototypes, and specific genetic backgrounds are more strongly predisposed to the appearance of dark circles or the valley of tears. This individual variability justifies a personalized approach, taking into account not only anatomy but also ethnic, constitutional, and behavioral factors.
Risk profiles for dark circles :
Risk profiles for the valley of tears :
Identifying these risk profiles at the first signs allows for the implementation of an appropriate and personalized prevention strategy. It also helps optimize therapeutic management by precisely targeting the cause of the hollow: volume, bony support, or skin quality. A tailored approach, based on an analysis of the patient’s background, is essential to achieve a natural, harmonious, and lasting result.
Article written by Dr Romano Valeria
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