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 tear trough corresponds to a linear depression extending from the lower inner eyelid to the cheekbone, following the path of the orbitomalar 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 may be involved : bone resorption at the infraorbital rim, atrophy of the malar fat compartment, laxity of the suspensory ligament, and alteration of deep dermal structures (notably collagen and elastin).
The result is a pronounced shadow under the eye, not related to pigmentation but to a disruption in 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 tear trough 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 cases of underdeveloped cheekbones. It is not merely a superficial defect, but a true volumetric and structural issue, requiring precise morphological analysis for appropriate management.
Dark circles result from a set of well-identified pathophysiological mechanisms. There are mainly three types of dark circles : pigmentary, vascular, and structural. Pigmentary dark circles are due to an excess of melanin in the epidermis or dermis, frequently observed in darker 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 under-eye fat loss 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, circulation 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 tear trough 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 under-eye hollow when it is pronounced. Tear trough filling with hyaluronic acid often alone reduces the shadow, significantly diminishing the visual perception of dark circles.
A two- to four-week interval is then recommended to allow the product to stabilize and to precisely assess the result. If a hollow persists despite volume restoration, an additional treatment may be proposed. This could include a vascular or pigment laser, a targeted chemical peel, or medical treatments aimed at improving skin quality and local microcirculation.
This progressive approach, focused on analyzing the real causes of the dark circles and hollow, helps avoid overcorrection and ensures a harmonious, subtle, and natural result.
Many patients, sometimes over several years, try to mask or correct the tear trough using over-the-counter cosmetic products. Anti-dark circle creams, draining serums, decongesting patches, or so-called “illuminating” treatments are used in the hope of reducing the visible hollow under the eye. This approach, often driven by appealing marketing claims, is ultimately ineffective when dealing with a true anatomical sagging.
Contrary to a widely held belief, the tear trough does not result from simple dehydration or superficial pigmentation. It is a structural phenomenon, linked to the loss of support in the deep tissues. Over time — or sometimes constitutionally in young patients with thin faces — there is atrophy of the malar fat compartments, resorption of 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 can temporarily improve the superficial appearance of the skin: they enhance 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 a tear trough is established, only targeted medical intervention 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 precisely, this procedure smooths the transition between the eyelid and the cheekbone while respecting the natural proportions of the face. In cases of very pronounced hollows, it may be necessary to combine other techniques, such as collagen stimulation through biorevitalization or photorejuvenation.
It is therefore essential during consultation to clarify these points with the patient. Many patients come with expectations heavily influenced by cosmetic marketing, hoping that a simple surface treatment will correct an issue that actually involves deep anatomical structures. The physician’s role is twofold: to dismantle 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, respecting each patient’s unique anatomy, can achieve a result that is natural, harmonious, and durable.
Certain facial morphologies, phototypes, and genetic backgrounds predispose individuals more strongly to the appearance of dark circles or the tear trough. 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 tear trough :
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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