Dark Hollows / Circles (Tear Trough Deformity) 

Dark hollows or circles can develop below the eyes as we get older. This can result in an undesirable tired appearance. This is particularly noticeable in certain types of lighting when more of a shadow may be cast over the tear trough area and so exacerbating the dark hollow appearance. Also known as tear trough deformities, these dark circles and hollows become noticeable due to the following changes:

  • Puffy bags can appear in the lower eyelids (lower eyebags) due to fat prolapsed. The area of the tear trough immediately below looks hollower relative to this puffy area.
  • Loss of soft tissue volume in the area of the lower bony rim of the eye socket. This leaves a thin layer of skin through which the dark colour of the muscle can be seen.
  • The cheek fat descends as we age to exacerbate the tear trough deformity
  • The skin in the tear trough area becomes more pigmented so looks darker

This young woman has had dark hollows below her eyes.

These give an undesirable tired look to her eyes even though she feels rested and alert.

Dark hallows under eyes


Some people with significant lower eyelid bags may be more suitable for cosmetic eyelid surgery (blepharoplasty). However many others may be more suitable for non-surgical improvement with Tear Trough Rejuvenation using Restylane

Restylane is a very safe plant-derived injectable gel made from Hyaluronic Acid (HA). HA is a substance we all have in abundance in our bodies.For example, the back of our eyes, the vitreous cavity, is filled with HA.

The use of HA fillers also has the advantage of reversibility. If there is some over-filling or lumpiness in the treated area that persists then this can be reversed by dissolving the HA gel away with an injection of hyaluronidase.

Tear trough rejuvenation is a much less invasive treatment than cosmetic surgery usually with minimal downtime. 

The introduction of the blunt-tipped reinforced PixL cannula to treat the tear trough hollows has made this treatment even safer with less swelling and discomfort and faster recovery time.The improvements last between 6 and 18 months. (average 12 months). After this period the treatment can be repeated.

Some people will benefit from a combination of HA filler to the tear trough and the cheek to address any co-existing volume loss in the cheek. A thicker gel is usually used in the cheek area (SubQ or Juvederm Voluma).

Tear Trough Rejuvenation Steps 

Step 1: Anaesthesia

This is an outpatient treatment that is very well tolerated using minimal anaesthesia.

Topical anaesthetic cream can numb the lower eyelid skin in 10-20 minutes prior to treatment.

A very small local anaesthetic injection is given under the skin at the entry site for the reinforced PixL cannula (Mr Ataullah uses this fine blunt-tipped tube in preference to a needle when treating hollows around the eyes).

Restylane filler also has some anaesthetic mixed in so this further numbs the area being treated.

Step 2: The Procedure

Tear trough rejuvenation has for several years been performed using a fine needle to deliver the HA filler beneath the skin and muscle in the tear trough area. This has proved a very effective method in improving the appearance but is inevitably associated with some risk of bleeding / bruising and a tiny risk of needle injury to the tear ducts and eyeball.

Mr Ataullah now performs tear trough rejuvenation using a specially designed blunt-tipped cannula  (the reinforced PixL cannula).

The reinforced PixL cannula has the advantage of minimising injury to blood vessels (so reducing risk of bleeding / bruising) and minimising the risk of injecting the gel into a blood vessel. The cannula can deliver the gel in the form of thin fine threads  and so reduce the risk of a lumpy appearance.

One or two cannula entry sites are marked on the outer part of the lower eyelid /cheek junction and outer corner of the eyelids. A tiny entry hole is made through the skin and the cannula introduced through this to enter the space between the muscle and the lower bony rim of the eye socket.

Multiple fine threads of Restylane are delivered to the tear trough area and the area is moulded to ensure a smooth contour and even correction of the tear trough deformity.

The improvements are instant with usually only a mild degree of swelling or bruising that settles after a few days.

Step 3: Post-Treatment care

It is important to avoid pressure on the treated areas overnight so the gel does not get inadvertently displaced.  Avoid rubbing the eyes for 2-3 days. You should rest semi-upright with cushions by your side to prevent you sleeping on the side or the front of your face for the first night following treatment.

Avoid heavy straining and vigorous exercise for 2-3 days.

Cool packs can help minimise any bruising and swelling.

You can also apply some moisturiser (e.g.Auriderm XO which also contains some agents to reduce bruising) and if you do notice some slight lumpiness then this can be gently massaged to remould the gel to further smooth the appearance in the first 2-3 days after treatment.

Repeat Treatments / Top-up treatments

When treating the tear trough I aim to achieve a good symmetrical result from the first treatment. However I prefer to be conservative to avoid an unnatural-looking overfill or puffy appearance to the eyes.

Any mild bruising or swelling may take a 2-3 weeks to settle. After this period if you are aware of a residual hollow which may benefit from further treatment then I would be happy to see you with a view to performing a top-up treatment.

With conservative treatment and the use of the reinforced PixL cannula it is very uncommon to have an excessively swollen or lumpy appearance that persists despite massage for 2-3 weeks. However if this is the case then I may need to dissolve this with a hyaluronidase injection to the area.

Risks and Complications

In the hands of an experienced oculoplastic surgeon you are highly unlikely to experience any serious complication following tear trough Restylane treatment. Most problems are amenable to further treatment if need be.

  • Infection – very rare
  • Bruising and swelling of eyelids – this usually settles after a few days
  • Contour irregularities – these can settle with massage but can be corrected if persistent by top-up Restylane treatment or dissolving the gel with hyaluronidase if need be
  • Tenderness
  • A localized allergic reaction in the form of firm swelling at the injection site. This is very rare and has been seen in approx 1:10,000 patients, and may occur a few days up to several weeks after the injection. It can last a few weeks or up to several months in rare instances
  • Prolonged firmness, abscess, formation, scarring, or a grey discolouration may occur in less than 1:15,000 cases, lasting several months
  • Damage to the eye or eyesight including blindness from this procedure is an extremely remote risk in the hands of an experienced oculoplastic surgeon. All precautions are taken to minimize such a risk. The use of the blunt-tipped PixL cannula reduces this risk further because the cannula is likely to push a vessel or structure to one side rather than puncture it
  • Blue discolouration over the injections can occur in some patients – this may occur in people with very thin eyelid tissues or if the Restylane is too superficial in it’s location. If it persists then the gel may need to be dissolved with hyaluronidase
  • Further treatment – top-up Restylane treatment may be needed after 2-3 weeks

Tear Trough Rejuvenation

Tear Trough Rejuvenation before


Tired appearance due to dark hollow circles below eyes

Tear Trough Rejuvenation after


1 week following Tear Trough treatment using Restylane with the PixL cannula

Your consultation

The success and safety of your eyelid surgery procedure depends very much on your complete candidness during your cosmetic eyelid surgery consultation. You'll be asked a number of questions about your health, desires and lifestyle.

Please be prepared to discuss:

  • Why you want the surgery, your expectations and desired outcome
  • Medical conditions, drug allergies and previous medical treatments
  • Use of current medications, vitamins, herbal supplements, alcohol & tobacco
  • Previous surgeries

The following will also take place at your consultation

  • Evaluation of your general health and any pre-existing health conditions or risk factors
  • An assessment of your vision and a thorough eye examination including a slit-lamp examination of the eye.
  • Photographs for your medical record
  • A discussion about treatment options
  • Recommendations for treatment most appropriate for you
  • Discussion about likely outcomes of eyelid surgery and risks or potential complications
  • The type of anaesthesia that will be used (This is usually “Twilight anaesthesia” using local anaesthesia with intravenous sedation administered by a consultant anaesthetist. However, a full general anaesthetic can be arranged if you prefer this option)

After the consultation I will send you a letter summarising your concerns and desires relating to your appearance along with my assessment and advice to you regarding treatment options.

You will also receive a quote for your proposed surgery and have the opportunity to attend for a further consultation prior to proceeding should you wish to ask any further questions.

Arrange a consultation