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“Can you fix my dark circles?”
That sounds like a simple question.
It usually isn't.
The area under the eyes can look dark because of bags, hollows, pigment, visible blood vessels, thin skin, loose skin, swelling or shadows.
Often it is more than one of these at the same time.
That is why there are so many treatments for the under-eye area.
It is also why there is no single gold-standard treatment for dark circles.
Before deciding on filler, laser, PRP, skincare or surgery, the first job is to figure out what is actually creating the problem. Current reviews consistently describe under-eye concerns as multifactorial and emphasize matching treatment to the underlying anatomy.
At FORM Face + Body, that assessment matters more to me than the treatment menu.
Patients use these terms interchangeably.
I don't.
A true lower-eyelid bag is usually caused by orbital fat pushing forward.
There are normal fat compartments behind the lower eyelid. As the tissues supporting them change with age and genetics, those fat pads can become more visible.
The result is a bulge.
That bulge can cast a shadow underneath it, making the area look darker even when there is very little actual pigmentation.
That is an important distinction.
If the darkness is caused by a shadow from a bag, a pigment cream is unlikely to solve it.
The tear trough is the groove running from the inner corner of the eye downward and outward toward the cheek.
Some people have it when they are young.
In others it becomes more obvious with age.
The hollow may become deeper because of changes in bone support, fat distribution, the ligamentous attachments beneath the eye and the relationship between the lower eyelid and cheek.
Again, the hollow itself creates a shadow.
That shadow may look like a dark circle.
But adding a bleaching cream to a shadow does very little.
True darkness can come from several different sources.
Some people have genuine brown pigmentation in the skin.
Others have thin lower-eyelid skin that allows the underlying muscle and blood vessels to show through, creating more of a blue, purple or reddish colour.
Inflammation can also play a role.
People with eczema, allergies or chronic eye rubbing can develop more pigmentation around the eyes.
And many people have a mixture of pigment, blood vessels and structural shadowing.
This is one reason under-eye darkness is frustrating to treat.
The literature recognizes pigmentary, vascular, structural and mixed forms of periorbital dark circles.
This is another important distinction.
A festoons or malar bag sits lower than a typical lower-eyelid bag, usually over the cheekbone.
These can involve a combination of lax skin, muscle, fluid and altered lymphatic drainage.
They can fluctuate.
Some patients notice they are worse in the morning, after alcohol, after salty food or during allergy season.
Festoons are among the more difficult problems in the under-eye region.
And filler can sometimes make them worse.
If someone already has a tendency toward lower-eyelid or cheek edema, adding a water-attracting hyaluronic acid filler into that area needs to be considered very carefully.
Before recommending anything, I want to know whether the dominant problem is:
a bulging fat pad,
a tear-trough hollow,
true pigmentation,
visible vessels through thin skin,
crepey or loose skin,
lower-eyelid laxity,
midface descent,
fluid retention or festoons,
or some combination of these.
We also assess eyelid position, skin quality, cheek support and whether there are symptoms such as dry eye.
Sometimes I can improve a patient's “dark circles” dramatically by correcting a structural shadow.
Other times the anatomy looks excellent and the main problem is true pigmentation.
Those are completely different patients.
Because none of them works for everybody.
This is the part patients don't always hear.
If there were one reliable treatment that erased under-eye darkness in every patient, the market would not contain dozens of creams, lasers, fillers, peels, PRP treatments, polynucleotides and surgical techniques.
A systematic review of 39 studies found potential benefit from fillers, fat grafting, surgery, topical agents, chemical peels, lasers and PRP.
But the authors also emphasized that the quality of evidence was limited and that treatment needed to match the cause.
That is the important part.
The number of available treatments reflects how difficult the problem is, not how easy it is to solve.
Hyaluronic acid filler can be very effective when the dominant problem is a true tear-trough hollow.
The goal is to reduce the depression between the eyelid and cheek and therefore soften the shadow.
A 2024 systematic review and meta-analysis including 31 studies and more than 2,500 patients found an overall satisfaction rate of about 91% after tear-trough filler.
That sounds excellent.
But patient selection is everything.
Filler is not a good treatment for every dark circle.
It does not remove a fat bag.
It does not reliably erase brown pigment.
It does not tighten loose skin.
And it may be a poor choice in someone prone to lower-eyelid swelling.
It is also very much dependent on the anatomic relationship between your cheek and undereyes, as sometimes we need to treat the cheek to make the undereyes look less hollow.
The under-eye area is unforgiving.
The skin is thin.
Small contour irregularities can be visible.
Filler can attract water.
In the same 2024 meta-analysis, swelling occurred in about 19% of patients and bruising in about 18%. Contour irregularities or lumps occurred in roughly 5%, while blue-grey discoloration, sometimes called the Tyndall effect, was less common.
Delayed swelling can also occur months or sometimes longer after injection.
More recent reviews describe persistent edema, contour irregularities, discoloration and migration as recognized complications.
And, although rare, filler injection anywhere around the central face and periocular region carries the potential for a serious vascular complication, including vision loss.
That is why I do not think tear-trough filler should be treated like a casual injection.
Yes.
This is particularly true when filler is put into someone who did not need volume in the first place.
A patient may have a bag above and a hollow below.
Adding filler to the hollow can sometimes camouflage that transition beautifully.
But if too much filler is added, the entire lower eyelid can begin to look heavy or swollen.
In patients with festoons or fluid retention, it can amplify the problem.
This is why I am generally conservative with under-eye filler.
The goal should not be to eliminate every natural contour.
When the main problem is true lower-eyelid fat prolapse, surgery becomes much more logical.
Lower blepharoplasty can be performed through an incision inside the eyelid, called a transconjunctival approach, or through an external incision just beneath the lashes when skin treatment is also required.
Modern lower blepharoplasty has moved away from simply removing large amounts of fat.
Why?
Because aggressively removing fat can trade a bag for a hollow.
Contemporary techniques often preserve or reposition orbital fat to create a smoother transition between the lower eyelid and cheek. Reviews of modern lower-eyelid surgery describe fat prolapse, tear-trough hollowing, excess skin and midface changes as interconnected parts of lower-eyelid aging.
For some patients, fat is repositioned into the tear trough.
For others, selective fat removal may still be appropriate.
Fat grafting can also be used.
There isn't one lower blepharoplasty operation that fits every face.
Sometimes.
But again, only if the darkness is mainly structural.
If a bag creates a shadow, removing or repositioning the bag can improve the darkness.
If a deep tear trough creates a shadow, fat repositioning or grafting may improve it.
But if the lower eyelid is brown because of pigment, surgery does not remove that pigment.
If the skin looks purple because underlying blood vessels are visible through very thin skin, surgery may improve the contour without completely changing the colour.
This is one of the most important expectations to establish before lower-eyelid surgery.
Lower blepharoplasty treats anatomy. It is not a bleaching treatment.
Modern lower-eyelid surgery can produce meaningful improvements, but it is more complex than upper blepharoplasty.
A 2024 systematic review of more than 4,600 patients undergoing fat grafting or fat repositioning for lower-eyelid bags and tear-trough deformity found an overall complication rate of approximately 11%, with contour concerns, swelling, bruising and reoperation among the issues reported.
A more recent review found that both transconjunctival and transcutaneous approaches can be used effectively, while also emphasizing that the literature still lacks enough high-quality comparative evidence to identify one universally superior technique.
That reinforces the theme of this entire area:
there is no single procedure for every under-eye problem.
This is one of the harder groups.
If the colour is truly brown, we can consider pigment-directed treatments.
Depending on skin type and cause, these may include topical retinoids, hydroquinone, azelaic acid, kojic acid, chemical peels or pigment-targeting lasers.
But the evidence is far less robust than the marketing around “dark circle treatments” might suggest.
The major systematic review of periorbital hyperpigmentation found that topicals and chemical peels can help pigment-based dark circles and lasers can provide mild-to-moderate benefit in selected pigmentary and vascular cases. However, the authors emphasized the lack of high-quality trials.
This is particularly important in darker skin types, where aggressive pigment treatment can itself trigger post-inflammatory hyperpigmentation. A 2024 systematic review specifically examined treatments in Fitzpatrick IV–VI skin because safety and pigment response cannot simply be extrapolated from lighter skin.
Laser can be useful when the lower eyelid has fine lines, crepey skin or sun damage.
Fractional resurfacing can improve texture and stimulate dermal remodelling.
But resurfacing cannot remove a fat bag.
And if darkness is mainly due to a deep hollow, improving the skin will not eliminate the shadow.
Again, the treatment should match the problem.
Sometimes we combine lower-eyelid surgery with carefully selected resurfacing because one improves structure while the other improves skin quality.
That can be much more effective than asking one treatment to do both jobs.
Sometimes.
Pigment-specific lasers and some vascular lasers can improve selected forms of periorbital darkness.
A systematic review of laser treatment found generally favourable results across small studies, but protocols varied and follow-up was limited.
This is not a treatment where I would promise complete clearance.
The lower eyelid is thin, delicate skin.
The more aggressively you chase pigment, the more you also need to think about irritation, prolonged redness and post-inflammatory pigment change.
PRP and platelet-rich fibrin are frequently marketed for dark circles.
The theory is that growth factors may improve skin quality and dermal thickness.
The clinical evidence is much less dramatic.
A 2026 systematic review of 26 studies found high patient satisfaction overall, but PRP and PRF were only moderately effective for periorbital hyperpigmentation, while objective improvements in wrinkles and texture were mixed.
That is a useful example of the difference between:
“biologically interesting”
and
“reliably fixes dark circles.”
They are not the same thing.
These have become extremely popular.
Early data are interesting, particularly around skin hydration and quality.
But compared with established treatments, the evidence for treating true under-eye darkness is still limited.
I would not currently describe them as a gold-standard treatment for dark circles.
They may become useful adjuncts.
That is different from proving that they solve the underlying problem.
Sometimes it can improve them.
Usually it does not erase them.
If pigmentation is part of the problem, sunscreen matters.
If eczema or irritation is contributing, treating that inflammation and stopping chronic rubbing matters.
Retinoids may improve fine lines and skin quality in appropriately selected patients.
But no eye cream can surgically remove prolapsed orbital fat.
And no moisturizer can fill a significant tear trough.
This is another area where expectations matter.
There isn't one.
And I think that is the most important message of this entire article.
If the problem is a hollow, carefully selected filler or fat may help.
If it is a bag, lower blepharoplasty may be the more definitive treatment.
If it is excess skin, surgery or resurfacing may be appropriate depending on severity.
If it is pigment, pigment-directed skincare, peels or selected lasers may help.
If it is vascular, selected laser treatments may improve it.
If it is festoons or edema, that is a different and often more difficult problem again.
And if you have three of these problems at once, you may need more than one treatment.
At FORM Face + Body in Toronto, the consultation starts by asking a deceptively simple question:
Why does the area look dark?
I want to see what happens to the shadow when we change the lighting.
I want to see whether there is a true bag.
I look at the tear trough, cheek support, skin thickness, pigment, veins, laxity and whether there is swelling.
I also want to know whether someone has already had filler, because old filler can change the anatomy we are looking at.
Then we decide what actually needs treatment.
Sometimes the right answer is a small amount of hyaluronic acid filler.
Sometimes it is laser resurfacing.
Sometimes it is skincare.
Sometimes it is lower blepharoplasty with fat repositioning or fat grafting.
And sometimes the most important thing I can tell the patient is:
There is no treatment that is likely to completely eliminate the darkness you are seeing.
I would rather set that expectation before treatment than sell five different procedures trying to chase a problem that does not have a predictable solution.
Under-eye bags, hollows and dark circles are not the same thing.
They just happen to live in the same neighbourhood.
That is why diagnosis matters so much.
The best treatment is not the newest injectable, the most expensive laser or the procedure that happens to be popular on social media.
It is the treatment that matches the actual cause.
And when it comes to true under-eye darkness, patients deserve a little skepticism.
There are a lot of available treatments because none of them works perfectly for everyone.
That is not a failure of aesthetic medicine.
It is a reflection of complicated anatomy.
Treat the bag as a bag. Treat the hollow as a hollow. Treat pigment as pigment. And don't expect one treatment to solve three different problems.
Treatment around the eyes can involve risks including bruising, swelling, pigment change, contour irregularity, dry-eye symptoms, eyelid malposition and, with filler, rare but serious vascular complications. Individual assessment is required before treatment. This article is educational and is not a substitute for personal medical advice.
