Another look

The ring

Nicolas BRAULT, MD

Dr Nicolas Braud

What is the ring ? Anatomical and clinical definition

The ring corresponds to the dark jugo-palpebral or palpebrae-malar furrow delimiting the lower eyelid above and the malar region below.  Anatomically, it reflects the attachment of osteocutaneous ligaments (orbicularis retaining ligament) between the periosteum of the orbit and the skin-orbicular muscle complex. Two different clinical entities can be distinguished for the ring, the hollow ring and the colored ring. These two components can be associated to varying degrees.

  1. A hollow ring corresponds to a loss of volume of the jugo-palpebral sulcus which becomes deeper. This groove is due to a melting of the support tissue, the subcutaneous fat of the malar region. This delineation is accentuated with aging by the protrusion of "fat pockets" or lipoptosis, secondary to the relaxation of the orbital septum. The transparency of the skin associated with the melting of the tissues reveals the bony reliefs. We speak of skeletonization of the eyes.
  2. A colored ring also results from the thinness of the skin with a transparency effect. One can then guess the volumes located between the bone and the skin, which can cause different colorations. A bluish hue corresponds to the venous reflections and the slightly purplish orbicular muscle. A shade of red corresponds to the arterioles and dermal micro-capillaries, especially at the internal angle. A brownish-black hue corresponds to melanin deposits in the pigment cells of the skin. The more active the melanocytes, the more easily the coloring appears, which is the case with ethnic skins and darker phototypes.
  3. ClinicallyThe result is a furrow that is more or less deep and darker, profoundly altering the aesthetics of the eyes by darkening them. It also significantly modifies the expression of a face, giving it a permanently tired or severe look.

What are the different possible treatments for dark circles?

1/Treatment of the hollow ring : il consists in giving back the lost volumes, with a natural filling product such as fat (lipofilling) or hyaluronic acid. This correction must focus on filling the sulcus itself as well as restoring the volumes of the periorbital region.

A/ Hyaluronic acid injection is a very attractive method that can give very good results.  It is done during a medical consultation without anesthesia. The result is immediate and can last several months. However, the use of this type of product for this location is not trivial and can only be considered under certain conditions: a shallow or slightly marked ring, no pockets or fatty hernias, no contraindications to the product (autoimmune diseases, etc.), and the procedure is performed by an experienced physician using a suitable product. Otherwise, hyaluronic acid may be responsible for undesirable effects, such as the appearance of a bluish sheen (Tyndall effect), edema or granuloma.

B/ For the other cases, the surgical option seems the most interesting to avoid the complications of hyaluronic acid.

It consists of Injecting fat into the ring (micro-lipostructure or lipofilling). Lipostructure has revolutionized the treatment of dark circles and eyes. The interest in using our own tissues, our own fat, has increased in recent years with the discovery of the advantages it can have as a natural filling and rejuvenation product. Its manipulation and use require specific knowledge and skills.

The fat is removed using a fine cannula (microlipoaspiration) from one or more areas of the patient's body (abdomen, knees, etc.). The fat is meticulously treated through a sieve (rinsed, cleaned, defibrosed) to eliminate any connective tissue that could promote the formation of granuloma. (Video 1).
The transfer of fat is then done in a millimetric way through a microcannula to fill the ring and restore volume to the entire periorbital region. (Video 2).

The final results are very natural (figure 1. and 2.)

Fat grafting is a perfectly logical and appropriate response to the mechanism responsible for the hollowing and melting of fat in the lower eyelid.

Figure 1. 6-month result of microlipostructure treatment of hollow circles. Figure 2. 1-year result of microlipostructure treatment of hollow circles.
Figure 2. 1-year outcome of hollow ring treatment with microlipostructure.

2/ The treatment of dark circles:

They are treated by a recent method: the nano-lipostructure or nano-lipofilling, an injection of stem cells and growth factors from the patient's own fat to mask the staining. Nano-lipofilling is a technique derived from the lipofilling.

Nano-lipofilling is a technique derived from the lipofilling.

Video 3. Preparation of fat to obtain nanofat.

The defibrosed fat is passed through several sieves in order to extract a fraction rich in stem cells and growth factors favorable to skin tissue regeneration.

Video 4. Re-injection of the nanofat subcutaneously into the eye area. The compound obtained is injected into the area to be treated.

Within a few weeks, the topping thickens the dermis and creates a layer between the thin skin of the eyelids and the capillaries underneath. The transparency effect disappears and the shade of the dark circles fades significantly. It is the only effective technique for treating colored or pigmented rings.

Figure 3.6-month result of a colored ring treatment by nanolipofilling
Figure 4.2-year outcome of colored ring treatment by nanolipofilling.

Conclusion

The ring is therefore a component that should not be neglected in the treatment of the eyes. It is important to distinguish between purely medical indications and surgical indications. Surgical treatment has now become the reference with natural and stable long-term results.

Figure 5.  One year outcome of a hollow and colored ring treatment by microlipostructure and nanolipofilling.

Figure 6. One year outcome of a hollow and colored ring treatment by microlipostructure and nanolipofilling.

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