Eye Area Mesotherapy

What is eye area mesotherapy?

Eye area mesotherapy is the placement of active ingredients in the skin around the eyes through many small injections with fine needles. In general, mesotherapy means injecting active ingredients into the skin and the tissue just beneath it; the eye area is only one of the areas where this technique is used.

The eye area is discussed separately because of the nature of the area itself. Because of its thin skin, complex network of blood vessels, and tendency to oedema (swelling caused by fluid build-up) and contour irregularities, it is considered one of the most challenging areas in aesthetic medicine. While fillers are used to correct volume loss, interest has grown in substances that aim to renew the tissue to improve skin quality. Eye area mesotherapy largely falls into this second group: its target is not volume but the skin itself.

There is no internationally recognised, evidence-based standard for mesotherapy; a recent consensus statement says so clearly and offers practical steps and recommendations to fill this gap. What this means for you: the name ‘mesotherapy’ on its own does not tell you what is injected, at what depth or for what purpose. These questions are asked separately for each treatment, and they are answered at the consultation.

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Which substances have been studied around the eyes?

Eye area mesotherapy is not the name of a single product; what is injected varies from study to study. Studies in this area have used vitamin C, tranexamic acid, glutathione, sodium hyaluronate, non-cross-linked hyaluronic acid, amino acids and polynucleotides. Platelet-rich plasma (PRP), obtained from the person's own blood, has also been studied in the same area by injecting it into the skin.

These substances do not share the same targets either. Mixtures containing vitamin C and tranexamic acid have been tried for pigment-related darkening; non-cross-linked hyaluronic acid, amino acids and polynucleotides have mostly been assessed for skin thickness, elasticity, moisture and fine lines. The fact that a substance has been studied for one purpose does not mean it will also work for another.

The injection technique is not fixed either. When nine low- to moderate-quality studies with polynucleotides (219 patients in total) were reviewed together, injection sites and techniques were found to vary from study to study, and agreement on the best way to use them was limited.

In response to this variability, consensus recommendations on mesotherapy have been published. One consensus statement, developed through a structured consensus process, contains 49 recommendations covering everything from terminology to clinical use; one of its stated aims is to separate evidence-backed practices from outdated ones. The practical takeaway for you is simple: before treatment, it is reasonable to ask which substance will be used and for what purpose.

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Four separate sources of dark circles under the eyes

Dark circles under the eyes are not a single condition. Pigmented, vascular, structural and mixed types have been described; more than one source can be present in the same person, and each needs a different approach. Where mesotherapy fits in depends on which source is dominant.

These sources are:

• Excess pigment build-up in the skin.
• Shadowing from the tear trough (the hollow between the lower eyelid and the cheek) and from under-eye fat bulging forward.
• Shadowing caused by laxity and wrinkles under the eyes.
• Thin, translucent skin covering the muscle around the eye.

Because the causes differ, treatment should be chosen for each person; to do this, it helps to identify the underlying cause first.

How often each type occurs varies from study to study. In one study that classified 100 people with dark circles by cause, the vascular type was found in 35% and the mixed type (pigment and blood vessels together) in 54%. In another study of 100 patients in Malaysia, the most common type was again the vascular type (51%), and the least common was the pigmented type (6%). These figures do not agree with each other; they show that frequency varies with the population and the assessment method, but they do not tell you which type your own dark circles are.

Factors associated with dark circles have also been studied. In one study, the severity of pigment-related dark circles was associated with family history, stress, long-term sun and screen exposure, and use of medicines containing hormones; no significant association with sleep quality was shown.

A step-by-step assessment to identify the source includes these steps:

• Examination under suitable lighting.
• Examination of the cheek and tear trough, area by area.
• Feeling the rim of the eye socket by hand.
• Separate assessment of the pigment and skin quality of the lower eyelid.

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What is known about pigment-related dark circles?

For pigment-related dark circles under the eyes, injections into the skin (intradermal) have been tried in a small number of randomised trials (trials in which participants are randomly assigned to groups). The findings point towards improvement; however, because the studies are few, the comparisons differ and follow-up periods are short, these findings are not enough for a firm conclusion.

In one randomised trial, 18 patients had platelet-rich plasma (PRP) injected into the skin on one half of the face and tranexamic acid with vitamin C on the other half; the treatment was given in three sessions, three weeks apart. Similar rates of improvement were seen on both sides; patient satisfaction was higher on the PRP side, but the difference was not statistically significant. This study compares two treatments; there is no control side on which nothing was applied. The researchers also note that research in this area is limited.

In a larger randomised trial, 120 patients were divided into two groups. According to the study abstract, all participants received two injections two weeks apart, and the treatment group received a solution containing sodium hyaluronate, vitamin C, tranexamic acid and glutathione. At assessments 4 and 12 weeks after treatment, the treatment group showed significant improvement in colour measurements and in the grade of darkness, while the control group showed no significant change. However, the abstract does not state what the control group was injected with, and follow-up is limited to 12 weeks.

PRP is a separate method that is often used as a comparison in this area. When studies around the eyes comparing PRP with platelet-rich fibrin (PRF), also obtained from the person's own blood, are reviewed together, the stronger evidence on pigment appears to be on the PRP side. However, differences in preparation methods limit how clear a conclusion can be; the effect on dark circles around the eyes has also been reported to be only moderate.

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Fine lines and skin quality

There are studies of substances injected into the skin for fine lines and skin quality around the eyes. The findings point towards improvement in elasticity, moisture and fine wrinkles; however, most of the studies are small, and some have no control group for comparison.

In a randomised, double-blind trial (neither the patient nor the researcher knew which substance was given on which side), 27 people had polynucleotides injected on one side of the eye area and non-cross-linked hyaluronic acid on the other, three times, two weeks apart. Polynucleotides are purified DNA fragments obtained from salmon sperm. There was no significant difference between the two sides in overall aesthetic improvement scores. The improvement in skin elasticity and moisture decreased over time on both sides but remained higher on the polynucleotide side. No serious adverse effects were reported.

In an uncontrolled observational study (a study with no comparison group), 42 patients received polynucleotide injections into the skin under the eyes; on scales the patients completed themselves, improvement compared with baseline was reported at 1, 3 and 6 months. The researchers themselves note that these findings need to be confirmed by controlled studies.

In a single-group study (with no comparison group) of 40 women, a treatment containing non-cross-linked hyaluronic acid and amino acids was given in two sessions; three months later, lower eyelid skin thickness measured by ultrasound and some elasticity measurements had increased. In another study, which assessed a single session of non-cross-linked hyaluronic acid in 34 people with signs of sun-related ageing around the eyes, follow-up was only 7 days.

Taken together, the studies show a consistent improvement in skin quality measures with polynucleotides; however, because study design, product formulation and outcome measures differ, it is difficult to draw a firm conclusion. What these studies measure are skin properties such as elasticity, moisture and fine wrinkles, not volume.

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Mesotherapy does not treat hollows or sagging

If dark circles under the eyes come from the shadow of a hollow or from skin laxity, mesotherapy is not a method aimed at that component. Research reviewing treatments for dark circles together shows that fillers and transfer of the person's own fat come to the fore for darkness caused by volume loss, and eyelid surgery for marked skin laxity.

Under-eye hollows are a separate topic in their own right. They are considered a difficult area because of their complex anatomy and the features that can accompany them: a hollow can come with puffiness over the cheekbone (malar mounds), bagging known as festoons, and dark circles. Options include fillers as well as eyelid surgery involving fat transfer, and addressing volume in the midface affects the result.

The same distinction appears when fillers and substances aimed at skin quality are compared under the eyes: hyaluronic acid (HA) fillers stand out for structural correction, while polynucleotides show improvement in skin quality measures. The two approaches are not interchangeable. One person can have both a structural problem and a change in skin quality; which one is dominant is determined at the consultation, and on that basis filler, a treatment aimed at skin quality, a plan combining the two, or neither can be discussed.

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Why does the skin around the eyes need special care?

The thinnest skin on the face is around the eyes, and this area is prone to swelling (oedema). The needles used in mesotherapy are fine, but the skin here is thin too; this feature of the area matters when planning any injection in it.

In measurements taken with high-frequency ultrasound at 38 points on the faces of 45 people, the thinnest skin was found on the upper eyelid, with a median value of 573.5 micrometres. The thickest skin was at the tip of the nose. Skin thickness varied significantly by area and by age, while its relationship with measures such as weight and height was generally weak.

The difficulty of the under-eye area is explained by three features: thin skin, a complex network of blood vessels, and a tendency to oedema and contour irregularities. For hyaluronic acid fillers, a colour change called the Tyndall effect (the filler looking bluish through the skin) and a risk of oedema in the cheekbone area are also mentioned specifically. In filler treatments in this area, bruising, swelling, oedema of the lower eyelid and cheekbone area, and vascular occlusion (a blocked blood vessel) are listed among the possible side effects.

Most of this information comes from filler treatments; mesotherapy is not a filler and does not leave volume behind. Even so, the same thin skin, the same network of blood vessels and the same tendency to oedema also apply to mesotherapy. The aim is not to put you off treatment, but to show why this area needs care.

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Known risks

In studies of injections into the skin around the eyes, the reported adverse effects are mostly mild and temporary. Less common but longer-lasting problems have also been reported. Most of the data on the safety of mesotherapy come from publications describing individual patients or small groups of patients (case reports and case series).

Some examples from eye area studies: in one single-session study of non-cross-linked hyaluronic acid, the only reported adverse effect was mild bruising. In the randomised trial comparing polynucleotides with hyaluronic acid, no serious adverse effects were reported. PRP and PRF studies around the eyes also reported only mild and temporary adverse effects. However, these studies are small and not large enough to detect a rare complication.

Researchers reviewing mesotherapy complications found many case series and single case reports describing side effects of varying severity. In most cases, treatment of these side effects is tailored to the individual, and larger studies are needed to assess safety. Delayed granulomatous reactions (small lumps in the tissue caused by inflammation) are described as a chronic complication. A single-centre case series of six patients states that mesotherapy carries a risk of adverse reactions because of non-standard protocols and overuse; this series does not provide data specific to the eye area.

Non-tuberculous mycobacterial (NTM) skin infections, caused by mycobacteria other than those that cause tuberculosis, are a well-documented adverse effect after mesotherapy. Data on a total of 423 patients from 30 publications have been brought together on this topic; most cases involved the abdomen, buttocks and thighs. It has been reported that the infections came from injections contaminated from the environment, that treatment can last weeks, and that the infections can leave scars.

Rare but serious eye complications have also been described after aesthetic treatments near the eyes; these can lead to permanent vision loss. The information on this mainly concerns filler material being carried inside blood vessels; PRP is also among the treatments covered, but mesotherapy is not mentioned separately. Before the procedure, you will be asked about blood thinners, antiplatelet medicines (which stop platelets from clumping together) and supplements that can affect bleeding. Do not stop any prescribed medicine on your own. If needed, the procedure is planned or postponed after consulting the relevant doctor.

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How strong is the evidence in this area?

The short answer: limited. Studies on eye area mesotherapy are few, and most are small with short follow-up. Because the substances and protocols used differ, it is not possible to combine these studies and draw a common conclusion.

When 39 studies on treatments for dark circles under the eyes were assessed together, high-quality evidence was found to be scarce; recommendations should therefore be interpreted selectively, and more randomised trials are needed. The options found to be effective include:

• Lasers.
• Products applied to the skin (topical).
• Fillers.
• Chemical peels.
• Carboxytherapy (carbon dioxide delivered under the skin).
• PRP injections.
• Eyelid surgery.
• Oxygen at normal pressure (normobaric oxygen).

Mesotherapy does not appear as a separate heading in this list.

The situation is similar for the other topics. The quality of polynucleotide studies ranges from low to moderate, and more rigorous studies are needed. In PRP and PRF studies around the eyes, differences in preparation methods limit how clear the conclusions can be. The international consensus statement on mesotherapy also acknowledges its own limitations; it states that continuous high-quality research and regular updates are needed.

The picture is the same when individual studies are examined. One of the pigment studies included 18 patients and had no untreated control side; the skin thickness study had a single group, and follow-up in the sun damage study was 7 days. The observational study of polynucleotides under the eyes followed patients for up to six months but had no control group. For this reason, no reliable information can be given on how long the effect lasts.

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