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In 2024, a 20-year-old woman shared a problem that had bothered her since childhood. Her under-eyes looked deeply hollow. Concealer could cover some of the colour, but it could not hide the actual indentation beneath her eyes. She could even see the hollow from the side.
She had already tried PRP and felt it had done nothing for the problem. She was considering tear trough filler but was worried about the possible risks. What stood out in her story was the difference between what she called dark circles and what she could actually see. Her concern was not only colour. There was a real structural hollow beneath the eyes.
That distinction is important.
People often use the words "dark circles" for almost any darkness around the lower eyelid. Yet the tired look can come from several different things. The skin may contain more pigment. Blood vessels may show through thin skin. Puffiness can cast a shadow. A hollow tear trough can create a dark line even when the skin itself is not unusually dark.
Some people have more than one cause at the same time.
For a cosmetic doctor, identifying that cause should come before deciding whether any treatment makes sense.
Dark Circles Are a Visible Sign, Not One Single Condition
Two people can both say, "I have dark circles," while having very different under-eye problems.
One person may have brown pigmentation in the skin. Another may have a blue or purple tone because vessels are visible through thin lower-eyelid skin. Someone else may have normal skin colour but a deep groove that creates a shadow under overhead light.
Medical research supports this distinction.
A clinical review in the Journal of Clinical and Aesthetic Dermatology describes several recognised causes of periorbital dark circles. These include excess pigmentation, genetics, inflammation, swelling, visible blood vessels, thin skin and structural shadowing from features such as a tear trough. More than one factor may contribute to the same patient.
This is why dark circles are better thought of as a visible sign rather than one diagnosis.
Doctors often consider four broad patterns. Pigmented circles tend to look brown. Vascular circles can look blue, pink or purple. Structural circles are created mainly by facial shape and shadow. Mixed circles contain two or more of these features.
The treatment question becomes much easier once the cause is clearer.
A Hollow Tear Trough Can Look Like Dark Skin
The tear trough is the groove where the lower eyelid meets the upper cheek. It normally begins near the inner corner of the eye.
Some people naturally have a noticeable groove from a young age. Others develop a deeper appearance as the face changes over time.
The anatomy around the eyes is complicated. Skin, muscle, fat, ligaments, bone and blood vessels all sit close together. The skin covering the eyelid is also particularly thin. This is one reason small changes beneath the surface can become easy to see.
Age can affect several supporting structures. Facial fat can change in volume and position. The transition between the eyelid and cheek may become less smooth. Skin quality also changes over time.
Then there is light.
Imagine a small dent in a wall. With soft light coming directly from the front, the dent might barely be noticeable. Shine a light from above and a shadow suddenly appears inside it.
A tear trough can work in a similar way.
This explains why someone may look much more tired in bathroom lighting or under office lights than they do near a window. The skin has not suddenly become darker. The shape of the under-eye area is changing how light falls across the face.
A doctor therefore needs to distinguish actual pigment from a shadow created by anatomy.
True Pigmentation Needs to Be Recognised Separately
Pigmented dark circles are different because the colour exists within the skin itself.
Genetics can contribute. Inflammation around the eyes can also leave pigmentation behind. People who have dermatitis around the eyelids may develop post-inflammatory darkening. Repeated eye rubbing can contribute to irritation as well.
Research shows how varied under-eye darkness can be.
A study of 200 patients published in the Journal of Dermatology assessed different types of periorbital hyperpigmentation in an Asian study population. The researchers identified vascular causes in 41.8% of participants and constitutional pigmentation in 38.6%. Post-inflammatory pigmentation accounted for 12%. Shadow-related causes were identified in 11.4%.
Those percentages should not be treated as rates for people living in the Netherlands. The study population was different and some patients had overlapping causes. What the research does demonstrate is that one visible complaint can come from several different mechanisms.
That has a direct effect on treatment.
A procedure designed to change facial volume cannot simply remove excess melanin from the skin.
Thin Skin and Visible Blood Vessels Can Change the Colour
Some people notice that their circles are more blue or purple than brown.
This can happen because lower-eyelid skin is thin enough for blood vessels and deeper tissue to influence the colour seen at the surface.
The Journal of Clinical and Aesthetic Dermatology review identifies superficial vessels and thin skin over the orbicularis oculi muscle as possible contributors to under-eye darkness.
Doctors can sometimes gather useful clues by examining how the area behaves when the skin is gently moved or stretched. Pigmentation tends to remain visible. A structural shadow may become less obvious when the contour changes. Vascular colour can become clearer.
This is only one part of an examination. It is not a reliable home test.
Lighting, skin type, facial structure, medical history and other features also need to be considered before drawing conclusions.
Puffiness Can Produce a Shadow That Looks Like a Dark Circle
Under-eye bags create another common source of confusion.
A raised bag can catch the light. The area immediately below it then sits in shadow. From a normal viewing distance, the person may simply see a dark line beneath the eye.
The real issue is partly a difference in contour.
Swelling can make this more complicated. Fluid can collect around the eyelids and may be more obvious at certain times of day. Medical reviews note that periorbital swelling may appear worse in the morning in some people.
That matters when treatment involves adding volume.
A person with a clean structural hollow and very little swelling is not the same candidate as somebody who already has significant under-eye fullness or frequent puffiness.
Adding volume without understanding that difference can produce a result the patient did not expect.
Mixed Causes Are More Common Than People Realise
The most useful diagnosis is not always "pigment" or "hollow."
Sometimes the answer is both.
A person might have a deep tear trough that creates a strong shadow and also have genuine brown pigmentation in the skin. Another may have thin skin, visible vessels and a mild hollow.
This matters when discussing expectations.
Imagine that structural shadow causes half of what a patient sees as a dark circle while pigmentation causes the rest. Improving the hollow may soften the tired appearance without removing every trace of darkness.
The remaining colour does not necessarily mean the structural treatment failed. It means the original problem had more than one cause.
A good consultation should explain that before treatment rather than leaving the patient to discover it afterwards.
Why Diagnosis Matters Before a Traangoot Behandeling
People researching a traangoot behandeling are often trying to solve one simple problem. They want to look less tired.
The medical assessment needs to be more specific.
A doctor should look at the depth and shape of the tear trough. Skin quality and colour matter. So do under-eye bags, swelling and the support provided by the cheek.
Previous cosmetic procedures are also relevant because existing filler may affect the appearance of the area and future treatment decisions.
The patient's own description is important too.
Someone may say that dark circles bother them when the feature they really notice is a deep groove in photographs. Another person may use the same words even though their main concern is pigmentation.
These are different treatment conversations.
This distinction is especially important in the Netherlands because injectable cosmetic treatments fall within medical care.
The Inspectie Gezondheidszorg en Jeugd, or IGJ, states that Botox and filler injections are medical procedures. Dutch rules require practitioners to have the appropriate authority and competence to perform injections safely. The IGJ also stresses the need for knowledge of facial anatomy, products and a patient's medical profile.
The KNMG training framework for cosmetic medicine specifically covers facial anatomy, changes related to ageing and the use of injectables such as hyaluronic acid fillers.
The reason is straightforward. Before changing anatomy, a practitioner needs to understand it.
Cosmetic Filler Treatments Have Grown in the Netherlands
Dutch figures also show why careful assessment is becoming more relevant.
According to information published by the IGJ in 2026, research from Erasmus MC found that the number of filler treatments in the Netherlands increased by 81% between 2019 and 2022.
The estimated number rose from about 162,000 filler treatments in 2019 to approximately 294,000 in 2022. The IGJ states that newer nationwide figures are expected later in 2026 and that Erasmus MC researchers expect the overall growth trend to continue.
The IGJ also received 175 reports concerning Botox and filler treatments in 2025. In 117 cases, or 67% of those reports, the reporter stated, or IGJ investigation found, that treatment had been performed by someone who did not have the required authority.
That figure needs careful interpretation.
It does not mean that 67% of filler treatments in the Netherlands are performed by unauthorised practitioners. It refers only to the reports received by the regulator.
Still, it shows why checking who is performing a medical cosmetic procedure matters.
What Does Research Show About Tear Trough Filler?
When a true structural hollow is a major part of the tired appearance, hyaluronic acid filler is one treatment that a doctor may consider.
The strongest evidence should include both results and side effects.
A systematic review and meta-analysis published in Aesthetic Plastic Surgery examined 31 reports involving 2,556 participants treated with hyaluronic acid for tear trough deformity.
The pooled overall satisfaction rate was 91%.
That is a high figure, but it should not be separated from the complication data.
The same analysis found a pooled rate of 19.2% for swelling or oedema and 18.4% for bruising. Redness was reported at 7.1%. Contour irregularities or lumps had a pooled rate of 5.3%. Blue discoloration, often called the Tyndall effect, was reported at 0.9%.
These figures come from multiple studies. They cannot predict what will happen to one individual patient.
They show something more useful. Tear trough filler can have high satisfaction in appropriately selected patients, while unwanted effects still occur.
Both parts of the evidence matter.
Real Patient Experiences Show Why Diagnosis Cannot Be Replaced by Before-and-After Photos
Hours of research through clinical studies provide averages. Real patient experiences show how different individual situations can be.
In March 2025, one patient shared that she had gone to a plastic surgeon because of dark circles and under-eye hollowness. Her surgeon treated her cheeks first to provide support and later treated the tear trough itself. She reported little bruising or swelling but still felt the improvement was not as noticeable as she had hoped.
Another patient shared a much more positive experience in May 2025. She said she had naturally hollow under-eyes and had previously tried PRF and PRP without seeing the change she wanted. After a small amount of under-eye filler, she described the result as subtle and natural.
Other experiences are less positive. One person reported significant puffiness after tear trough filler and said the product became visible beneath the skin, making the dark appearance worse.
These accounts are anecdotes from social media. They are not scientific evidence. We usually do not know every detail about the patient's anatomy, medical history, product or injection technique.
They are still useful for one reason. They show why another person's result cannot tell you what will happen to your own under-eyes.
Patient selection matters.
Filler Cannot Correct Every Cause of a Tired Look
Hyaluronic acid filler mainly changes volume and contour.
If a structural hollow creates much of the shadow, changing that contour may reduce the appearance of the groove.
If the main problem is pigmentation, the situation is different. Adding volume does not remove pigment from the skin.
The same applies when visible vessels are the main reason for a blue or purple tone.
Prominent bags, loose skin and regular swelling create different considerations again.
This is why treatment should never be chosen simply because someone has seen an impressive before-and-after photograph online.
The photograph may show someone with different anatomy and a completely different cause of under-eye darkness.
The Under-Eye Area Also Requires a Serious Discussion About Safety
Filler is minimally invasive, but it is still a medical injection.
The more common unwanted effects include swelling, bruising, redness and contour changes. The large 2,556-participant meta-analysis confirms that these reactions occur in real clinical practice.
Rare vascular complications can be far more serious. Facial filler accidentally entering a blood vessel can cause tissue injury and, in exceptional cases, visual complications.
The practical lesson is not that everyone should avoid treatment. It is that an injection around the face should not be treated like an ordinary beauty service.
Product choice also matters in the Netherlands.
Rijksoverheid states that permanent wrinkle fillers cannot be used for cosmetic purposes in the Netherlands. The government advises patients to ask what substance will be injected before treatment begins.
What a Proper Under-Eye Assessment Should Establish
A useful consultation should answer more than whether an area can technically be filled.
The doctor needs to understand when the problem began and whether it has changed with age. Family features can be relevant. So can allergies, dermatitis, eye rubbing and regular morning swelling.
The face should then be assessed as a whole.
The relationship between the lower eyelid and cheek matters. So do under-eye bags, skin quality, visible pigmentation and the depth of the tear trough.
Different lighting can provide additional clues because a structural shadow may change more dramatically than true pigmentation.
Previous filler should be discussed as well.
Most importantly, the doctor should explain which part of the tired appearance a proposed treatment is expected to improve and which part is likely to remain.
Sometimes the most useful outcome of a consultation is finding out that the procedure someone originally wanted is not the best match for the problem.
The Best Under-Eye Decision Starts With the Right Diagnosis
Dark circles and hollow under-eyes can create the same tired expression, but they do not always come from the same cause.
Pigmentation can darken the skin itself. Thin skin can make blood vessels more visible. Puffiness and under-eye bags can create shadows. A hollow tear trough can also produce a dark line simply because of the way light falls across the face.
Many people have a combination of these factors.
That is why the key question is not simply, "How can I get rid of my dark circles?"
A better question is, "What is causing them?"
The answer may be pigment. It may be a vascular colour. It may be swelling, facial structure or several things together.
Research involving 2,556 participants shows that hyaluronic acid tear trough treatment can have high satisfaction when used for structural hollowing, but the same evidence also documents swelling, bruising and other unwanted effects. Dutch health authorities treat filler injections as medical procedures for good reason.
Understanding the cause first gives both the patient and the doctor a more realistic starting point. It helps explain what may improve, what may remain unchanged and whether a treatment is appropriate at all.
For tired-looking under-eyes, that diagnosis is not a small first step. It is the part that determines everything that follows.
