eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Arcus Marginalis Release

Author: Steven L Henry, MD, Hand & Microsurgery Fellow, The Hand Center of San Antonio
Coauthor(s): Lawrence Ketch, MD, FAAP, FACS, Head, Program Director, Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Colorado Health Sciences Center; Chief, Pediatric Plastic, The Children's Hospital of Denver
Contributor Information and Disclosures

Updated: Feb 7, 2008

Introduction

An emerging concept in cosmetic surgery is that the characteristics of facial aging are a result of not only elastosis and sagging but also the atrophy of soft tissue and, particularly, fat.1,2 The evolution of this concept is well illustrated in the field of lower lid blepharoplasty, in which the traditional approach to the amelioration of so-called bags is to resect the "herniating" orbital fat.3 While this method can indeed eliminate bags, it may also eliminate the soft tissue that conceals the infraorbital rims, creating a hollowed, skeletonized appearance (see Image 2, top). This is in contradistinction to the truly youthful face, in which soft tissue fullness creates a smooth, almost imperceptible transition from the cheek to the lower lid, with no visibility of the bony orbital rim.

Multiple alternative approaches have been and continue to be devised to address this problem.⁴ One such technique that has gained prominence is the arcus marginalis release, in which orbital fat is advanced (rather than resected) to reconstruct the soft tissue of the lower lids.^5,6,7 This technique is designed to conceal the underlying bony structure of the inferior orbit in an attempt to impart a more youthful contour to the periorbital area.

History of the Procedure

Loeb was among the first to describe the advancement of the medial lower lid fat pad to recontour the nasojugal groove.⁸ Shortly thereafter, Hamra published his description of the arcus marginalis release technique, in which he extended Loeb's concept to include advancement of all of the lower lid fat pads in an effort to conceal the infraorbital rim and to recreate the youthful fullness of the lower lid.⁵ As originally described, the arcus marginalis was incised and the orbital fat alone was advanced and sutured to the preperiosteal fat of the upper cheek. Subsequently, Hamra refined his technique to include advancement of the septum and orbital fat en bloc, providing more secure purchase for suturing. He termed this procedure the septal reset.⁹

Indications

Almost any blepharoplasty patient with lower lid bags and/or infraorbital skeletonization is a candidate for arcus marginalis release. Even among those who have previously undergone traditional blepharoplasty and were dissatisfied with the hollow appearance of their eyes, finding and advancing enough orbital fat to correct the iatrogenic depression is usually possible.

Relevant Anatomy

See Image 1. The orbicularis oculi muscle is immediately deep to the skin of the lower lid. This muscle extends from near the ciliary margin past the infraorbital rim to the cheek. Deep to the orbicularis is the orbital septum. The suborbicularis fascia, a plane of loose, fibrous connective tissue, intervenes between the orbicularis and orbital septum and provides an excellent dissection plane. The orbital septum fuses superiorly with the tarsal plate and inferiorly with the periosteum of the infraorbital rim; this inferior attachment of the septum is termed the arcus marginalis.

The orbital septum serves to retain orbital fat within the orbit. Although composed of inelastic fibrous tissue, the septum can slacken with age, permitting orbital fat to herniate anteriorly into bags.

The arcus marginalis is strongest and most sharply defined medially, where it attaches to the anterior lacrimal crest. As it extends laterally, the arcus marginalis thins and weakens. It also assumes a more inferior and anterior insertion; thus, medially, it runs along the inner aspect of the rim, but laterally, it attaches approximately 2 mm inferior to the rim on the facial aspect of the zygomatic bone.

Three compartments of orbital fat are located posterior to the orbital septum. Many delicate fibrous septa invest these compartments. The inferior oblique muscle, originating from the anteromedial orbital wall, separates the medial and central fat compartments as it extends posterolaterally under the globe. The arcuate expansion, an extension of the fascial sheath of the inferior oblique, continues laterally to attach to the lateral orbital rim and separates the central and lateral compartments.

Subtle differences exist among the 3 orbital fat pads. The fat of the medial compartment is typically white and membranous, while that of the other 2 compartments appears yellow and fluffy. The lateral fat pad contains more septa than the others and is therefore less likely to herniate anteriorly. Lower palpebral vessels travel directly through the medial fat pad.

The capsulopalpebral fascia, a structure analogous to the levator apparatus of the upper lid, extends between the orbital fat pads and the globe. The capsulopalpebral fascia arises from the fascial sheaths of the inferior rectus and inferior oblique and, along with the orbital septum, inserts at the inferior margin of the tarsal plate. Included among its many layers are a lax superficial membrane, a muscular component (inferior tarsal muscle), and a deep layer that attaches to the conjunctival fornix.

Contraindications

Contraindications for arcus marginalis release mirror those of any blepharoplasty procedure. In particular, patients should be questioned about a history of dry eye symptoms, and evaluation by an eye specialist should be obtained if there is any question of lacrimal insufficiency. Extreme caution should be exercised when considering this procedure for patients with a personal or family history of bleeding disorders, as the risk for retrobulbar hematoma may be higher in these individuals.

Arcus marginalis release is generally not indicated in young patients with a congenital excess of orbital fat. Traditional resection of the excess fat is appropriate for these patients.

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