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The Long-Term Static and Dynamic Effects of Surgical Release of the Tear Trough Ligament and Origins of the Orbicularis Oculi in Lower Eyelid Blepharoplasty

Wong, Chin-Ho M.Med.(Surg.), F.A.M.S.(Plast.Surg.); Mendelson, Bryan F.R.C.S.(Ed.), F.R.A.C.S.

Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 583-591
doi: 10.1097/PRS.0000000000005908
Cosmetic: Original Articles
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Background: Release of the tear trough ligament and the origins of the orbicularis oculi is a key maneuver with many lower blepharoplasty techniques. The long-term static and dynamic effects of this release have not been studied previously.

Methods: From December of 2012 to June of 2017, 105 patients were treated with the extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution as described previously. The long-term effect of the release was assessed by evaluating the effectiveness in correcting the tear trough deformity, the effect on the lower eyelid position, and the dynamic changes of the patient’s smile.

Results: The mean patient age was 41 years (range, 23 to 62 years). The mean follow-up was 31 months (range, 12 to 53 months). The tear trough was effectively corrected with this maneuver. This release did not compromise the tarsoligamentous support of the lower eyelid, with no increase in scleral show in 99 percent of patients and with no patients developing ectropion. Functionally, the change in the action of the orbicularis oculi as a result of detachment of its origins resulted in a change in appearance of the smile. Elimination of the tethering at the tear trough ligament and the downward pull toward the medial suborbital maxilla resulted in elevation of the lid-cheek junction with smiling. Reduced efficiency of orbicularis contraction resulted in a diminished pretarsal bulge and in reduction of crow’s feet with smiling.

Conclusions: The maneuver is effective in correcting the tear trough deformity while not weakening the lower eyelid tarsoligamentous support. Functionally, the patient’s smile became more youthful and rejuvenated, with less wrinkling and elevation of the lid-cheek junction with smiling.


Singapore; and Toorak, Victoria, Australia

From W Aesthetic Plastic Surgery and The Centre for Facial Plastic Surgery.

Received for publication August 7, 2018; accepted February 28, 2019.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

Related digital media are available in the full-text version of the article on

Chin-Ho Wong, M.R.C.S.(Ed.), F.A.M.S.(Plast.Surg.), W Aesthetic Plastic Surgery, No. 06-28/29, Mount Elizabeth Novena Specialist Center, 38 Irrawaddy Road, 329563, Singapore,

Copyright © 2019 by the American Society of Plastic Surgeons