I thank Drs. Atiyeh and Hayek for their kind comments. They correctly express surprise with the take-home point: septal suture can be performed with preservation of lid height and no changes in aperture shape. Mendelsohn and Muhlbauer showed us the same in their experience, via the subciliary approach.
Why weaken the muscle if this is not necessary? Preservation of orbicularis muscle integrity/innervation reduces risks in the treatment of the lower eyelid bulge.
Tightening the septum clearly rejuvenates the lower eyelid. In some patients, it is all that is required. In other patients, much more is needed. Transconjunctival septal suture is clearly not a panacea for all aging manifestations of the eyelid and/or face.
We all have seen too many patients in our offices with lax lower lids after undergoing some unknown subciliary approach many years previously. Even without a blepharoplasty, aging patients may have a loss of aperture shape. The corner of the eye becomes more rounded and open in a vertical dimension. It behooves us to offer procedures to our patients that do not create or hasten this deformity.
Drs. Atiyeh and Hayek avoid or enhance aperture change with their orbicularis sling and canthoplasty in the treatment of bulging fat. These interventions can be obviated with transconjunctival septal suture. If we do not break it, we do not have to fix it.
Richard Sadove, M.D.
Department of Surgery
P. O. Box 100286
Gainesville, Fla. 32610
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