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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.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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 www.PRSJournal.com.

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, drwong@waesthetics.com

The tear trough ligament is the main anatomical basis for the tear trough deformity (Fig. 1).1 Release of the tear trough ligament is a key maneuver for effective long-term correction of the tear trough deformity and is an essential step in many lower eyelid blepharoplasty techniques, whether performed by means of the transconjunctival or the subciliary approach.2–16 The routine use of tear trough ligament release has been reported in many published blepharoplasty techniques, with good long-term results.2–16 The released tear trough ligament is usually not reconstructed by resuspension or fixation. Indeed, it is necessary to prevent reattachment of the ligament to effectively correct the tear trough deformity. This is usually achieved by placing a soft-tissue spacer such as orbital fat pad transposition, septal reset, or maxillary augmentation with implants.2–18 The tear trough ligament is a facial retaining ligament that functions to support and bind the facial soft tissues to the skeleton. It is understandable then that some surgeons are concerned about the long-term consequences of release of the tear trough ligament without reconstruction and continue to have reservations about this technique.19–21 Furthermore, the long-term dynamic changes on the function of the orbicularis oculi, with its origins detached during the release of the tear trough ligament, are unknown, as they have not previously been studied. This article is a long-term follow-up study analyzing the static and dynamic changes of the lower eyelid of our patients who had surgical release of the tear trough ligament and the origins of the orbicularis oculi.

Fig. 1.

Fig. 1.

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PATIENTS AND METHODS

Our surgical technique has been published previously.22 Our inclusion criteria consisted of the following: (1) patients who underwent the extended transconjunctival lower eyelid blepharoplasty, (2) patients that have not had periorbital botulinum toxin injection after surgery, (3) patients that did not have any further surgical intervention on the lower eyelid after the primary procedure, and (4) patients with a minimum follow-up of 1 year. Our surgical technique of precisely releasing the tear trough ligament in the preperiosteal plane using electrocautery was demonstrated. [See Video (online), which demonstrates our technique of precise and complete release of the tear trough ligament and the origins of the orbicularis oculi. The dissection was performed as atraumatically as possible by using the dissection through the facial soft-tissue spaces approach, connecting the preseptal space above with the premaxillary space below.] This technique entails a sequential release of the palpebral part of the orbicularis oculi, the tear trough ligament, and then the orbital part of the orbicularis oculi. This release (with reference to the right orbit) extends approximately from the 4-o’clock position to the 8-o’clock position and connects the preseptal space with the premaxillary space.23 To prevent reattachment of the tear trough ligament and orbicularis oculi origins to the medial suborbital maxilla, free interpositional fat grafting was performed into this area secured with percutaneous sutures. No canthopexy or canthoplasty was performed in our patient cohort.

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Standard high-resolution photographs of patients in repose and with their widest smile were taken preoperatively and at least 1 year postoperatively. For the image in repose, patients were instructed to look straight into the camera without expressing emotion. For the smiling photographs, patients were instructed to give their widest/happiest smile. For the analysis of the resting lower eyelid position, the preoperative and postoperative images were standardized to match using the midpupillary light reflex distance 1 of the images for reference to ensure comparable forward gaze. The preoperative and postoperative smiling images were matched by location of the oral commissure to ensure consistent intensity of the smile to provide fair comparison of periorbital smile aesthetics. Three preoperative and postoperative images were taken for every patient, and the best-matched images based on the midpupillary light reflex distance 1 and commissure locations were selected for comparison of the repose and smiling positions, respectively. The long-term postoperative changes were assessed for the following: (1) lower eyelid position/posture, (2) effectiveness of long-term correction of the tear trough deformity, and (3) long-term animation changes with contraction of the orbicularis oculi.

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RESULTS

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 and fulfilled the inclusion criteria of this study. The mean age of our patients was 41 years (range, 23 to 62 years), and the mean follow-up was 31 months (range, 12 to 53 months).

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Lower Eyelid Position

No patients developed ectropion in the long term. Of the 105 patients in our study, only one patient (1 percent) developed long-term increased scleral show. Figures 2 and 3 show patients with stable and unchanged lower eyelid position in the longterm follow-up. The lower eyelid was stable even for patients who had preexisting scleral show (Fig. 4).

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

Fig. 4.

Fig. 4.

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Tear Trough Deformity

All patients had good correction of the tear trough deformity, with long-term elimination of the tight attachment at the tear trough contour and correction of the tethering at the tear trough (Figs. 2 through 4).

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Changes with Animation

In observing the lower eyelid on animation/smiling, four observations were made. First, the tethering that was centered at the tear trough deformity (the line of fixation provided by the retaining ligament) and the accordion of the skin above and below the tear trough that resulted from effective contraction of the orbicularis oculi toward its origins, that exaggerated the prominence of the groove here, had been eliminated postoperatively. Second, the bulge above the tear trough ligament was reduced or eliminated. This can be attributed mainly to the removal of the excess prominence of the medial and central orbital fat pads. Third, for patients with prominent pretarsal bulge (hypertrophic pretarsal orbicularis oculi) when smiling, this bulge was significantly reduced after release of the tear trough ligament. Fourth, the crow’s feet when smiling were reduced postoperatively. These changes in the effects on orbicularis oculi contraction, although varying in degree and intensity from patient to patient, were consistently seen in every patient (Figs. 5 through 8).

Fig. 5.

Fig. 5.

Fig. 6.

Fig. 6.

Fig. 7.

Fig. 7.

Fig. 8.

Fig. 8.

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DISCUSSION

To accurately analyze the specific effects of the release of the tear trough ligament and the associated origins of the palpebral and orbital parts of the orbicularis oculi, this maneuver should be performed in relative isolation, to minimize surgical trauma associated with other surgical releases and dissections inherently associated with lower eyelid blepharoplasties.22,24,25 The transconjunctival approach was selected for this reason, as the subciliary approach causes more surgical trauma with dissection through the anterior and middle lamellae of the lower eyelid. Furthermore, to get to the tear trough ligament as atraumatically as possible, we used the “dissecting through facial soft-tissue spaces” approach.22,23,26–30 Facial soft-tissue spaces are anatomical cleavage planes to facilitate gliding of facial soft tissue. Accordingly, these are essentially “predissected” planes that may be opened gently by blunt dissection, thereby keeping trauma associated with the access part of the procedure to a minimum. The preseptal space was accessed through a transconjunctival incision and bluntly opened to its boundaries, formed inferomedially by the origins of the palpebral part of the orbicularis oculi just caudal to the arcus marginalis. With precise identification, the origins of the palpebral part of the orbicularis oculi, the tear trough ligament, and the orbital parts of the orbicularis oculi were sequentially released with cutting cautery in the preperiosteal plane.22 The dissection was then connected with the premaxillary space that was similarly atraumatically opened by blunt dissection. With this technique, the surgical effect of releasing the tear tough ligament may reasonably be studied in isolation and the observations attributed mostly to this maneuver (Fig. 9) (see Video, online).

Fig. 9.

Fig. 9.

We found that the release of the tear trough ligament and placement of interpositional orbital fat grafts were effective in correcting the tear trough deformity, with the improvement consistently maintained in the long-term results. This was consistent with previous reports in the literature, affirming the key role that surgical release plays in correcting the tear trough deformity.2–16 The lower eyelid position remained stable at long-term follow-up. Significantly, in our surgical technique, no canthopexy or canthoplasty was performed. The vast majority (99 percent) of our patients did not develop any discernible increased scleral show. This was even for patients with negative vector orbit and preexisting tarsoligamentous laxity and scleral show (Fig. 4). It may be concluded that release of the tear trough ligament does not weaken the tarsoligamentous supporting structures of the lower eyelid.

In close association with the tear trough ligament, cephalad and caudal to the ligament are located the origins of the orbicularis oculi (the palpebral and orbital parts, respectively), which contract toward this point of fixation with animation (Fig. 1).1 This anchor point provides a strong attachment for the orbicularis oculi to contract effectively and efficiently. The dynamic changes that occurred with detaching the origins of the orbicularis oculi have not previously been examined or discussed. Logically, releasing the origins of the orbicularis oculi would reduce the effectiveness of the muscle actions. As we know, botulinum toxin also has this effect of reducing the effectiveness of orbicularis contraction.31,32 It was interesting then to note the effect of this release on periorbital aesthetics.

In its natural state, with animation or smiling, contraction of the palpebral and orbital parts of the orbicularis oculi pulls the orbicularis toward its origin. The bulging of the muscles accentuated the fixation at the tear trough ligament between the orbicularis oculi origins, which gives the appearance of tightness and gathering centered at the tear trough ligament. This results in the bunching of the lower lid soft tissue toward the tear trough ligament in a downward and inward vector for the lower eyelid. The tear trough ligament also has the effect of blocking the vertical elevation of the cheek soft tissues. The combination of these dynamic changes and strong fixation at the tear trough occurring concurrently, visually creates a prominent lid-cheek junction that is “low,” a feature of the aging midcheek (Figs. 5, left, and 6, left).

With release of the ligament, the following long-term and permanent changes were evident. First, the tethering with smiling was eliminated (Fig. 5). Second, the vector of contraction of the orbicularis oculi changed to a more upward and outward direction. This, in combination with the elimination of the blocking effect of the tear trough ligament on elevation of cheek soft tissues with smiling, resulted in elevation of the visual location of the lid-cheek junction when the patient smiles, giving the profound impression of a more youthful and pleasant smile (Fig. 6).33 Third, with release of the orbicularis origins, the muscle contraction becomes less efficient or effective. This has two benefits on the aesthetics of the smile. For patients who have a prominent pretarsal bulge caused by orbicularis hypertrophy, the bulge on smiling will become less prominent postoperatively (Fig. 7). This softened pretarsal bulge resulted in a more aesthetic appearance. The reduced efficiency of contraction also resulted in slightly less crows’ feet with smiling. Although these effects are not as powerful and profound as those of neurotoxins, the benefits obtained are long term and essentially permanent (Fig. 8).

These observations on the effects of the release of the tear trough ligament were derived from the use of the transconjunctival approach to lower eyelid blepharoplasty. The subciliary (transcutaneous) approach is known to have a higher incidence of scleral show and ectropion compared with the transconjunctival approach.34,35 The difference may be related to the greater extent of dissection involved with the subciliary approach, which necessitates cutting through the anterior and middle lamellae (orbicularis oculi) of the lower eyelid. With even more aggressive techniques that incorporate a midcheek lift with the procedure, a greater extent of release of the periorbital retaining ligaments (release of the orbicularis retaining ligament and lateral orbital thickening) may potentially weaken the tarsoligamentous support of the lower eyelid even more. To compensate for the weakening of the tarsoligamentous support for the lower eyelid, routine canthopexy or canthoplasty has been advocated by some authors for these subciliary approaches.2,5,6,16 However, based on the findings of this current study, even with the subciliary approach, the component of the operation that releases the tear trough ligament located more medially does not weaken the lower eyelid support mechanism.

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CONCLUSIONS

Release of the tear trough ligament with interpositional fat grafts is effective in correcting the tear trough deformity. This maneuver does not weaken the integrity of tarsoligamentous support of the lower eyelid. Periorbital aesthetics are improved by the functional changes that accompany the release of the origins of the palpebral and orbital parts of the orbicularis oculi that are intimately associated with the tear trough ligament. The tethering centered at the tear trough ligament that was exaggerated when patients smile is eliminated. This produced a visual impression of elevation of the lid-cheek junction with smiling. The reduced efficiency of orbicularis contraction softened the prominence of the pretarsal bulge and lessened the crow’s feet. The combination of these functional changes results in a more pleasant and youthful smile.

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PATIENT CONSENT

Patients provided written consent for the use of their images.

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