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).
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.
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.
Patients provided written consent for the use of their images.
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