Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution

Abstract

Sir: In the August of 2017 issue of Plastic and Reconstructive Surgery, Wong and Mendelson published an interesting article in which the authors described in detail their methods of subtotally releasing the tear trough ligament and the orbicularis retaining ligament and redistributing the free orbital fat for the correction of the tear trough (lacrimal groove, nasojugal crease) and palpebromalar groove (lid-cheek junction) through the transconjunctival approach.1 Because the authors and we have similar treatment subjects (mainly Asians), and the periorbital rejuvenation is a subject on which we have worked intensively, we would like to share our thoughts about this technique. Wong and Mendelson have been consistently committed to studies of the anatomy of the periorbital region and midcheek and the antiaging treatments of the middle face.1–4 Their research achievements and surgical techniques of course contribute to better understanding the structures of these regions and choosing the optimum surgical procedure. The tear trough deformity is considered to be directly associated with the tear trough ligament, and the formation of the palpebromalar groove is mainly attributable to the orbicularis retaining ligament.2 It is also well known that the degree of infraorbital groove depends on the status of the tissue above (i.e., eye protrusion, prominence of the orbital fat pads, and looseness of the orbicularis oculi muscle and skin) and below (i.e., atrophy and descent of the malar fat pad and retrusion of maxillary) this furrow. Once the groove is seen, does it have to deal with the region? Everyone has the structure of the tear trough ligament (although it may be fragile and thus invisible), and almost all of the patients with eye bags have different degrees of prominence of the nasojugal crease. With these factors in mind, it is important for us to classify the tear trough deformity according to the morphologic features of the lacrimal groove and the situations of the surrounding tissue (because of the limit of article length, this section is not described here in detail). In other words, a judgment of which factor (i.e., the tear trough ligament, the surrounding tissues, or a combination of them) plays the major role in increasing the prominence of the tear trough must be correctly made preoperatively. In the article by Wong and Mendelson,1 the extended transconjunctival lower eyelid blepharoplasty with ligament release was performed on the patient (shown in Fig. 11) who had a mild eye bag and a slight tear trough even when smiling on the frontal view. According to our experience, we usually attribute the formation of this type of crease to the protruded orbital fat compartment. We do believe that transconjunctival blepharoplasty only with orbital fat removal can achieve a similar effect. The tear trough deformity that is visible in the static condition should be treated by ligament release, as shown in Figures 6 through 10. However, the surgical approach should be appropriately selected based on the laxity of the orbicularis oculi muscle and skin. Thus, we think that a transcutaneous approach may be preferential for the patient shown in Figure 10. Skin removal and tightening/suspending the orbicularis oculi can be performed simultaneously for better cosmetic outcome. It has been widely accepted that lifting is an essential step after releasing the tear trough ligament and orbicularis retaining ligament for treatment of the aging middle face, and that tissue suspension or repositioning seems unnecessary following the release of the two ligaments when aiming at correcting the periorbital groove. Although releasing the ligament does not lead to tissue ptosis in young patients or in short-term follow-up (as most of the cases presented in previously published articles), it is uncertain whether such a release procedure without suspension or repositioning will contribute to tissue ptosis over a long observation period such as 10 or 20 years. After all, a ligament, although it may create a depression or a crease/groove, may play a role in balancing the related tissue and preventing ptosis of tissue. DISCLOSURE The authors declare no potential conflicts of interest with the respect to the research, authorship, or publication. Qianwen Wang, M.D., Ph.D.Jiaqi Wang, M.D.Head & Neck Cosmetic Surgery CenterPlastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People’s Republic of China