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

Abstract

Sir: We thank Dr. Hwang for his detailed review of our article1 and for sharing data from his previous published studies.2,3 With regard to Figure 11, the numbers indicated on our diagram represent the average distances of key landmarks at various points. These measurements were taken from our previous cadaver dissection studies of 60 hemifaces.4,5 The figures 6 mm and 5 mm denote the distance of the orbital rim/arcus marginalis to the orbicularis retaining ligament at the midpupil and lateral canthus, respectively. The measurement 8 mm indicates the average span of the origins of the palpebral parts of the orbicularis oculi, tear trough ligament, and orbital parts of the orbicularis oculi. The measurements 7 mm and 5 mm indicate the average distances between the superior and inferior lamella of the orbicularis retaining ligament. The orbicularis retaining ligament continues at the lateral orbit as the lateral orbital thickening, and here the distance widens to approximately 10 mm. Dr. Hwang presented some measurements from his previous studies and cited two articles for these data. In the article that studied the origins of the orbicularis oculi and its relations to the tear trough,2 we agree with the authors’ findings that the origins of the palpebral parts of the orbicularis oculi were located 0.1 to 0.7 mm inferior to the orbital rim. Furthermore, as Dr. Hwang noted in the article, the origins of the orbicularis oculi on the anterior maxilla end at approximately the medial pupil line, which we also agree with. Measurements on the span of the origin of the orbicularis oculi (the combined palpebral and orbital parts of the orbicularis oculi) were generally in agreement with our measurements.4 However, there were some confusing descriptions in the article that we hope to be able to clarify. The surface grooves that we see on the midcheek are caused by facial retaining ligaments and not by the muscles of facial expressions such as the orbicularis oculi. The anatomical origin of the tear trough deformity is the tear trough ligament, an osteocutaneous ligament that arises from the anterior maxilla and inserts into the dermis at the tear trough deformity. Contrary to what was stated in the article by Hwang et al.,2 the orbicularis oculi is not responsible for the tear trough deformity. Contraction of the palpebral and orbital parts of the orbicularis oculi, located cephalad and caudal to the tear trough ligament, does accentuate the tear trough deformity by causing the orbital fat above to bulge forward against the strong fixation provided by the tear trough ligament. The main etiologic factor in the tear trough deformity is the fixation provided by the tear trough ligament. This is evident when one examines photographs of patients when they smile before and after surgical release of the tear trough ligament. Before surgery, contraction of the orbicularis oculi accentuates the tear trough deformity (Fig. 1, above). After surgical release of the tear trough ligament and the origins of the orbicularis oculi, when the patient smiles, the orbicularis oculi is still contracting and functioning normally (as is evident by the bulging of the pretarsal orbicularis), but the previous tethering at the location of the tear trough has been surgically eliminated and is no longer present (Fig. 1, below).Fig. 1.: (Above) When the patient smiles, the contraction of the orbicularis oculi pushes the orbital fat forward against the strong fixation provided by the tear trough ligament, causing a deep groove on the skin, accentuating the tear trough deformity. (Below) After surgery, with contraction of the orbicularis oculi, the tear trough is no longer present and the fixation by the tear trough ligament has been eliminated by its surgical release. This demonstrates that the tear trough ligament is the primary etiologic factor for the tear trough deformity and not the orbicularis oculi, which is still contracting and functioning normally after surgery, as evident by the continued presence of the pretarsal bulge and crow’s feet with smiling after surgery.More laterally, the orbicularis retaining ligament is present to bind the midcheek skin to the anterior maxilla, and is the anatomical cause of the palpebromalar groove. The orbicularis oculi, located in the roof of the prezygomatic space, is not directly attached to the underlying zygoma here. In the lateral orbit, the orbicularis retaining ligaments continue as the lateral orbital thickening. The lateral orbital thickening was the structure that was measured by Dr. Hwang in his second article as the lateral periorbital ligament.5 These measurements were consistent with our measurements.4,5 Finally, with regard to the terminology, indeed, nasojugal groove is the accepted anatomical name for this surface anatomy landmark. The term “tear trough groove” was introduced by Flowers6 to describe the deepened groove as an aesthetic deformity. Since then, tear trough and nasojugal groove have been used interchangeably and are accepted to refer to the same structure. We used the term tear trough ligament, as the term has become widely used in the surgical and nonsurgical fields of plastic surgery, and in aesthetic medicine. DISCLOSURE The authors declare no conflict of interest in this present work. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Chin-Ho Wong, M.Med.(Surg.), F.A.M.S.(Plast. Surg.)W Aesthetic Plastic SurgerySingapore Bryan Mendelson, F.R.C.S.(Ed.), F.R.A.C.S.The Centre for Facial Plastic SurgeryToorak, Victoria, Australia