Possible Long-term Effects from Arcus Marginalis Release?

Question

It just seems like cutting that muscle may contribute to facial sagging in the future or something awful, since it's a muscle in your face. What are any possible long term effects from arcus marginalis release?

Kenneth D. Steinsapir, MD · Answer

Dear Snuggly,
The arcus marginalis is a diaphanous fascial condensation formed where the lower eyelid septum inserts into the dense periosteal covering along the orbital rim. The orbital septum is a plane of connective tissue that separated the contents of the orbit from the eyelids. As such, the lower eyelid septum effectively holds back the lower eyelid fat.
Classic lower eyelid cosmetic surgery involves making a cut through the lower eyelid skin, muscle and septum to gain access to the lower eyelid fat. The fat is resected and "excess" skin and muscle are then trimmed and sutured closed. We now understand that this almost always results in a hollow, pulled down lower eyelid with distortion of the shape of the lower eyelid and the outer corner of the lower eyelid.
The transconjunctival lower eyelid surgery was re-popularized by the UCLA eye plastic surgery division at the Jules Stein Eye Institute in the mid-eighties. This procedure was done behind the lower eyelid so there was no skin incision. It was the ideal surgery for a younger person whose issue was just a little too much lower eyelid fat. It continues to be a fantastic option for the right individual. Like any procedure, when performed on the wrong person or over done, it can lead to problems, the most common being a lower eyelid deflation making the undereye circle worse.
In an effort to improve results, again the UCLA eye plastic surgery division lead by Robert Goldberg, M.D., repopularized the procedure now known as the arcus marginalis release in the mid nineties. However, this procedure was first described by Raoul Loeb, a Brazilian plastic surgery, who first reported the procedure in 1981. The concept is centered on the observation that for many individuals seeking help with the lower eyelid, there is a convexity/concavity effect. The lower eyelid is too full but the area just under the eye, the nasojugal goove or tear trough hollow, lacks fullness. This lack of fullness is related to a descent of the cheek soft tissues. The surgery is performed again transconjunctivally, or from behind the lower eyelid.
It is not accurate to depict the procedure as a lifting of the arcus marginalis. The surgery can actually be performed in several aways. The bone covering can be incised and elevated off the orbital rim. This leaves the septum and its insertion into the periosteum or bone cover intact. Or the arcus marginalis can be cut along the orbital rim just above its insertion into the periosteum at the orbital rim. In the former, a subperiosteal pocket is made to receive the lower eyelid fat, and in the later the pocket is made just above this level over the cheek periosteum. There are no studies that suggest that one approach is better than another. Fat from the lower eyelid is then sutured into these pockets. The effect of surgery is less fullness in the lower eyelids and more fullness in the tear trough hollow.
Long term, the surgery provides a modest improvement in both the lower eyelid and the top of the cheek. It is much more predictable than inject fat grafts into this same space but it is not quite as predictable as filling the tear trough with Restylane.

David Shafer, MD, FACS · Answer

The arcus marginalis release is only releasing the connection of the muscle and not the muscle itself.  This helps soften the transition between the lid and cheek and allows for redraping of the orbital fat.  If done properly, you should have no long-term negative effects.  If you are having fat grafting concurrently, this should also have no negative long-term effects if done properly.  Good luck with your procedure.

Brent Moelleken, MD · Answer

The arcus marginalis is not a muscle and there are no long-term effects known from its division.  Since it is a part of the orbital septum, it is possible that during or after surgery scarring can occur in the layer and cause lid retraction.
We have essentially abandoned the procedure however because the fat that is spilled over the edge in an attempt to blunt the eye-cheek junction often balls up long term and a bulge reappears.
You may wish to read our book chapter on this subject for further anatomical diagrams, etc.

Daniel Reichner, MD, FACS · Answer

The Arcus Marginalis(AM) is the bone attachment of the orbital septum. Think of the orbital septum as a "dam" holding back the lower eyelid fat and the AM is at the bottom of the dam. As we age, the orbital septum loses its elasticity and begins to bulge out forming a "bag".  The rate at which we lose this elasticity is different from person to person and depends on many factors.  This bulging is also enhanced by the deflation and dropping of the cheek and sub-obicularis oculi fat pads - just like the outgoing tide reveals the rocks on the beach.  
In the past, many surgeons thought that there was too much orbital fat and the treatment of choice was to remove this excess fat.  However, as the aging process continues, this approach leaves a skeletonized or hollow appearance.  
I believe a better approach is to release the AM, reposition the orbital fat into the deflated upper cheek and tear trough. There are still limitation for this approach, including the lack of volume for a full correction, accurate positioning of the orbital fat and dealing with the orbital septum.
I think the best approach is a composite correction involving upper cheek fillers/fat grafting, correction of fat pseudo-herniation with the orbital septum tightening/conservative orbital fat excision and addressing canthal tendon, tarsal plate and eyelid skin elasticity, laxity and excess. Each of these areas should be addressed in the surgical plan, however not everyone will require all of the corrections.
I recommend that you seek consultation with a Board Certified Plastic Surgeon who understands this composite approach to lower eyelid, peri-orbital soft tissue and upper cheek rejuvenation.

William Portuese, MD · Answer

There should be no long-term effects of the arcus marginalis release as long as the brows have been put up to the new anatomical position.  Once they have been suspended and sutured in place, the scar tissue will reattach the arcus marginalis to a new level, which will be permanent.

Possible Long-term Effects from Arcus Marginalis Release?

Answers (8)

Answer: Arcus Marginalis Release

Answer: Arcus Marginalis Release

Answer: No long term effects

Answer: No long term effects

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Possible Long-term Effects from Arcus Marginalis Release?

Answers (8)

Answer: Arcus Marginalis Release

Answer: Arcus Marginalis Release

Answer: No long term effects

Answer: No long term effects

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Everything you need to know about Eyelid Surgery

Our mission is to create a world where every investment in modern beauty is Worth It.