For lower eyelids, is "arcus marginalis release" the same procedure as "fat repositioning"?

I'm middle aged with puffy lower eyelids. I've talked to two plastic surgeons and I'm still confused about terminology. Are arcus marginalis release (AMR) and fat repositioning two ways of saying the same thing, or is AMR one of several technique that can be used to reposition fat in the lower eyelid area? Is it possible to do a fat repositioning blepharoplasty without doing arcus marginalis release? If so, what are the different techniques for repositioning fat that I should ask about?

Doctor Answers 13

Arcus release and transposition are related but not the same

The arcus marginalis is the ligamentous attachment of the  cheek/lower eyelid skin and muscle to the inferior orbital rim.   The reason why this area of anatomy is important is because the "tear trough hollow" which is a major source of most people's concern when they consider lower blepharoplasty is caused by this attachment.   An arcus marginalis release  can be performed as an isolated procedure during lower blepharoplasty with or without fat removal or transposition. 

Most commonly, we will perform a transposition of the inferior orbital fat (these fat pads create the lower eyelid fullness that many people called bags)  along with an arcus marginalis release  which can be a more substantial and powerful recontouring maneuver for the right patients.  This is the approach I use for greater than 90% of my patients-  I've published this in JAMA Facial Plastic Surgery (sept/oct  2015 issue). The article has many detailed images on the subject that can be very informative. 

This is certainly worth a detailed discussion with facial cosmetic surgeon who is experienced with these techniques. Each individual human has unique anatomy and the lower eyelid/midface surgery should be customized for each individual's particular anatomy and goals. Good luck! 

Austin Oculoplastic Surgeon
5.0 out of 5 stars 23 reviews

Lower blepharoplasty with fat repositioning with arcus marginalis release

Fat repositioning during lower blepharoplasty moves the fat/bags to lower position to fill the hollow area. The fat is either repositioned deep or superficial to the periosteum, which is a tissue covering the cheek bone. Arcus marginalis release refers to placing the fat deep to the periosteum.  Studies have shown it doesn't make a difference if fat is placed deep or superficial to the periosteum but I personally place it deep to the periosteum as I believe it will avoid any bumpiness and also it results in quicker healing since less bruising with this technique.

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 72 reviews

Arcus marginalis release and fat repositioning

Great question. The answer is those are two separate maneuvers performed to achieve one goal: improve the depression (or "sunken") look under the lower eyelid. The Arcus tissue is released from the orbital bone in order to allow passage of the lower eyelid fat over the bone into the cheek area. This renders a smoother look, which ultimately is more youthful. I hope this helps. 

Arnold Almonte, DO
Roseville Plastic Surgeon
4.9 out of 5 stars 31 reviews

Arcus marginalis vs fat repositioning... What is the difference?

This is a very smart question.

Lets start by saying that the arcus marginalis are attachments from the bone to the skin that create the indentation between your lower eyelids and bulgy bags, and your cheek. Releasing this structure will help effacing this trait.

Fat repositioning is the transfer of fat from the eyelids to the arcus marginalis area to prevent the indent of the area.

Truly there are complementary procedures. One destroys the attachment. The other one helps create padding in an area that is desirable to prevent scaring from recreating the indent.

Wishing you the best in your journey

Fat repositioning

Yes, I believe the two doctors are describing the same thing.  The arcus marginalis is the surface anatomy marker of an attachment point of your lower eyelid to the lower bony rim.  This is the point where the "bag" ends in lower lid baggy deformities.

Years ago, there was a tendency to only remove fat from the lower lid to correct the bag.  We..."emptied" the bag.  We have learned that, over time, this created its own deformity and, in fact, made the patient look older.

Now, we are more likely to release the attachment, and reposition the "bag" fat more evenly across the lower lid and cheek. It can be done through the lid skin or through the conjunctiva (inside the lid).  The lid does need good suspension when this is done, but the results are much better. It is a trickier procedure then just taking out some fat.  Once the arcus marginalis attachment is released, the fat is mobilized from it's native position and moved beneath the site where the arcus marginalis was formally attached.  Sometimes it is secured there with self absorbing suture. Some excess skin can be removed after this, and the lid is typically checked to be sure that it is tight enough to avoid post operative lag...ectropion / scleral show.  Several techniques are available to correct lid laxity.           

Mark A. Brzezienski, MS, MD, FACS
Chattanooga Plastic Surgeon
4.3 out of 5 stars 8 reviews

Lower eyelid surgery

Hello Erdberdb-
'Puffy' lower eyelids usually imply that you have fat bulges with a concomitant lower lid trough that extends along the bony orbital rim. If there is also loose skin, then an external approach would be helpful to also remove any extra skin/muscle. That fat is best released from its compartments and sewn over the rim to help fill out the depressed 'trough' area and then remove any excess fat that remains. Releasing the tissues (Arcus marginalis) along the orbital rim also helps with this feathering. 
If your skin is tight, then an internal (transconjunctival) approach can be used to release the tissues along the rim and remove the excess orbital fat pads, followed by fat transfer with a cannula to the eyelid trough.
Good luck.

Mark Anton, MD, FACS
Newport Beach Plastic Surgeon
5.0 out of 5 stars 37 reviews

Eyelid surgery techniques

There are many different techniques for lower lid surgery and each surgeon gas their preference.  I am not a fan of fat repositioning.  I prefer the fat removal instead.  The problem with fat repositioning is that it may not hold up over the leg term, whereas with fat removal instead, the fat will not return.  The acts release I think is useless.

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 27 reviews

The arcus is released to allow for fat repositioning

which is favored by most plastic surgeons.  So technically arcus release and fat repositioning are the same.  Oculoplastic surgeons in my town prefer to simply remove the fat with the transposition or repositioning.  I prefer the fat repositioning as it preserves the fat and has less tendency to allow the eyes to become hollow as you age.  Both removal and repositioning of fat create excellent early results but I am thinking long term when doing such procedures and repositioning is a far superior technique in my opinion.

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 33 reviews

For lower eyelids, is "arcus marginalis release" the same procedure as "fat repositioning"?

If fat re-positioning is needed than sometimes the AMR is combined to help allow the fat re-positioning.  Sometimes the AMR is not needed to allow the fat o be re-positioned.

Fred Suess, MD (retired)
San Francisco Plastic Surgeon
4.5 out of 5 stars 8 reviews

Lower blepharoplasty procedure for puffy eyelids

 The primary goal of lower eye lid surgery is to get rid of puffiness look with either a removal or repositioning of the lower eyelid fat. Choose your surgeon based on results( in their photo gallery), rather than trying to pick which procedure is best the patient. It is far too technical  for the patient is to understand  the nuances and differences  in  the procedure.  In our practice we remove a conservative amount of fat to rejuvenate the  eyelid and pinch excess skin when needed

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 143 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.