Download Title: The Anatomic Basis for the Tear Trough and Crescent

Title: The Anatomic Basis For The Tear Trough and Crescent Deformities at the Lower Eyelid - Cheek
Junction
Authors: Patrick K. Sullivan, MD, Richard Y. Kim, MD, David P. Singer, MD, and Albert S. Woo,
MD.
Purpose: The clinical manifestations of eyelid deformities are extremely variable and tend to be
genetically mediated. The tear trough and crescent deformities are pervasive complaints amongst
patients seeking to improve the appearance of their lower eyelid region. The arcus marginalis, defined
as the confluence of the orbital septum and periosteum, has been determined to be a key component in
this deformity pattern. The purpose of our study is to examine the position of the arcus marginalis and
measure its relationship with the infraorbital rim through cadaver dissections. Our goal is to come to a
more precise understanding of how the arcus marginalis position can bring about these deformities at
the lower eyelid – cheek junction. Ultimately, we aim to enhance the efficacy of arcus marginalis
release with lower lid blepharoplasty and facial rejuvination surgery in each individual patient.
Methods: Dissection of the eyelid and cheek region with analysis of the orbital septum and arcus
marginalis position was carried out on 17 caucasian cadavers obtained from the Brown Medical School
anatomy course. Of these cadavers, 22 periorbital regions could be accurately measured, 13 from male
cadavers and 9 from females. Measurements of the orbital septal attachment into the orbital floor were
taken at 5mm intervals starting from the medial canthus and continuing laterally along the infraorbital
rim to the lateral canthus. Two measurements were taken at each interval, the first being the anteriorposterior distance from the arcus marginalis to the superior apex of the infraorbital rim, and the second
being the distance form the arcus marginalis to the most anterior extent of the infraorbital rim.
Results: In both male and female cadavers, the arcus marginalis was found to insert posterior to the
superior most point of the infraorbital rim. The distance between the arcus marginalis and the
infraorbital rim varied from medial to lateral. In male cadavers, the distance between the arcus
marginalis and the superior apex of the infraorbital rim measured 4.8mm (3-6) medially to 1mm
(1.0mm) laterally. In the female cadavers, this measured 2.9mm (1-5mm) medially to 1mm (1mm)
laterally. The distance to the most anterior point of the infraorbital rim measured 8mm (6-9) medially
to 1.8mm (1-4mm) laterally in the male cadavers. In the female cadavers, the distance to the most
anterior point measured 5.7mm (4-7mm) medially to 1.3 mm (1-2mm) laterally.
Discussion: Our goal is to determine the anatomic basis for the tear trough and crescent deformities so
to optimally blend the lower lid cheek junction in each individual patient. From cadaveric dissections,
we have come to three conclusions: First, medially the arcus marginalis attaches posterior to the actual
orbital rim as it meets the orbital floor. However, the actual measurement varies dramatically, as does
the deformity, in individual patients. Secondly, the attachment sweeps anteriorly as it goes from medial
to lateral, but again the amount is variable (figure 1 A-C). This information is useful when planning
each surgery, as some individuals have a full crescent deformity, or “deep circle”, extending laterally all
the way around the lid – cheek junction (figure 2 A-B). Thirdly, the distance of the orbital septal
attachment posteriorly from the infraorbital rim differs between males and females. In performing an
arcus marginalis release, it should be noted that the inferior oblique muscle has previously been found to
originate 5.14 mm +/-1.21 posterior to the central infraorbital rim. Hence, special care should be taken in
the central release of the arcus marginalis in male patients, as not to injure the inferior oblique muscle.
Our surgical approach has centered around individualizing each surgical procedure to address the
specific anatomic deformity. We have been able to perform this arcus marginalis and fat repositioning
primarily through a transconjunctival approach using internal suture.
Figure 1: The position of the arcus marginalis from medial to lateral.
A- The arcus marginalis at its most medial and posterior position.
B- Centrally
C- Laterally, with some periosteal fibers blending over the infraorbital rim apex.
Figure 2:
A- A patient with full crescent deformities at the lower eyelid-cheek junction, pre-operatively.
B- The same patient post-operatively, after undergoing facial rejuvenation, including an arcus
marginalis release with fat repositioning, performed via a transconjunctival approach.