Commentary on: A Novel Method for Lower Blepharoplasty: Repositioning of the Orbital Septum Using Inverted T-Shaped Plication

Commentary on: A Novel Method for Lower Blepharoplasty: Repositioning of the Orbital Septum Using... The authors have designed a truly innovative treatment of the septum orbitale for lower eyelid rejuvenation.1 In 1988, Dr Mendelson2 and I, during his visit to Dallas, compared our experience utilizing the de la Plaza3 technique that we learned from the author of that technique. The logic was a simple plication of the septum orbitale, which would tighten the redundancy of the septum caused from aging. This essentially caused the septum to “push back” the subseptal orbital fat to its original youthful position in the orbit. The suture technique was a very simple horizontal “smile” pattern, which at the time seemed superior to fat removal in patients with minimal excess fat. At that time there was no attention paid to the eyelid−cheek junction, as the suture technique was designed to obscure the appearance of aging lower eyelids that had the appearance of excess subseptal fat. My experience was almost always in an aging European population, who frequently was undergoing facelift procedures. Although the results seem gratifying at first, after many months the tighter contour of the lower lids seem to slacken and the initial youthful contour frequently resulted in a suboptimal result. In the cases of young patients with a true excess of inherited fat, the technique could never really push the excess fat into the subseptal space. The authors in this paper have modified the suture technique, which seems to actually double the thickness of the septum in its lower half, which of course makes a lot of sense, since when the patient is standing, the subseptal fat influencing the lower eyelid contour, like all parts of the aging face, descend, resting over the arcus marginalis at the eyelid−cheek junction. The authors show impressive results, particularly in a younger population of Asian patients. After my disappointment in 1990 with the suture techniques of de la Plaza as well as with the fat removal techniques,4 which had been practiced for over 50 years in plastic surgery, my technique evolved to the arcus marginalis release5 with preservation of the fat and transposition of the orbital fat across the orbital rim. While this provided frequent positive results in improving the eyelid cheek junction, it still was not optimal. I then modified it by preserving the septum and resetting the inferior septal border inferiorly over the orbital rim. I called this a “septal reset.”6 The theory here was that the eyelid would now sit on a firm structure, since without the septum included in the reset, the fat without the septum was difficult to suture and maintain. Since that time, I have utilized it for essentially every patient having lower eyelid rejuvenation procedures. The only time I find the transconjunctival7 approach helpful is the rare case of a very young patient with excess lower eyelid fat and if only a small amount of medial excess fat need be removed. In these cases, I depend on the young lower eyelid skin and muscle to contract, as in the case of liposuction for the young patients, so there is no appearance of excess skin remaining. Unfortunately, in older patients, skin does not shrink and there is often the appearance of a hollow eye that occurs. I am not sure why the X or Y techniques are helpful with a true septal reset. When one does an arcus marginalis release, the pattern of the inferior septal border is smaller than the semicircular recipient site of the preperiosteum soft tissue. Therefore, it would seem counterproductive to do the X or Y, which would shorten the semicircular lower border of the septum. The authors show very impressive results with the Asian population, who generally have excellent skin types, as opposed to many European descended patients. I am pleased that the authors have referenced my articles on the septal reset, but the one very important factor that I find necessary to achieve optimal results is the cheeklift utilizing the zygomaticus-orbicularis flap,8 which is distinctly different from a subperiosteal cheeklift. I feel like the lower eyelid−cheek complex extends lower than the lower border of the orbicularis oculi muscle and that this complete complex must be lifted in a superior medial vector and placed over the septal reset to achieve the two characteristics that a young face must have—an absent eyelid cheek junction and a high cheek mass (Figure 1). The septal reset that I have described needs a recipient site of soft tissue to suture the distal septal edge in place. A subperiosteal dissection disallows suturing the septal reset since the periosteum has been stripped off of the boney orbital rim. Optimal results are achieved when there is a true cheeklift, which is impossible with the transconjunctival approach. For that reason, I routinely use a subciliary incision, allowing the cheek flap to be suspended and fixed to the lateral orbital rim in a superior medial vector. Figure 1. View largeDownload slide (A) A 53-year-old woman with (B) one-year postoperative results following a composite rhytidectomy and forehead lift utilizing a septal reset and a zygomaticus-orbicularis cheeklift. All of the orbital fat was utilized and transposed inferiorly with the septal reset. The absent eyelid−cheek junction and high cheek mass are the sine qua non of a comprehensive facial rejuvenation. Figure 1. View largeDownload slide (A) A 53-year-old woman with (B) one-year postoperative results following a composite rhytidectomy and forehead lift utilizing a septal reset and a zygomaticus-orbicularis cheeklift. All of the orbital fat was utilized and transposed inferiorly with the septal reset. The absent eyelid−cheek junction and high cheek mass are the sine qua non of a comprehensive facial rejuvenation. The true measure of any surgical technique is longevity. The long-term results for the septal reset and zygomaticus orbicularis flap that I have used since 1998 attest to the stability of the created youthful eyelid cheek junction after many years. The patient in Figure 2 is 14 years postoperative composite facelift with septal reset. The absent eyelid cheek junction and the high cheek mass are maintained. Figure 2. View largeDownload slide (A) This 65-year-old woman underwent a composite facelift, septal reset, and rhinoplasty. Her (B) one year and (C) 14-year postoperative results are shown. The elevated cheek mass and septal reset have remained stable. Figure 2. View largeDownload slide (A) This 65-year-old woman underwent a composite facelift, septal reset, and rhinoplasty. Her (B) one year and (C) 14-year postoperative results are shown. The elevated cheek mass and septal reset have remained stable. I congratulate the authors on their innovative technique, which no doubt has great use for many types of patients. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Pak C, Yim S, Kwon H, et al.   A novel method for lower blepharoplasty: repositioning of the orbital septum using inverted T-shaped plication. Aesthet Surg J . 2018. doi: 10.1093/asj/sjy010. [Epub ahead of print] 2. Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg . 1993; 20( 2): 323- 330. Google Scholar PubMed  3. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg . 1988; 81( 5): 677- 687. Google Scholar CrossRef Search ADS PubMed  4. Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg . 1998; 102( 5): 1658- 1666. Google Scholar CrossRef Search ADS PubMed  5. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg . 1995; 96( 2): 354- 362. Google Scholar CrossRef Search ADS PubMed  6. Hamra ST. The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg . 2004; 113( 7): 2124- 2141; discussion 2142. Google Scholar CrossRef Search ADS PubMed  7. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg . 2000; 105( 2): 743- 748; discussion 749. Google Scholar CrossRef Search ADS PubMed  8. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg . 1998; 102( 5): 1646- 1657. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: A Novel Method for Lower Blepharoplasty: Repositioning of the Orbital Septum Using Inverted T-Shaped Plication

Aesthetic Surgery Journal , Volume Advance Article (7) – Apr 25, 2018

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

The authors have designed a truly innovative treatment of the septum orbitale for lower eyelid rejuvenation.1 In 1988, Dr Mendelson2 and I, during his visit to Dallas, compared our experience utilizing the de la Plaza3 technique that we learned from the author of that technique. The logic was a simple plication of the septum orbitale, which would tighten the redundancy of the septum caused from aging. This essentially caused the septum to “push back” the subseptal orbital fat to its original youthful position in the orbit. The suture technique was a very simple horizontal “smile” pattern, which at the time seemed superior to fat removal in patients with minimal excess fat. At that time there was no attention paid to the eyelid−cheek junction, as the suture technique was designed to obscure the appearance of aging lower eyelids that had the appearance of excess subseptal fat. My experience was almost always in an aging European population, who frequently was undergoing facelift procedures. Although the results seem gratifying at first, after many months the tighter contour of the lower lids seem to slacken and the initial youthful contour frequently resulted in a suboptimal result. In the cases of young patients with a true excess of inherited fat, the technique could never really push the excess fat into the subseptal space. The authors in this paper have modified the suture technique, which seems to actually double the thickness of the septum in its lower half, which of course makes a lot of sense, since when the patient is standing, the subseptal fat influencing the lower eyelid contour, like all parts of the aging face, descend, resting over the arcus marginalis at the eyelid−cheek junction. The authors show impressive results, particularly in a younger population of Asian patients. After my disappointment in 1990 with the suture techniques of de la Plaza as well as with the fat removal techniques,4 which had been practiced for over 50 years in plastic surgery, my technique evolved to the arcus marginalis release5 with preservation of the fat and transposition of the orbital fat across the orbital rim. While this provided frequent positive results in improving the eyelid cheek junction, it still was not optimal. I then modified it by preserving the septum and resetting the inferior septal border inferiorly over the orbital rim. I called this a “septal reset.”6 The theory here was that the eyelid would now sit on a firm structure, since without the septum included in the reset, the fat without the septum was difficult to suture and maintain. Since that time, I have utilized it for essentially every patient having lower eyelid rejuvenation procedures. The only time I find the transconjunctival7 approach helpful is the rare case of a very young patient with excess lower eyelid fat and if only a small amount of medial excess fat need be removed. In these cases, I depend on the young lower eyelid skin and muscle to contract, as in the case of liposuction for the young patients, so there is no appearance of excess skin remaining. Unfortunately, in older patients, skin does not shrink and there is often the appearance of a hollow eye that occurs. I am not sure why the X or Y techniques are helpful with a true septal reset. When one does an arcus marginalis release, the pattern of the inferior septal border is smaller than the semicircular recipient site of the preperiosteum soft tissue. Therefore, it would seem counterproductive to do the X or Y, which would shorten the semicircular lower border of the septum. The authors show very impressive results with the Asian population, who generally have excellent skin types, as opposed to many European descended patients. I am pleased that the authors have referenced my articles on the septal reset, but the one very important factor that I find necessary to achieve optimal results is the cheeklift utilizing the zygomaticus-orbicularis flap,8 which is distinctly different from a subperiosteal cheeklift. I feel like the lower eyelid−cheek complex extends lower than the lower border of the orbicularis oculi muscle and that this complete complex must be lifted in a superior medial vector and placed over the septal reset to achieve the two characteristics that a young face must have—an absent eyelid cheek junction and a high cheek mass (Figure 1). The septal reset that I have described needs a recipient site of soft tissue to suture the distal septal edge in place. A subperiosteal dissection disallows suturing the septal reset since the periosteum has been stripped off of the boney orbital rim. Optimal results are achieved when there is a true cheeklift, which is impossible with the transconjunctival approach. For that reason, I routinely use a subciliary incision, allowing the cheek flap to be suspended and fixed to the lateral orbital rim in a superior medial vector. Figure 1. View largeDownload slide (A) A 53-year-old woman with (B) one-year postoperative results following a composite rhytidectomy and forehead lift utilizing a septal reset and a zygomaticus-orbicularis cheeklift. All of the orbital fat was utilized and transposed inferiorly with the septal reset. The absent eyelid−cheek junction and high cheek mass are the sine qua non of a comprehensive facial rejuvenation. Figure 1. View largeDownload slide (A) A 53-year-old woman with (B) one-year postoperative results following a composite rhytidectomy and forehead lift utilizing a septal reset and a zygomaticus-orbicularis cheeklift. All of the orbital fat was utilized and transposed inferiorly with the septal reset. The absent eyelid−cheek junction and high cheek mass are the sine qua non of a comprehensive facial rejuvenation. The true measure of any surgical technique is longevity. The long-term results for the septal reset and zygomaticus orbicularis flap that I have used since 1998 attest to the stability of the created youthful eyelid cheek junction after many years. The patient in Figure 2 is 14 years postoperative composite facelift with septal reset. The absent eyelid cheek junction and the high cheek mass are maintained. Figure 2. View largeDownload slide (A) This 65-year-old woman underwent a composite facelift, septal reset, and rhinoplasty. Her (B) one year and (C) 14-year postoperative results are shown. The elevated cheek mass and septal reset have remained stable. Figure 2. View largeDownload slide (A) This 65-year-old woman underwent a composite facelift, septal reset, and rhinoplasty. Her (B) one year and (C) 14-year postoperative results are shown. The elevated cheek mass and septal reset have remained stable. I congratulate the authors on their innovative technique, which no doubt has great use for many types of patients. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Pak C, Yim S, Kwon H, et al.   A novel method for lower blepharoplasty: repositioning of the orbital septum using inverted T-shaped plication. Aesthet Surg J . 2018. doi: 10.1093/asj/sjy010. [Epub ahead of print] 2. Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg . 1993; 20( 2): 323- 330. Google Scholar PubMed  3. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg . 1988; 81( 5): 677- 687. Google Scholar CrossRef Search ADS PubMed  4. Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg . 1998; 102( 5): 1658- 1666. Google Scholar CrossRef Search ADS PubMed  5. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg . 1995; 96( 2): 354- 362. Google Scholar CrossRef Search ADS PubMed  6. Hamra ST. The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg . 2004; 113( 7): 2124- 2141; discussion 2142. Google Scholar CrossRef Search ADS PubMed  7. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg . 2000; 105( 2): 743- 748; discussion 749. Google Scholar CrossRef Search ADS PubMed  8. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg . 1998; 102( 5): 1646- 1657. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Aesthetic Surgery JournalOxford University Press

Published: Apr 25, 2018

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