Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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A Novel 3D Scanning Approach to Understanding the Relationship of the Arcus Marginalis and Tear Trough Deformity
Jillian E. Schreiber, BA1, Carrie S. Stern, MD1, Evan S. Garfein, MD1, Elizabeth B. Jelks, MD2, Glenn W. Jelks, MD2, Oren M. Tepper, MD1.
1Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA, 2NYU Langone Medical Center, New York, NY, USA.

Purpose
The tear trough deformity is a common complaint among aesthetic surgery patients. Various treatments have been described, including non-surgical methods with volume replacement, as well as surgical release of the arcus marginalis (AM) with some form of fat replacement or transposition. While some have supported the need for arcus marginalis release(AMR) in severe cases, scientific evidence for this viewpoint remains sparse. The following study used 3D photography and computer facial analysis to document changes in the tear trough in response to fat grafting and surgical release of the AM.
Methods
A cadaver study was undertaken in which fat grafting of the medial cheek compartment was performed bilaterally in order to improve contour of the lower eyelid and cheek junction. On one side, the AM was released surgically with a transconjuctival approach, while the contralateral side was left intact (n=4). Injections of fat analogue were performed at 0.5,1,2,3,4cc. 3D photographs were taken at each interval and used for analysis. Points along the tear trough were measured from the medial canthus to the mid pupil. Spatial changes of these points were analyzed at each interval. Surface changes of the lower lid were studied, including changes in volumetric augmentation set at lower limit of 1mm change from baseline.
Results
The pattern of change within the lower eyelid and tear trough was different depending on whether surgical AMR was performed. (Figure 1) For the hemiface with AMR, the mean volume change to the lower lid steadily increased with injection (0.1±0.1cc, 0.4±0.3cc, 1.0±0.5cc, 1.5±0.5cc, 2.0±0.6cc). In comparison, the lower eyelid volume did not significantly change for the side that was not released (0±0cc, 0.1±0.1cc, 0.2±0.1cc, 0.2±0.2cc, 0.4±0.2cc). (Figure 2) Improved projection of the tear trough was greatest at the midpoint between the medial canthus and midpupillary line for both hemifaces. However, the extent of projection in the tear trough was greater with AMR (1.3±0.5mm
vs. 0.7±0.7mm, 2.1±0.3mm vs. 1.3±1.0mm, 3.2±0.7mm vs. 1.5±1.2mm, 3.8±0.9mm vs. 1.5±1.5mm, 4.6±0.8mm vs. 2.4±1.2mm). This difference in projection resulted in a smoother mid-face contour for the hemiface in which the arcus was released. Notably, at no point up to 4cc injection did the non-released lower lid gain clinically relevant volume or projection.
Conclusions
Surgical release of the AM resulted in unique topographical changes to the lower lid in response to augmentation of the deep medial cheek. AMR allows expansion of fat analogue to the lower lid, resulting in a more unified mid-face contour compared to the restricted augmentation to the medial cheek without release. By creating an anatomical communication between the retro-orbicular space and deep malar fat compartments, lipostructure to the deep malar fat compartment results in softening of the lid-cheek junction and more pronounced correction of tear trough deformity.


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