Arcus marginalis effacement and support of the lower lid by malar skin-fat flap blepharoplasty.
Various methods have been proposed for correction of the arcus marginalis (the externally visible rim sulcus or dark circle) along the lower orbital rim. For correction of lagophthalmos and scleral show of the lower lid, the standard technique has been lateral tarsal suspension. Instead, this method of lower blepharoplasty employs (1) extramuscular undermining and advancement of the skin and malar fat pad overlying the lateral orbicularis and zygomaticus, and (2) direct undermining of the arcus marginalis at the surface of the orbicularis, but without preseptal lid skin undermining and with reduced orbital fat pad excision. This technique evolved over a period of 6 years and, since, has been employed successfully in 85 primary and secondary cases over 5 years. It offers effacement of the arcus marginalis and improved support of the lid margin without the need for tarsal suspension, even in secondary blepharoplasty and in patients with a positive snap test for lower lid marginal laxity. Reoperation has consisted of skin adjustment in 3 patients and an additional orbital fat pad resection in 2 patients. No patient has required secondary tarsal suspension.