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Patrick K. Sullivan, MD
Richard Kim, MD

Patrick K. Sullivan, MD
Dept of Plastic and Reconstructive Surgery
Brown University School of Medicine, Rhode Island Hospital
235 Plain St, Suite 502
Providence, RI 02905


A select group of patients request treatment for “the circles” under their eyes in addition to the “puffiness.” Some of the treatments designed to address this have led to lower eyelid malposition and irregularities along the orbital rim.


  1. Develop a low risk procedure to treat patients with tear trough and lid cheek junction deformities.
  2. Avoid injuries to both the orbicularis oculi muscle and orbital septum
  3. Elevate the posteriorly positioned arcus marginalis in the tear trough area, fill the space and prevent re adherence using vascularized tissue rather than free fat
  4. Fixation of the vascularized tissue throughout the lower lid under direct visualization precisely correcting the deformity and preventing variable resorption and irregularities that we have seen with free fat grafts


A transconjunctival incision is made about 5mm below the tarsus and proceeds through lower lid retractors. A retroseptal approach (Fig 5) is made to the arcus marginalis. The periorbita is incised posterior to the arcus marginalis and the arcus is carefully dissected anteriorly lifting it off the orbital floor from lateral to medial and then continuing the dissection in a subperiosteal plane to a level about 1 cm. below the orbital rim. The orbicularis oculi muscle is intrinsically associated with the arcus marginalis and periostium anteriorly and thus releasing the origin of the muscle creates a space. This space is filled by fat (Fig 6) that is transposed over the orbital rim to keep the arcus marginalis and orbicularis muscle from going back to its original position. The fat is kept in continuity with its blood supply. It is then sutured to the underside of the periosteum inferior to the arcus marginalis. This is done with a continuous running suture from medial to lateral (PDS). This technique is carefully altered to precisely treat each individual patient’s deformity.

Some patients have fat removed in addition, but many do not.

A lateral canthopexy is frequently done.

A temporary tarsorrhaphy is placed and frequently a temporary lateral traction suture as well.

A “skin pinch” excision technique is occasionally added to treat excessive lower lid skin but the transconjunctival approach is still used to prevent any trauma to the septum and orbicularis.

Figure 5 Figure 6


72 patients who had lower lid deformities were treated with a transconjunctival procedure.

A subset of 22 patients with lower eyelid fat herniation, tear trough and lid-cheek junction abnormalities had the transconjunctival retroseptal approach with fat transposition and internal continuous suture fixation

Figure 7 Figure 8
Figure 9

Figure 10


Both patient and physician satisfaction has overall been high. (Fig 7-10) We have had no ectropion or lower lid malpositions. One patient (Fig 11-14) had a second surgery for transconjunctival removal of additional fat, as we had been overly conservative.

Figure 11 Figure 12
Figure 13 Figure 14


  1. Diminished risk has been an advantage of this technique since the muscle and the orbital septum are not transected. The “no touch” technique encouraged by Dr. Glenn Jelks caused us to choose a retroseptal approach. This has less risk of ectropion and lower lid abnormalities because it does not transect the orbital septum or orbicularis muscle.
  2. After the arcus marginalis and orbicularis muscle is elevated from its posterior position in the orbit (which led to the tear trough and lower lid cheek junction abnormality) 1 a space is created that must be filled in order to prevent the deformity from recurring. The vascularized fat is placed where the patient needs it and suture fixation keeps it in that position.
  3. A smooth contour is obtained through this precise placement of vascularized tissue that has less chance for reabsorption or irregularities.
  4. The continuous suture along the orbital rim is entirely internal with no external pledgets, sutures or knots.

This procedure is beneficial for selected patients who have lower eyelid fat herniation, tear trough and lid cheek junction abnormalities. It is not indicated or needed in every patient.


1. Sullivan, P. K., Kim, R.Y., Singer, D.P., Woo, A.S. The Anatomic Basis for the Tear- Trough And Crescent Deformity at the Lower Eyelid-Cheek Junction, American Society of Plastic Surgeons Meeting, San Diego, CA, October 2003 Albert S. Woo MD



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