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Topic 17 - 10
Lower Eyelid Pretarsal Fullness:
A Sign of Aging?
festoons malar mounds Lower Eyelids tissue sparing lower blepharoplasty

Some patients object strongly to a roll of tissue that appears just below the lashes of the lower eyelid only upon smiling or squinting, complaining that it makes them look older. The roll is generated by contracting orbicularis muscle that courses between the skin and the underlying tarsal plate ("pretarsal orbicularis muscle"). The muscle is sometimes described as abnormally "hypertrophic," meaning over-developed.

Removing a strip of muscle at this location is not that difficult and so it's been tempting in years past to comply with such patient requests. Orbicularis muscle trimming can be performed as either a stand-alone procedure or as part of a transcutaneous lower blepharoplasty.

In our opinion, the operation is ill-conceived and should seldom, if ever, be undertaken.

The pretarsal orbicularis muscle is an important component of an intricate support system that holds the lower eyelid edge into proper position against the eyeball and helps pump the tears across the eye surface and into the opening of the tear drainage system.

One might think that removing a small strip of what seems like a large muscle would be harmless in younger and middle-aged patients who still possess excellent muscle strength accompanied by strong support from the canthal tendons. The problem arises in later years. Once the support system ages, absence of a healthy orbicularis muscle in this crucial position can serve as the "straw that breaks the camel's back," allowing the overly relaxed eyelid edge to drift away from the eye's surface (ectropion) and cause eye irritation and overflow tearing.

Ironically, this "objectionable" roll of orbicularis muscle that so bothers too many patients is actually a sign of youth and best developed during childhood to middle age, after which it typically thins as time passes.

Like other misguided components of overly aggressive "classical lower blepharoplasty," this is a clear example of surgery undertaken to make the face look younger that, in fact, accomplishes precisely the opposite effect.

Interestingly, in East Asia and particularly South Korea, it is not uncommon for very young woman who lack this natural roll of muscle to request implant surgery to create one (the" Love Band operation," shown in the lady just below). Why do they request it? That's right: to look younger.

love band operation

• • •

The following surgery series is provided for archival purposes and because the operation is still in use.

Trimming of "Hypertrophic"
Orbicularis Muscle

Roll of tissue present only when patient smiling

Skin incised just below the lashes

Dissection of a narrow but long strip of muscle

Orbicularis muscle strip removed

Tiny amount of excess skin outlined

Excess skin removed; incision sutured

Next: Tissue-Sparing Lower
Eyelid Blepharoplasty

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Frank Meronk, Jr., M.D.
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