How can I ensure complete release of the tear‑trough (orbicularis‑retaining) ligament during lower‑lid blepharoplasty?

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Last updated: February 28, 2026 • View editorial policy

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Complete Release of the Tear Trough (Orbicularis-Retaining) Ligament in Lower Blepharoplasty

To ensure complete release of the tear trough ligament during lower-lid blepharoplasty, sequentially release the palpebral orbicularis oculi origins, the tear trough ligament itself, and the orbital orbicularis oculi origins from medial to lateral, connecting your dissection plane from the preseptal space through the premaxillary space medially and the prezygomatic space laterally. 1

Surgical Technique for Complete Release

Access and Initial Dissection

  • Enter the preseptal space through a transconjunctival incision, which provides excellent exposure while minimizing complications like ectropion or lower lid retraction 1
  • Alternatively, a transcutaneous approach with CO2 laser can be used for simultaneous skin excision 2

Sequential Release Protocol (Medial to Lateral)

Medial Release:

  • Release the palpebral part of the orbicularis oculi origins first 1
  • Then release the tear trough ligament itself 1
  • Finally release the orbital part of the orbicularis oculi origins 1
  • Connect this dissection with the premaxillary space to ensure complete mobilization 1

Lateral Release:

  • Release the orbicularis retaining ligament laterally 1, 2
  • Connect this dissection with the prezygomatic space 1

Verification of Complete Release

Intraoperative Assessment:

  • After release, the lower eyelid and cheek soft tissues should be freely mobile without tethering 3
  • The lid-cheek junction should elevate smoothly without restriction when manipulated 3
  • There should be no visible bands or tethering points remaining along the infraorbital rim 2

Key Anatomic Landmarks:

  • The dissection must extend beyond the orbital rim into the midcheek to address the full extent of the ligamentous attachments 1
  • CO2 laser lysis can be particularly effective for precise division of these fibrous attachments when using a transcutaneous approach 2

Expected Outcomes Confirming Complete Release

Static Changes

  • Effective correction of the tear trough deformity without residual depression 3
  • No increase in scleral show in 99% of patients, confirming preservation of tarsoligamentous support 3
  • Zero incidence of ectropion when properly performed 3

Dynamic Changes (Functional Verification)

  • Elevation of the lid-cheek junction with smiling rather than deepening of the tear trough—this is a key indicator of complete release 3
  • Diminished pretarsal bulge with smiling due to altered orbicularis mechanics 3
  • Reduction of crow's feet with smiling 3
  • More youthful smile appearance with less wrinkling 3

Critical Technical Points

Avoiding Incomplete Release

  • Incomplete release leaves residual tethering that prevents smooth lid-cheek contour 2
  • The dissection must be carried sufficiently deep to reach the maxillary periosteum medially 1
  • Lateral dissection must extend to fully release the orbicularis retaining ligament attachments to the zygoma 2

Maintaining Lower Lid Support

  • Complete ligament release does not compromise tarsoligamentous support when performed in the correct tissue plane 3
  • The release targets the orbicularis muscle origins and retaining ligaments, not the canthal tendons or tarsal plate attachments 3
  • Consider canthal anchoring with canthopexy or canthoplasty for additional support, particularly in patients with pre-existing lid laxity 4

Common Pitfalls to Avoid

  • Superficial dissection: Staying too superficial will miss the deeper ligamentous attachments and result in incomplete release 1
  • Inadequate medial extension: Failing to connect the dissection to the premaxillary space leaves medial tethering 1
  • Inadequate lateral extension: Not releasing the orbicularis retaining ligament laterally prevents full cheek mobilization 2
  • Confusing denervation with ligament tethering: Lower lid malposition after blepharoplasty is due to inadequate support or incomplete ligament release, not nerve injury 4

Fat Redistribution After Release

  • Once complete release is achieved, excised orbital fat can be grafted under the released tear trough ligament to fill the tear trough deformity 1
  • This fat redistribution is only effective after complete ligament release creates the proper recipient space 1
  • Additional structural fat grafting to the maxilla may be needed in patients with significant maxillary retrusion 1

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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