Arcus Marginalis Release Technique
Yes, the periosteum must be incised at the orbital rim to properly release the arcus marginalis, and this requires direct contact with the bony orbital rim. This is a well-established surgical principle in lower eyelid and midface rejuvenation procedures.
Technical Approach
The arcus marginalis release requires a specific sequence of steps that involves periosteal incision:
The periosteum at the orbital rim must be incised to release the arcus marginalis attachment, which is the fibrous connection between the orbital septum and the periosteum along the inferior orbital rim 1, 2.
Direct visualization and palpation of the bony orbital rim is necessary during this procedure to ensure complete release of the arcus marginalis 1.
The incision is made directly at the periosteum overlying the infraorbital rim, typically using cautery cutting to release the arcus marginalis 1.
Surgical Rationale
The anatomical basis for this technique is clear:
The arcus marginalis represents the attachment point where the orbital septum fuses with the periosteum at the inferior orbital rim 2.
Without incising the periosteum and releasing this attachment, orbital fat cannot be advanced beyond the infraorbital rim to achieve the desired aesthetic result 2.
A supraperiosteal pocket is created below the orbicularis oculi muscle after the arcus marginalis release, which requires working directly on the bony surface 1.
Clinical Evidence
Multiple studies demonstrate the necessity of periosteal incision:
In a prospective study of 20 young Asian patients, the technique specifically involved extending dissection over the arcus marginalis and releasing it by cautery cutting at the periosteum, with 90% excellent results and no major complications 1.
A 152-case series over 3 years confirmed that arcus marginalis release is accomplished at the periosteal level, allowing subseptal fat to be advanced and sutured beyond the entire infraorbital rim 2.
The technique has been successfully employed in 85 cases with direct undermining of the arcus marginalis at the surface of the orbicularis, confirming the need for periosteal manipulation 3.
Important Caveats
The periosteal incision should be precise and controlled to avoid unnecessary trauma to surrounding structures 1.
Blunt dissection is used to create the supraperiosteal pocket after the initial periosteal incision, minimizing bleeding and tissue damage 1.
This is distinct from oncologic surgery where periosteum serves as an anatomical barrier; in soft tissue sarcoma surgery, periosteum is recognized as a "resistant anatomical barrier" that can serve as an adequate margin 4.