In an adult patient undergoing lower‑eyelid or mid‑face rejuvenation, should the periosteum be incised down to the bony surface of the orbital rim to release the arcus marginalis?

Arcus Marginalis Release Technique

Yes, the periosteum must be incised sharply down to the bony surface of the orbital rim to properly release the arcus marginalis and access the subperiosteal plane. This is the fundamental step that allows advancement of orbital fat beyond the infraorbital rim for midface rejuvenation 1.

Surgical Technique for Arcus Marginalis Release

Understanding the Anatomy

• The arcus marginalis is the periosteal attachment of the orbital septum to the inferior orbital rim 1
• This fibrous attachment creates the visible "tear trough" deformity and must be completely released to allow fat repositioning 1
• The periosteum serves as a resistant anatomical barrier in this region 2

Step-by-Step Release Technique

Initial Exposure:

• After reflecting the orbicularis muscle, expose the inferior orbital rim 1
• Identify the arcus marginalis as the periosteal thickening along the entire length of the orbital rim 1

Periosteal Incision:

• Make a sharp incision through the periosteum directly at the orbital rim, cutting down to bone 1
• This incision must be carried along the entire infraorbital rim to achieve complete release 1
• The periosteum is incised at its attachment point to the bone surface, not superficial to it 3

Subperiosteal Dissection:

• Once the periosteum is incised to bone, you can then elevate in the subperiosteal plane 1
• This creates the space needed to advance the subseptal fat beyond the orbital rim 1
• The released fat is then sutured beyond the infraorbital rim under the repositioned orbicularis muscle 1

Critical Technical Points

Complete Release is Essential:

• Incomplete periosteal incision will prevent adequate fat advancement and compromise results 1
• The release must extend the full length of the orbital rim where fat repositioning is planned 1

Avoid Common Pitfalls:

• Do not attempt to release the arcus marginalis by blunt dissection alone—sharp periosteal incision to bone is required 1
• Inadequate depth of incision (not reaching bone) will leave residual periosteal attachments that limit fat mobility 3
• Failure to release along the entire rim creates an uneven contour 1

Preservation vs. Manipulation:

• While some procedures emphasize avoiding periosteal damage (such as lateral bone augmentation where you "try to avoid damage to the periosteum" 4), arcus marginalis release specifically requires intentional periosteal incision 1
• This is a context-dependent decision: in rejuvenation surgery, periosteal release is therapeutic, not traumatic 1

Clinical Results

• This technique has been successfully performed in 152 cases over 3 years with impressive results and minimal complications 1
• The approach provides effacement of the arcus marginalis and improved lid support without requiring tarsal suspension 3
• Reoperation rates are low, with only minor adjustments needed in select cases 3