In an adult undergoing lower‑eyelid or mid‑face rejuvenation, after incising the periosteum at the orbital rim to release the arcus marginalis, how can the dissection be continued inferiorly in the supraperiosteal plane rather than the subperiosteal plane?

Transitioning from Subperiosteal to Supraperiosteal Dissection After Arcus Marginalis Release

After releasing the arcus marginalis and entering the subperiosteal plane at the orbital rim, you transition to the supraperiosteal plane inferiorly by deliberately stopping your dissection at the periosteal layer and redirecting your instruments superficial to the intact periosteum below the rim, creating a pocket between the orbicularis muscle and the periosteum of the maxilla. 1

Understanding the Anatomical Planes

The key to understanding this transition lies in recognizing that the arcus marginalis release is a localized periosteal incision at the orbital rim only, not a complete periosteal stripping procedure:

• The periosteum at the inferior orbital rim must be sharply incised down to bone to release the arcus marginalis and allow fat advancement 1, 2
• This creates a subperiosteal exposure only at the rim itself 3
• Below the orbital rim on the maxillary surface, the periosteum remains intact and adherent to bone 3

Surgical Technique for Plane Transition

Step 1: Complete the Arcus Marginalis Release

• Make a sharp incision through the periosteum at the orbital rim, extending along the entire length where fat repositioning is planned 2, 4
• This exposes bare bone at the rim level only 1

Step 2: Create the Supraperiosteal Pocket

• After releasing the arcus marginalis, redirect your dissection superficially using blunt scissor dissection 5
• Dissect in the plane between the orbicularis oculi muscle (superficial) and the intact periosteum of the maxilla (deep) 3, 5
• This supraperiosteal pocket extends inferiorly onto the maxillary surface, typically 10-15mm below the rim 4

Step 3: Maintain Proper Plane Recognition

• The supraperiosteal plane is identified by the white, glistening appearance of intact periosteum deep to your dissection 5
• Avoid penetrating through the periosteum into the subperiosteal space on the maxilla, as this increases bleeding and provides no additional benefit 3
• The dissection should feel relatively avascular if maintained in the correct supraperiosteal plane 5

Clinical Rationale

The supraperiosteal dissection below the rim is intentional and therapeutically distinct from the subperiosteal release at the rim itself:

• The subperiosteal exposure at the rim allows complete release of the arcus marginalis attachment 1, 2
• The supraperiosteal pocket below the rim provides a recipient bed for fat repositioning while preserving periosteal blood supply to the maxilla 3, 5
• This technique elevates the orbicularis muscle edge 6-12mm above the orbital rim (average 8.8mm), effectively treating the tear trough deformity 3

Common Pitfalls to Avoid

• Continuing subperiosteal dissection onto the maxilla: This is unnecessary, increases bleeding, and provides no advantage over the supraperiosteal plane 3, 5
• Inadequate arcus marginalis release: Failing to incise completely through the periosteum at the rim prevents effective fat advancement 2, 4
• Confusing the planes: The transition point is at the inferior orbital rim—subperiosteal AT the rim, supraperiosteal BELOW the rim 1, 3

Technical Modifications

For Asian patients with brachycephalic facial structure, the same preseptal dissection with supraperiosteal pocket technique is effective and safe, with 90% excellent results in patients under 40 years old 5. The technique does not require modification based on ethnicity, though individual anatomical variations should be recognized 5.