Aesth. Plast. Surg.

28:359–372, 2004
DOI: 10.1007/s00266-004-0053-1

The Concentric Malar Lift: Malar and Lower Eyelid Rejuvenation

Claude Le Louarn
Paris, France

Abstract. Midface rejuvenation surgery is most challeng- reliable result is achieved because the vectors of traction
ing. The margin of error for the lower lid is on the order of with this technique are exactly opposite those of the mid-
0.5 mm, and the cosmetic result can sometimes look face aging process, and because a very stable fixation is
unnatural. A minimally invasive technique for malar and created between the lifted malar periosteum and the malar
lower lid lift is proposed. Two incisions are used: the and latero-orbital rim bones.
standard subciliary lower eyelid incision and one on the
lateral part of the upper eyelid. Through these incisions a
skin flap lower eyelid dissection and a subperiosteal malar Key words: Lower lid blepharoplasty—Midface lift—Sub-
dissection are performed. The arcus marginalis itself is not periosteal dissection—Suspension suture—Tear trough
transected as is the case when the malar area is entered from
the lower eyelid. Rather, a subperiosteral release of the
arcus marginalis is performed through a muscle-splitting
incision at the lateral canthus. Eyelid malposition is avoi-
ded because the muscles, vessels, and nerves converging
toward the medial canthus are not interrupted. The sub-
Malar and the Lower Eyelid Aging Process
periosteal dissection of the arcus marginalis extends to the
medial canthus and also releases the insertion of the or-
Rejuvenation of the lower lid must include the peri-
bicularis oculi superior malar part. Consequently, all the
orbital area to achieve a harmonious midface reju-
attachments of the tear trough are released. Two subpe-
venation. As part of the aging process, the junction
riosteal suspensions connect the central part of the naso-
between the lower lid and cheek develops into a
labial volume and, more laterally, the central part of the
nasojugal or tear trough depression [4] medially and a
malar area to the inferolateral orbital rim. The elevation of
palpebromalar groove [9] laterally.
the malar volume resulting from these suspensions is con-
The aging process of the anterior malar area is
centric with the orbit. A final third suspension vertically
linked in large part to the presence and function of
connects the orbicularis oculi muscle with the underlying
the levator muscles of the upper lip because as the
periosteum to the bone of the lateral orbital rim. Significant
malar fat pad does not have a direct connection with
skin excess is removed from the lower eyelid. Complete
these muscles and descends with time. As a direct
disinsertion of the tear trough attachments combined with
result of this descent, the nasojugal or tear trough
the malar elevation treats the entire palpebromalar groove.
depression above and the underlying nasolabial fold
The lifted fat volume fills the space resulting from the
progressively develop. The rejuvenation vector must
subperiosteal disinsertion. A safer, more natural and more
be perpendicular to these folds to restore the malar
fat pad at its original location (Fig. 1).
The aging process of the periorbital contour is
Publication presented at the meeting of the Societe Franc- caused largely by the action of the malar part of the
aise des Chirurgiens Esthetiques et Plasticiens 23 June 1996, orbicularis oculi muscle (Fig. 2). During orbicularis
and at the meeting of the Australian Society of Plastic contraction, the malar soft tissues move both medi-
Surgery 9 March 2002 ally and superiorly. Specifically, (the superior malar
Correspondence to Claude Le Louarn, French Society of part of the orbicularis muscle is the most mobile and
Plastic and Reconstructive Surgery, 59 rue Spontini, 75116, most effective part of the orbicularis in causing the
Paris, France; email: lelouarn-claude@noos.fr oblique (vertical and medial) movement of the lower
360
Fig. 1. Concentric malar lift performed with two suspen-
sions through points B and C. Point B is the vertical anchor
of the malar volume B1 (lateral part of the malar fat pad) at
the same horizontal level as C1, which is lateral to the
vertical line passing through the lateral canthus bone
insertion. Point C is the anchor through the inferior orbital
rim lateral part of the nasolabial volume C1 (malar fat
pad).
eyelid. This oblique translation stops at the medial
canthus, as shown by the lack of wrinkles there (Fig.
2, area 3). The medial insertion of this superior malar
part of the muscle is on the bone at the medial can-
thus.
The contraction of the orbicularis oculi superior
malar part presses the soft tissue against the inferior
orbital rim (Fig. 3). During relaxation of the muscle,
the malar tissues descend. Over time, the resting po-
sition of the malar tissues becomes progressively
lower. The location of fat in relation to the orbicu-
laris oculi (both superficial and deep) is progressively
moved around the orbital contour in a centrifugal
way.
The tear trough depression and the palpebromalar
groove appear at the junction between the lower
eyelid and the cheek [8]. Over time, the skeleton-
ization of the orbital rim contour becomes more
prominent and lower [5]. More precisely, the semi-
circular aging process is excentric. The usual vector
used in rejuvenation surgery of the periorbital con-
tour is upward and lateral, toward the temple.
Consequently, the malar volume is transposed to-
ward the temple, resulting in an unnatural appear-
ance because the malar volume does not originate in
this area [10].
In fact, to be most effective, the vector of
rejuvenation must be perpendicular to the furrow
resulting from the aging process. The vectors for
rejuvenation of the tear trough and palpebromalar
groove should converge to a point near the pupilla
(Fig. 4). If this could be replicated surgically, the
result achieved would be more natural because each
of the ptotic volumes would be restored to its
The Concentric Malar Lift
Fig. 2. Left: lower eyelid at rest. Right: eyelid with forced
orbicularis oculi muscle contraction. Segment 1 is the
superior malar part of the orbicularis oculi muscle sup-
ported by the inferior orbital rim when it is contracting.
The wrinkling stops at point 3. Segment 2 is the inferior
orbital part of the orbicularis oculi muscle at the superior
orbital rim (the superior orbital part is concerned with
eyelashe position) supported by the superior orbital rim
when it is contracting. The contraction of these two muscle
parts creates two symmetric furrows. The furrow at the
medial lower eyelid is the tear trough. Area 3 is the bone
insertion of these two converging muscles, medial to the
medial canthal tendon.
original location, and the anterior malar vol-
ume, particularly, would be lifted to fill the tear
trough.
The aging process of the lower eyelid is attributable
primarily to the action of the septal part of the or-
bicularis oculi muscle. During muscle contraction,
the septal part of the lower eyelid is transposed up-
ward and medially. The vector of rejuvenation of the
lower eyelid must be perpendicular to this direction,
from the lateral canthus. If the vector of traction is
applied to the lid 3 mm inside the lateral extremity of
the eyelid margin, this traction recreates the young
subtarsal fold (Fig. 5).
C. Le Louarn
Fig. 3. The two key attachments of the orbicularis per-
taining to the tear trough. (1) Insertion of the septal part of
the orbicularis oculi muscle at the medial extremity of the
inferior orbital rim. (2) Insertion of the superior malar part
of the orbicularis oculi muscle medial to the medial canthal
tendon. Release of the arcus marginalis and these medial
muscle insertions fade the tear trough. Concerning the
upper eyelid, the permanent contraction of the inferior
orbital part of the orbicularis oculi muscle, inserted 2 is
responsible for a trough symmetric to the tear trough in the
lower eyelid. (O.O.S.M.P.: orbicularis oculi superior malar
part).
Tear Trough Anatomy
Anatomic dissections demonstrate that tension ap-
plied laterally to the orbicularis oculi after malar
subperiosteal dissection does not reduce the depth of
the tear through (Fig. 6). Two additional components
must be specifically released to allow the tear trough
to be smoothed out when the orbicularis oculi muscle
is tightened laterally.
The first element is the arcus marginalis, which
must be released from its inferior orbital rim attach-
ment, from the lateral canthus to the medial canthus.
This also releases the medial insertion of the septal
part of the orbicularis oculi muscle (Figs. 7 and 8).
361
Fig. 4. The natural way to rejuvenate the periorbital con-
tour is to use vectors of traction perpendicular to the tear
trough and palpebromalar groove converging toward the
pupilla.
Fig. 5. Orbicularis oculi muscle and periosteum suspension
from A1 (end dissection between the skin and the muscle,
also lateral extremity of the subtarsal fold) to the hole A
through the lateral orbital rim.
The second element is the medial insertion of the
superior malar part of the orbicularis oculi (Fig. 9).
The superior malar part of the orbicularis oculi is the
section of the muscle sustained by the inferior orbital
rim when it is contracting at a forced squint. The
bone insertion of this part of the muscle is immedi-
ately medial to the medial canthal tendon (Fig. 2).
The inner part of the upper eyelid also has a furrow
corresponding to the lower eyelid tear trough. This
furrow deepens at forced contraction of the orbicu-
laris oculi muscle on the upper eyelid. Forced con-
traction of the orbicularis oculi muscle converges to
the same insertion location, medial to the medial
canthus, as does the superior malar part of the or-
bicularis oculi muscle (Fig. 3). Correction of the
362
Fig. 6. Cadaver dissection. Lateral tension (arrow) on the
orbicularis oculi muscle, after a partial subperiosteal malar
dissection does not reduce the tear trough.
Fig. 7. This partial detachment of the arcus marginalis
(AM) from the inferior orbital rim (IOR) clearly shows the
medial insertion of the orbicularis oculi septal part (OO).
lower eyelid tear trough can be associated with cor-
rection of the upper eyelid groove, resulting in a
harmonious eyelid rejuvenation.
Fortunately, experience has shown that the release
of these two insertions (the arcus marginalis and the
superior malar part of the orbicularis oculi does not
lead to complications. The purpose of this release
(Fig. 10) is to allow for the elevation of the entire
lower eyelid and the entire malar fat pad volume
(medial and lateral) with the two concentric suspen-
sion sutures (Fig. 1). Because of the detachments, the
volume is able to fill the tear trough and the palpe-
bromalar groove.
Preoperative Considerations and Markings
If a significant skin excess already exists in the crows
foot area, the malar suspensions and the orbicularis
oculi muscle suspension further increase this tem-
poral excess of skin. Therefore, a temporal lift is
The Concentric Malar Lift
Fig. 8. Complete detachment of the arcus marginalis from
the inferior orbital rim (IOR) including the origin of the
septal part of the orbicularis oculi allows lateral elevation
of the entire septal part of the lower lid (superior border of
the tear trough).
Fig. 9. Detachment of the orbicularis oculi muscle superior
malar part (OOSMP, red line) at the medial canthus (MC
yellow line). This is the second insertion responsible for the
tear trough (inferior border of the tear trough).
needed to redrape this excess of skin. This temporal
lift is achieved by the temporal part of the mask lift
using TessierÕs [11] technique, without skin excision.
A temporal dissection usually is not necessary for
middle-aged patients undergoing a midface rejuve-
nation.
The first marking is a semicircular line located at
the deepest part of the tear trough and palpebromalar
groove (Fig. 4). The dissection of the lateral skin flap
will stop at or above that level depending on the
amount of excess skin to be removed. The second
marking is point C1 overlying the center of the
prominence of the nasolabial fullness (Fig. 11). The
third marking is the classical malar point B1 at the
intersection between the projections from the nasal
alar and the lateral canthus [7]. Other preoperative
markings are the same as for a standard blepharo-
plasty.
C. Le Louarn
Fig. 10. The lateral tension (arrow) on the orbicularis oculi
muscle after release of the two insertions of the two the tear
trough (arcus marginalis with orbicularis oculi muscle
septal part and superior malar part) reduces the tear trough
(compare with the Fig. 4).
Fig. 11. Entrance with a straight needle at point C1 direc-
ted toward point C, located on the inferior orbital rim. The
infraorbital nerve (ION) is more medial, indicated with a
thin needle in the infraorbital opening. There is no risk of
entrapping a lateral branch of this nerve. Elevation of the
malar fat pad volume is mandatory for filling of the free
space resulting from disinsertion of the tear trough
attachments.
Surgery
Subcutaneous Dissection
Dissection through the subciliary lower eyelid inci-
sion is subcutaneous as far as the level of the new
subtarsal fold. The extent of subcutaneous dissection
extends laterally part way or all the way to the pal-
pebromalar groove depending on the amount of ex-
cess skin present in the lower lid. The amount of skin
to be removed is calculated by a pinch test below the
lateral canthus using moderate tension with a smooth
forcep. The upper edge of the forcep is placed at the
363
lateral canthus and the lower edge on the skin at
point A1 (Fig. 5).
Subperiosteal Dissection
The subperiosteal dissection of the malar area is
performed through the upper eyelid incision extend-
ing onto the inferior orbital rim (Fig. 12). This sub-
periosteal dissection of the orbital rim must be only 1
cm wide to avoid damaging the zygomaticofacial
nerve.
A 1-cm incision is made through the orbicularis at
the lateral canthus level, just below and parallel to the
lower lid skin incision. Through this incision, the
entire malar area is dissected subperiosteally. This
dissection must avoid damage to the zygomaticofa-
cial nerve, which is dissected easily under direct vi-
sion, and also the infraorbital nerve. A thin needle is
entered through the skin in the infraorbital opening
to locate the origin of the nerve. The extent of the
dissection laterally involves the body of the zygoma
(dissection of the zygomatic arch is not needed),
inferiorly involves the inferior border of the zygoma
and the pyriform aperture, and medially involves the
nasal bone after release of the arcus marginalis and
the medial insertion of the superior malar part of the
orbicularis oculi muscle. The release of the medial
part of the arcus marginalis must avoid the lacrimal
sac. It is not necessary to dissect intraorbitally in this
area. However, dissection is 1 cm intraorbitally along
the lateral and inferior orbital rim for performance of
the orbital rim suspension. The use of a retractor to
check the disinsertion of the levator labii Superioris
muscle is mandatory. Otherwise the contraction of
this muscle would push down the underlying lifted
malar fat pad. Traction with a hook confirms the
adequacy of the release and the lift of the dissected
malar volume with the suborbicularis oculi fat [1].
Two holes are drilled through the lateral orbital rim
and one through the inferior orbital rim. The first hole
(A) is placed above the lateral canthus, at the junction
between the orbital rim and continuation of the line of
the concave margin of the lateral lower eyelid margin.
This hole is created to suspend the orbicularis oculi
muscle and the underlying periosteum (Figs. 1 and
13A). The second hole (B), placed at the junction of
the lateral and inferior orbital rim, is used to perform
the vertical malar suspension (Fig. 13B).
A third hole (C), placed at the junction of the
medium third and lateral third of the inferior orbital
rim, is used for the nasolabial suspension (Fig. 13C).
Suspension Sutures
Nasolabial Volume Suspension Suture
For nasolabial volume suspension suture, (Figs. 1
and 11) a straight needle is used. The entry point
364
Fig. 12. Cadaver dissection (right side, viewed from above).
(A) Subperiosteal dissection of the malar area through the
lower eyelid. Point M is the middle of the inferior orbital
rim. (B) Malar fat pad suspension at C1 toward C. The
disinserted tear trough area is to be filled with the elevated
malar fat volume. (C) Malar volume suspension at B1 to-
ward B. The disinserted arcus marginalis area is filled with
the elevated malar fat volume. The palpebromalar groove is
faded
The Concentric Malar Lift
(C1) of the needle is through the skin overlying the
center of the nasolabial fullness, lateral to the in-
fraorbital nerve. The needle entrance is facilitated
by a 2-mm stab incision made with a number 11
scalpel blade, which does not leave a visible scar.
The needle goes deeply through the periosteum, and
then is directed upward, perpendicular to the axis of
the nasolabial fold. It exits through the muscle
opening to be threaded with the end of a 3/0 Pro-
lene suture previously passed through the bone at
point C. The needle then descends to the level of
point C1 and, without exiting the skin completely,
is redirected upward toward point C at a more
superficial level. Accordingly, the double pass of the
needle grasps the full thickness of the nasolabial
mass.
Once the needle has been returned to the level of
the bone hole, the end of the suture is removed from
the needle and tied under moderate tension. The knot
is positioned inside the bone to keep it from becom-
ing palpable. The elevation of the medial malar fat
pad combined with the tear trough disinsertion de-
creases the depth of the tear trough.
Vertical Malar Suspension Suture
The axis of this suspension is slightly oblique medi-
ally, making it perpendicular to the orbital rim at the
point B level. The medial oblique direction of this
vector minimizes the appearance of a lateral skin
excess. Point B1 is at the same horizontal level as C1
and 3 mm lateral to a vertical line passed down from
the lateral canthus (bony rim insertion).
The suspension between points B and B1 is per-
formed through the muscle opening, under direct vi-
sion without a skin incision (Fig. 1).
Vertical Orbicularis Oculi Muscle and Periosteum
Suspension
For this procedure (Figs. 5 and 14), a 3/0 Prolene
suture is passed through the bone at point A, then
along the lateral orbital rim, on the bone, to exit
through the muscular opening at the lower eyelid. It
is important to note that the subperiosteal dissection
performed in the malar area near the lateral orbital
rim should elevate all the periosteum. This allows a
strong adhesion between the elevated orbicularis
oculi muscle with its underlying periosteum and the
bone, which is necessary for the long-term stability of
this lateral elevation. This technique has been used by
Besins [3] with the RARE (Reverse and Reposition-
ing Effect) technique. Failure to remove the perios-
teum from the bone predisposes the procedure to
secondary slipping of the muscle with loss of the skin
tension of the lower eyelid
The suture is then passed through the periosteum
and the orbicularis muscle from deep to superficial
C. Le Louarn
Fig. 13. Drill holes through oribital rim. (A) Lateral orbital
rim, above the lateral canthus. (B) Lower part of the lateral
orbital rim. (C) Lateral part of the inferior orbital rim as
the basis for stable suspensions. A 1-cm muscle opening at
the lateral canthus is sufficient for drilling the inferior
orbital rim, thanks to the tissue laxity.
near the inferior border of the muscle flap (point
A1). Next, the suture is returned through the
muscle and the periosteum, and another suture bite
is taken through the muscle near the top of the
triangular muscle flap. The suture is returned along
the orbital rim to exit at point A. The benefit of
this tension on the lower lid is tested before the
suture is tied. The vertical and triangular orbicularis
oculi muscle flap is spread accordingly onto the
365
Fig. 14. Lateral orbicularis oculi muscle (with its perios-
teum) suspension is performed with a 3/0 Prolene suture
passing through the lateral orbital rim at A, then going to
A1 to suspend the muscle and the periosteum with a U-
shaped pass. At the top of the triangular muscle flap, the
thread then makes a loop to lift this triangular flap and
finally returns to A. When the thread is tightened, the
muscle flap is pressed on to the bone to favor its adhesion.
A1 elevation tenses the whole malar area.
bone at the lateral orbital rim. The position of the
new subtarsal fold ( point A1) must be 3 mm below
the lash line.
Skin Excision
Excision of skin usually is important, even if only a
minor excess is present before the surgery. This is
because the elevation of the malar volume and the
vertical orbicularis oculi muscle suspension create a
vertical excess of skin. The skin excision is particu-
larly safe, thanks to the stability of the muscular and
periosteal suspensions. These suspensions are secured
by the strong adhesions between the elevated peri-
osteum and the malar bone. A slight overcorrection
of elevation is performed, and the excess of skin is
removed with moderation. Although the amount of
skin removed using this technique is more than usual,
it still must be undertaken with great care. The sub-
tarsal fold created by the tension on the orbicularis
oculi muscle at that level (3 mm under the eyelashes)
is stable and reduces the risk of ectropion. Sufficient
366 The Concentric Malar Lift

Fig. 15. (Continued).

C. Le Louarn 367

Fig. 15. (A, B, C) A 54-year-old patient with a low positioned lower eyelid associated with a tear trough deformity and a
palpebromalar fold. (D, E, F) Appearance 4 months after a concentric malar lift associated with a lower facelift, an upperlip
lift, and nasal tip elevation. The upper lid has been improved with the suture of the periorbital fat on the superior periorbital
rim. The lower eyelid position is elevated, and the palpebromalar groove and tear trough are improved. No canthopexy or fat
reinjections were performed. The result appears natural because the inferior periorbital contour is rejuvenated exactly the
opposite of the aging process.

skin must be left between the fold and the eyelashes
(3–4 mm).
Clinical Material
This study analyzed 67 patients who underwent
concentric malar lift with lower eyelid and malar
rejuvenation (Figs. 15, 16, and 17). Of these patients,
52 also had upper eyelid surgery and 45 underwent a
facelift during the same operative procedure. Only
five of these patients underwent canthopexy to
achieve a more lateral position of their canthus (al-
mond-shaped eye), and none underwent the proce-
dure to secure the elevation of the lower eyelid.
Surgery was performed to elevate the eyelash’s level
for 7 of the patients because previous standard lower
eyelid surgery had caused a descent of this line.
In 1995, first patients underwent surgery using a
variation of the current concentric malar technique,
with positive results. The current evolution of the
technique has been in regular use for 2 years. The
patients ages ranged from 30 to 69 years (median, 44
years). This technique was used for 10 men.
General anesthesia was used when a facelift was
performed at the same time. Local anesthesia with
nerve block and sedation were used in 30% of the
concentric malar lift case. General anaesthesia was
used for the other 70%.
Discussion
During the concentric malar lift procedure, dimples
must be avoided when the sutures are tightened from
point C1 and from point B1. The positioning of the
suspension sutures must be sufficiently deep and low
to lift the deeper tissue near the periosteum primarily
and to lift the superficial tissues near the skin only
partially.
The loop of suture at C1 could potentially result in
paraesthesia caused by compression of lateral bran-
ches of the infraorbital nerves. In fact, there are no
main branches lateral to the infraorbital nerve at C1.
368 The Concentric Malar Lift

Fig. 16. (Continued).

C. Le Louarn 369

Fig. 16. (A, B, C) A 34 years-old patient with a low positioned lower eyelid associated with a tear trough deformity and a
palpebromalar groove. She had undergone two previous lower lid blepharoplasties. (D, E, F) Appearance 5 months after a
concentric malar lift and a lateral canthopexy. The entire lower eyelid is elevated. The tear trough and the palpebromalar
groove are improved. No fat was reinjected, and no lower eyelid skin grafting was performed.

The C1 suspension has not resulted in numbness of
the infraorbital nerve territory for any of the patients.
In the authorsÕ 9 years of experience using these
suspensions, with some variations, they have en-
counted only a few problems. One stitch ‘‘slipped,’’
presumably because the bite was too small. One case
of residual lateral excess, more than expected, re-
quired a secondary temporal lift. Often the recovery
time was longer than for a standard blepharoplasty,
and not infrequently, excessive tearing lasted 3 weeks,
probably because of nasolacrymal swelling. No pa-
tient had chemosis more than 3 weeks, even in cases
of associated canthopexy.
Some problems can be minimized with the use of
this technique. The arcus marginalis is not incised as
with the standard lower eyelid approach [10]. Rather,
it is dissected from the lateral canthus opening. The
arcus marginalis is elevated gently from the inferior
orbital rim. Consequently, the point of convergence
for the whole area. (i.e., the medial canthus) is func-
tionally preserved. The medial canthus region is the
point of convergence for muscles (only fixed point of
the entire orbicularis oculi muscle system), vessels
(facial, palpebral arteries, and veins), tears (lacrimal
pump), and lymphatics for the palpebral and malar
area. The medial canthus also is the junction of the
palpebral and the nasal area through the lacrima
fossa. Preserving the entire anatomic and functional
unit of the eyelid in fact with no dissection going
through it is the most effective way to avoid pro-
longed edema [6] and to prevent secondary eyelid
malposition [6]. This is the reason that surgeons such
as Hester [6] and Ramirez [10] now recommend no
dissection through this area. No secondary eyelid
malposition attributable to posterior or medial la-
mella retraction occurred with the use of the con-
centric malar lift technique.
The malar area is dissected subperiosteally. Sub-
periosteal dissection is mandatory because it involves
the only dissection plane that does not move over
370 The Concentric Malar Lift

Fig. 17. (Continued).

C. Le Louarn 371

Fig. 17. (A, B, C) A 49-year-old patient who underwent a face-lift and four eyelid blepharoplasties 7 years previously. She was
a difficult case because she also had silicone injections in her nasolabial fold and her tear trough, with this pigmentation and
this inflammatory reaction. (D, E, F). Aspect 6 months after a new face-lift associated with a concentric malar lift. The
nasojugal fold is improved, and the tear trough is lifted and faded. The entire inferior orbital contour is rejuvenated in a
natural way. She had no canthopexy or fat injections.

time [11]. Reattachment, after subperiosteal dissec-
tion of the malar tissues, to a higher level, thanks to
tension applied on A1, is therefore stable. All the
other dissection planes over the malar area can re-
lapse with time. Subperiosteal malar elevation per-
manently transposes all the malar tissues to a higher
level without modifying them.
With the standard subperiosteal malar suspension,
the SOOF (Sub orbicularis Oculi Fat) is lifted later-
ally, toward the temporal area [2, 10]. But this fat
does not originate from the temporal area. The sur-
gical relocation can result in an unnatural appear-
ance. The centrifugal migration of this fat is caused
by orbicularis oculi muscle contractions. Rejuvena-
tion of the lateral part of the orbital contour must be
performed with a concentric, and therefore medial,
lift of the SOOF, which is achieved with the two
suspension sutures, B1 and C1.
The excess of skin in the temporal area resulting
from the concentric malar lift is the least possible for
the degree of malar elevation regardless which tech-
nique is used. When an oblique superolateral vector is
used, a larger skin excess results in the temporal re-
gion, frequently requiring an associated temporal lift
[2,3].
In cases of patients requesting an almond-shaped
eye, a lateral canthopexy frequently is associated with
this technique. As stated by Tessier [11], a more
extensive intraorbital subperiosteal dissection allows
all of the orbital tissues to rotate in a frontal plane in
the direction of the lateral canthopexy. A 4/0 Prolene
suture joins point A to the lateral extremity of the
inferior tarsal cartilage.
Conclusion
Through one upper and one lower lateral eyelid
opening, the reported technique combines the fol-
lowing:
 Subperiosteal tear trough release, with an arcus
marginalis and orbicularis oculi muscle (superior
malar part) detachment.
 Concentric malar lift at the orbital rim with two
subperiosteal suspensions. The elevation of the
372
full-thickness malar fat pad volume fills the tear
trough and the palpebromalar groove.
 Vertical suspension of the orbicularis oculi
muscle and periosteum at the lateral orbital rim.
 Minimal surgical trauma with no arcus margin-
alis incision, no risk of lymphatic or neurovas-
cular disruption, and consequently, no risk of
secondary lower eyelid malposition.
 Good stability of the elevation because of the
adhesion between the soft tissues and bone.The
reported procedure achieves a more natural
rejuvenation because the lower eyelid lift and
concentric malar lift act exactly the opposite of
the aging process.
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