Dr. Sam Lam Plastic Surgery Forum

Most plastic surgeons have NO idea about the malar septum since they really do not understand volume replacement as part of the aging face. The tear trough is the little triangular depression right near the lower eyelid in the inner corner of the eye along the bony orbital rim. The malar septum is the line you are speaking of that runs roughly from the tear trough down the anterior cheek with ongoing hollowness and volume loss to the anterior cheek.

As far as releasing the tear trough, that really is not possible. With the malar septum, you can break it down a bit with a cannula and that is what i do. Actually, I am not really destroying the malar septum, I just try to make sure that the fat (or Restylane) is placed ACROSS the septum perpendicularly so that the area blends well. I have seen some pretty bad disasters of plastic surgeons who do not do a lot of fat grafting and look at the anterior cheek without reference to the septum in which they placed the fat or filler parallel to the septum leaving fat deposits only on one side and thereby creating a deeper line across the septum itself and a very weird look that is virtually uncorrectable.
best,
sml

Boy, your questions are quite technical. But here are your answers:
1. Okay, the arcus marginalis is a term to describe the adherence of the orbital septum (a fibrous connective tissue layer) and the periosteum (lining of the bone) that circumscribes the eye along the bony orbital rim. In the past, when I performed browlifts, I would release the upper margin of the arcus marginalis to ensure that the brow would be adequately released to be lifted.
2. Now, let's talk about the arcus for the lower lid and the necessity for an arcus marginalis release for the lower eyelid. In the technique you asked me to look at, you NEED to perform an arcus release whereas my technique you do not, but I still perform one indirectly anyway. Now why is that the case? Here is the reason why: let's understand the approach, in a nutshell the other physician is going from top down and I am going from bottom up. Going through the conjunctiva, you must release the arcus in order to get to the hollow orbital rim since the arcus stands in your way. What the other surgeon is trying to do is to move the orbital fat down over the rim (fat transposition) but that would not be possible without releasing the orbital rim arcus. Now, I already explained to you why I do not believe that this technique is good. In short summary, you only have a limited quantity of orbital fat to move down over the rim and most of it is near the inner eye and not the outer eye. So 1) if you run out of orbital fat to move over and you are still hollow, too bad, you're done. 2) you typically do not have enough fat to move over the lateral rim because in about 70% of people there is no excess fat there, 3) i can't remember if you were the one who asked about filling up to the eyelid margin and I said that I never do that (if you are not, sorry) but here is another difference, to move fat over the rim down to the hollow rim, you must TAKE AWAY the fat near the eyelid thereby hollowing it further. In contrast, I only remove this fat (also through a transconjunctival approach) in 1 out of 10 people who require it. Now, my technique what I do is I come from below and at times above in combination. Let me explain, I "release" the arcus really not so much that I care about the structure but I do so with my cannula wth literally hundreds of micropasses of fat running across it perpendicularly in order to place fat in a safe plane. Even with Restylane placement, I am partially avulsing the arcus as anyone who has had the procedure done with me knows, since they can usually hear this release (since they are awake) but not feel any discomfort. I teach physicians if you do not feel a release, you are not in the right plane and you risk giving the individual not a smooth result. As mentioned, I do come from above transconjunctivally to take some orbital fat out when necessary but only think this is necessary in 1 out of 10 cases. Here's what is great about my technique: if the person still needs some fat bag removed, I can go back there and take a little bit out. If the person needs more fat placed, then I can do that. As the person ages, I maintain this flexibility, all with no incisions. (Btw, I totally agree with Dr. Seckel that no cutting on the lower eyelid should be performed if possible. Watch my safe strategies to the lower eyelid vlog. I see too many hound dogs coming in my office that are unfixable.)
3. Lasers in my opinion are an absolute no-no. There is no reason to use something that creates unnecessary thermal injury. With my technique there is no bleeding, whether I am doing a transconjuntival blepharoplasty and/or fat grafting. Since, I literally use no needles anywhere there should be minimal to no bruising. Lasers are a totally romaticized concept that was totally blown out 10 years ago in a fantastic article by Richard Anderson (whom I personally thanked for writing it) called Laser Madness in Oculoplastic Surgery. My mentor even taught me during fellowship, "Sam, if you can avoid any lasers around the eyes, you will save you and your patient a lot of problems." Lasers cause heat damage to the surrounding tissues that lead to prolonged healing and scarring. Now, if you use a laser to treat skin wrinkles, that is a whole different story. Lasers are fantastic for treating wrinkles (minus the long-term problems with carbon dioxide). They suck for unnecessary dissection. I try to perform as much as possible with a cold instrument. Lasers are used because the consumer thinks they sound cool. Laser by the way does not stand for Light Amplified by Stimulated Emission of Radiation, it stands for Latest Avenues for Stimulating Extra Revenue (You know I am kidding but I am serious about how unsuspecting consumers hear the word "laser" and become unduly enamored with something that may actually detract from the procedure, especially for cutting eyelid tissue!). Now, I own 10 lasers but I use them for skin not for cutting the eyelid tissues. Okay, enough said.
4. Okay, the malar septum is a structure not really appreciated by most eye plastic surgeons or even facial plastic surgeons since they don't think about volume. Your question of why the malar septum is not an issue in youth may be thrown back at you to ask you why the arcus marginalis is not an issue in youth? The reason simply put is that when the area is full, you don't see the tethering effect of the septum. Think of a balloon filled up with a string inside of it holding one surface of it. You don't see the tethering effect of the string. Now, deflate the balloon and let it fall down. You will then see the tug of the string on the balloon surface when it is deflated. My goal is not to destroy the malar septum, it is to avoid placing fat only on one side of it when you inject parallel across the septum. Picture, my filling water on one side of the ballon's string (okay, let's change the string to a partition that runs horizontally across the balloon), the partition line will look much worse. ditto for fat grafting. That is why I approach the arcus marginalis of the lower eyelid perpendicularly so that I can also "release" it, really so that I don't place fat just on one side of the partition not that it actually has to be released (unless again you are approaching it from above and you need to pass through it to place a large lump of fat across it in a fat transposition technique. Remember my technique involves only tiny droplets, a transposition means pulling a large lump of fat in sewing it over the rim, which of course necessitates cutting and releasing the entire arcus.

Hope that is clear enough.
best,
sml

No, I can't tell you if the malar septum is elastic but my thought is that it is not elastic. You have misinterpreted what I wrote in my response. I did not talk about the malar septum's elasticity. I am talking about how the soft tissue deflates so that the malar septum then starts to tether the skin. The malar septum does not need to be elastic to tether the skin. Remember I used initially the string analogy, and a string is not elastic (at least in most cases).

The malar mound is a rare occurrence that I perhaps see only once to twice a year, which I do believe in severe cases is not entirely correctable but can be improved (also worsened temporarily). We are not talking about a malar mound in this case, which refers instead to an abnormal confluence of skin, soft tissue, lymphatics, and orbicularis oculi muscle that can lead to cyclical swelling and abnormal contour and quality of the skin.

A malar depression that occurs from a malar septum just being exposed and hollowing of the anterior cheek can be essentially 100% corrected with fat grafting (minus the psychotic mode that a lot of patients get into of staring at themselves 20 to 30 times a day from 2 inches following a procedure in which case they may still think they see something there). Remember two more things: 1) most men look good with a little hollow there so the objective is not to get rid of the line completely per se, 2) EVEN young people who are quite thin (or at times overweight) can show some linear depression in the anterior cheek and that would be fine.

Here's the bottom line: I think if we micromanage the face, we can always find a small flaw after any procedure. My objective is just making someone look better, younger, fresher, rested, etc. I have a lot of men say, "Man, I look a lot better but I still have this depression somewhat under my eye." That is normal to have a little bit there. I need to set up realistic expectations with patients. Remember that if most of your questions are geared toward intellectual curiosity, that is all well and good. However, if you are really obsessed with all of these details in terms of your result, it would be hard for any surgeon to make you happy. Let me quote from my first book, Comprehensive Facial Rejuvenation (page 198, 2nd column) on a physician's picking a male rhinoplasty patient: "The classic, 'engineer'-minded individual approaches the physician, often clutching in tow elaborate, self-executed diagrams that attempt to instruct the physician how best to alleviate the nasal impairment. Typically, these illustrations serve to impart little substantive information but only to underscore the fixated frame of mind that the patient is exhibiting. Most often, this type of patient has already journeyed tirelessly to find the elusive surgeon who will address his or her every complaint. The plastic surgeon always should be attentive during the preoperative phase to determine not only which patient should be operated on but more important, which one should not."

In all respect, I know you are very technical but I am afraid that that level of technical detail (all of which I can easily answer) can predispose you to dissatisfaction with any cosmetic procedure you have. Nevertheless, I hope I have satisfied some of your intellectual curiosity, and I do thank you for making this forum quite technically expository.
best,
sml

Ok, I'm not trying to suggest that you are obsessed. However, two things are important. Most people focus more on the outcome than on the technical details and go to some level with seeing one's physicians results as a statement for his or her work. I certainly understand if you were burned in the past that you would be extra wary and do your homework before committing to anything. The other fear that I have is that I know that what I wrote in my book is true. When I deal, particularly with a man, who goes into inordinate detail to try to understand the anatomy like a surgeon and can quote from my textbook (which is an expensive book), it makes me anxious to operate on that person. You must understand that trying to understand how the malar septum works is irrelevant to your outcome since I get very nice results just filling in and around that area. I don't think a meticulous understanding of the septum will improve your outcome, but it does help me explain why I get safe results by hitting the septum perpendicularly. Anyway, I trust that you are just doing your homework more than any other patient I have ever have.

As far as the analogy, I am not entirely certain I get what you are saying. If my analogy does not work for you, I am hard pressed to explain it any better. Honestly, I think the malar septum is really not so critical a structure to understand. I just fill the anterior cheek to get a balanced result in that area.

Okay, let me take one more stab at explaining this structure (which probably 90% of plastic surgeons don't even know about). Pretend that when the balloon is maximally filled, you don't see any tethering effect. When the balloon deflates and hangs, the tethering and pulling on the deflated structure becomes apparent. Remember that any model to explain an anatomic structure is merely that. It is imperfect and cannot do justice to reality. Maybe you can find someone smarter than I who can give you a better artificial model. I am failing to do any more. I apologize if my explanation is unsatisfactory.

thanks lisa. i also think summertan is a smart guy. i just can't do any more to answer this question. i think my elaborately long answers are all i can do. i have spent hours trying to respond to minutiae. i ask, summertan, that we don't discuss the malar septum anymore. i may actually scream very loudly if i write another response or clarification to this structure.
best,
sml

okay, let's all just chill out. i appreciate everyone's participation in this forum as vehicle for education. also, thanks to the all the readers who read this daily for updates. i hope all this work helps someone out there.
best,
sml

the "malar septum" is not in the tear trough. it is further down. basically, think of the anterior cheek. people that do not do volume have no idea what we are talking about. even during medical school, residency in head and neck surgery, and a fellowship in facial plastic surgery, i had not learned this anatomy. only when i started fat grafting did i start to truly understand the impact of this structure when working on the face. that is why even most surgeons out there (that do not do volume, and that is the majority) probably have no idea about what this is all about either so don't feel bad.
best,
sml