Surgical correction of sunken upper eyelid with upper arcus marginalis release and precision fat distribution technique

Sunken upper eyelids, characterized by hollowing in the upper orbital region, can contribute to an aged or fatigued appearance. We aim to report on the surgical technique and its effects, involving the release of the arcus marginalis of the upper eyelid and the precise distribution of orbital fat.

7][8] Among these, fat grafting can be relatively easily applied, and its techniques have evolved, including the development of micro fat grafting techniques. 9,10Several surgical approaches involving the use of orbital fat pad flaps have been employed to reduce the absorption rate of fat, which is a primary concern with fat grafting. 3,11,12wever, the fat pad flap technique does not always guarantee stable fixation of the flap.Therefore, we explored strategies for the more effective placement of orbital fat.In this study, we aim to report on the surgical technique and its effects, which involve releasing the arcus marginalis of the upper eyelid and distribution of orbital fat.

| ME THODS
A retrospective chart review was conducted to identify patients who underwent sunken eyelid correction using the upper arcus marginalis releasing and fat distribution technique.The patients who underwent the surgery from December 2021 to March 2023 were included, and written consent and permission for the use of clinical photographs was obtained.We received approval from the hospital's ethics committee.The depth of the sunken eyelid was defined as the distance between the line extended downward from the most prominent point of the subbrow and the deepest point of the sunken eyelid (Figure 1).Patient demographics including age, sex, surgical technique, and the duration of follow-up were documented.Sunken eyelid depth was measured both preoperatively and 3-month postoperatively.At the 3-month follow-up, patients were asked to complete a questionnaire to assess the degree of improvement in their sunken eyelids, categorizing the results as "good," "fair," or "poor."The pre-and postoperative sunken depths were compared using a paired-sample ttest conducted with the SPSS Statistics 21.0 software package (IBM Corp., Armonk, NY, USA), and p < 0.05 was considered significant.

| Surgical technique
Before the operation, the sunken area was marked on the patient while in a seated position.The surgical procedure was performed with the patient in a supine position under local anesthesia.Local anesthesia was administered using a mixed solution of 0.5% lidocaine hydrochloride and 1:200 000 epinephrine.An incision was made along the marked line, including the skin and orbicularis oculi muscle, and in cases of blepharochalasis, a strip of skin was excised.
The levator aponeurosis and orbital septum were meticulously exposed and confirmed.Depending on the presence of ptosis, levatorrelated procedures were prioritized, followed by the correction of the sunken appearance.
Preseptal dissection was carried out in the superior direction, and at the level of the arcus marginalis, the orbital septum was meticulously opened with scissors.As a result of the incision, orbital fat protruded, and this fat pad was appropriately distributed into the sunken area.In most cases, no additional fixation was required, as this is typically the deepest area sunken eyelid (Figure 2).However, in cases with a significant amount of orbital fat or severe medial sunken eyelid, fixation was performed using 6-0 vicryl sutures.The sunken appearance was evaluated with the skin flap covered, and fat distribution was adjusted as necessary.
Hemostasis during the operation was ensured using electrocoagulation.Depending on the patient, levator to dermis sutures for creating a double eyelid were performed with 7-0 nylon, and skin incisions were closed using 7-0 silk.(See Video S1, Supplemental Digital Content 1).

| RE SULTS
A cohort of 42 patients was included in the study, with an analysis of 84 eyelids.The patient demographics are summarized in Table 1.The patient group consisted of 29 females and 13 males, with an average follow-up period of 9.9 months.Preoperatively, the sunken depths measured 9.2 ± 2.2 mm, with a range of 13.5-6.0mm.Postoperative depths were 5.9 ± 2.3 mm, with a range of 10.6-2.1 mm.In all patients, there was improvement in sunken depth compared to the preoperative measurements.The mean improvement measured 3.3 mm, and this change was statistically significant, with a p-value <0.01.Aesthetic satisfaction, assessed through patient questionnaires, showed that 41 out of 42 patients reported fair or good outcomes, with only one patient reporting "poor."Figures 3 and 4 show typical cases of sunken eyelid correction.During the follow-up period, no significant complications, including a recurrence of sunken eyelid, were observed.

| DISCUSS ION
Sunken eyelids frequently result from a deficiency in soft tissue or a prominent orbital rim in the Asian population and tend to worsen with age. 13The hollow or recessed area beneath sunken eyelids can create shadows that give the eyes a darker, more fatigued appearance.
Addressing sunken eyelids through surgical or non-surgical methods can help restore volume, reduce shadows, and rejuvenate the eye area, ultimately leading to a more refreshed and youthful appearance. 14 fact, the correction of ptosis or double eyelid blepharoplasty alone can lead to a natural correction of mild sunken eyelids, as these procedures can naturally fill the upper eyelid volume. 5,6However, in cases where a sunken depth exceeds 10 mm, it is generally anticipated that accompanying procedures for sunken correction are necessary to achieve proper surgical outcomes.Particularly in areas where relative fullness cannot be achieved through levator muscle-related procedures, specifically, in the medial portion, anticipating sunken correction without additional interventions is often challenging.
With the advancement of blepharoplasty, there have also been developments in various methods for correcting sunken eyelids.Some studies have proposed correction through the injection of hyaluronic acid filler as a straightforward method. 6,15,16However, this approach may give rise to concerns regarding the potential for filler migration and the likelihood of recurrence after filler absorption.As a traditional solution for volume deficiency of sunken eyelids, fat grafting has been widely used. 17However, many early attempts were associated with significant side effects due to improperly injected fat. 3,11The most observed complication resulting from fat necrosis due to overcorrection was the formation of lumps or irregularities.In recent years, the development of micro fat grafting techniques has substantially mitigated the potential for such issues. 18There have also been attempts to enhance effectiveness by filling the preaponeurotic fat with autologous fineparticle fat under direct vision. 19Nevertheless, concerns persist regarding imprecise absorption rate and, particularly in cases of severe depth sunken eyelids with insufficient soft tissue and thin skin, it appears that a learning curve is necessary to achieve effective results. 20Furthermore, although very rare, there have been reports of complications resulting in vision loss due to acute embolization. 21 addition, there have been attempts to correct sunken eyelid through simultaneous correction with blepharoplasty surgery.Chen et al. proposed the orbicularis oculi muscle flap rotation method for sunken correction. 6In the correction of mild sunken eyelids that are F I G U R E 2 Before orbital septum release at the level of arcus marginalis (left).After release, orbital fat is protruded, and fat pad is distributed into the sunken area (right).brow blepharoplasty and brow fat pad transfer. 22This method have significant advantages, given that the deepest sunken point aligns with the subbrow area and that the origin of the brow fat pad remains stable.However, we consider that this method be selectively employed in cases of individuals of Asian, who frequently require concurrent double eyelid or ptosis correction.

TA B L E 1 Patient characteristics and outcome data.
In this study, we aimed to effectively correct sunken eyelids using orbital fat.There have been previous attempts to correct sunken eyelids by using orbital fat.shown in Figures 3 and 4, sunken eyelids are often pronounced on the medial side, leading to a focus on this area during correction.Therefore, the measurement of outcomes from a lateral view may not provide a complete and accurate reflection of the results.Furthermore, because the volume of fat can change over time, the 3-month follow-up period is relatively short for a comprehensive evaluation.Therefore, longterm evaluations, more than 1 year, will be necessary to gain a more comprehensive understanding of long-term results.
In conclusion, we have introduced an effective technique for correcting sunken upper eyelids, involving the release of the arcus marginalis, extraction of orbital fat, and its precise distribution.By directly addressing the primary cause of sunken appearance, this method provides efficient volume replacement with minimal fat flap transposition.This technique represents a valuable alternative for individuals with moderate to severe sunken eyelids, offering aesthetically favorable results.
this muscle flap can serve as a useful method.Linghan et al. reported simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women through combined sub-

3 , 8 ,
23,24 Gao et al. analyzed the anatomy of the orbital fat pad and reported favorable outcomes by considering this in flap transposition.11However, as reported in other studies and from the author's practical experience, predicting the absorption rate of orbital fat flaps has been challenging, and the possibility of flap migration exists even with fixation.With these concerns in mind, we attempted an effective improvement by releasing orbital fat from the deepest part, which is considered the primary cause of the sunken appearance.In this study, the results demonstrated the effectiveness of this method in improving sunken eyelids, all without necessitating the rotation of orbital fat flaps or excessive fixation.Although it may be challenging to achieve full correction of all kinds of sunken eyelids solely F I G U R E 3 A 53-year-old female before (upper row) and after 3 months (lower row) of surgery.F I G U R E 4 A 32-year-old male before (upper row) and after 3 months (lower row) of surgery.| 1775 HONG et al. with our method, it is noteworthy that even in severe cases, we were able to achieve appropriate correction without the need for fat grafts or dermofat grafts.The technique involving the release of the arcus marginalis, extraction of orbital fat, and its subsequent distribution effectively addresses the deepest sunken area, offering an efficient volume replacement with minimal fat tissue transposition.Unlike other methods, the pivot point of the orbital fat remains relatively stable, ensuring a secure placement at the sunken point, thereby promoting stable engraftment of the distributed orbital fat.While implementing this method, we had concerns about the potential complications related to the release of the Arcus marginalis or the relative displacement of deep septal fat.However, no specific complications were observed during the follow-up period.This study has several limitations.Firstly, because the patient population consists exclusively of individuals of Asian descent, it may be challenging to apply the anatomical structure of the orbital bone uniformly to individuals of different racial backgrounds.Additionally, as