"A young-looking lower eye and cheek is convex," says Dr. Hamra, assistant clinical professor of plastic surgery, University of Texas Southwestern Medical Center. "The older eye, by age 40, is concave. And the vertical height of the lower eyelid — from the eyelid down to the cheek — widens as you get older. You want to make it more narrow and youthful by pushing tissues up toward the eye, not toward the ear."
Removing lower eyelid fat only exacerbates the hollowed-out appearance. However, while refining his composite facelift procedure in the early 1990s, Dr. Hamra built upon the knowledge that one can use the medial lower lid fat pad to improve deep nasojugal grooves.1 As in Dr. Loeb's procedure, Dr. Hamra continued to remove patients' middle and lateral fat pads when they were excessive. Unlike this procedure, however, Dr. Hamra's involves repositioning the entire orbicularis oculi muscle in order to shorten the vertical height of the lower eyelid.By 1993, unsatisfied with results from using only the medial fat pad, Dr. Hamra decided to preserve and use all of the orbital fat. The result was the arcus marginalis release with transposition of fat.2 He continued to develop the technique, which has resulted in the septum orbitale reset or "septal reset".3 It allows cosmetic surgeons to even better camouflage what he calls the skeletonization of the periorbit by covering the orbital rim with orbital fat along with the septum orbitale.
With this approach, Dr. Hamra noticed marked improvement in his results because it allows the repositioned orbicularis to rest on a firm undersurface of septum, not on the concavity created by fat removal (or the softness of fat only).
Before operating, one must decide whether fat must be resected or not, and if so, how much, based on each individual patient's anatomy. Once this determination is made, the procedure itself involves several steps.
The procedure First, Dr. Hamra develops a zygomaticus-orbicularis flap2 to mobilize the midface. Then, he performs an arcus marginalis release.
To do this procedure, he tells Cosmetic Surgery Times, "You release the arcus marginalis and determine how much fat should be preserved or removed."
More precisely, the arcus release requires incising the junction of the septum orbitale and the periosteum of the inferior orbital rim (the arcus marginalis). Dr. Hamra accomplishes this procedure with cutting cautery (and no local anesthetic injected in this area), after he's done a zygorbicular dissection. The septal reset follows the transcanthal canthopexy.
To perform the septal reset, Dr. Hamra uses 5-0 Vicryl sutures, usually eight to 12 of them to create a smooth transition. Tension hereby created must be sufficient to form a firm undersurface upon which the orbicularis will rest.
Dr. Hamra originally used 4-0 nylon for the transcanthal canthopexy. Later he experimented with nonpermanent suture materials including chromic catgut in an effort to shorten patients' recovery time. Patients recovered no more quickly with these methods, however. In addition, he learned that the stronger the tension he exerted on the superior-medial vector suspension of the cheek flap, the more effectively he could reposition the zygorbicular flap. For these reasons, he now believes that the permanent suture ensures more stable support for the reconstructed eye-cheek area.
If he's performing the reset as part of a composite facelift, Dr. Hamra ultimately advances and secures the zygorbicular flap to the orbital rim before closing facelift and forehead dissections. The tension of this superior medial vector must be maximal, he says. That's because it must overcome and balance the lateral tension of the superficial musculoaponeurotic system fixation. The last step of the reset procedure is trimming skin, if needed.