Reply: Temporal Modified Orbicularis Repositioning: Going beyond the Limits of Temporal Lifting

We sincerely appreciate the insightful points raised by Dr. Cotrufo. They provide us with the opportunity to further clarify key concepts regarding the relationship between the technique described in our article, “Temporal Modified Orbicularis Repositioning: Going beyond the Limits of Temporal Lifting,”1 and the anatomical structures of the periorbital region. Regarding the concern that a complete denervation of the orbicularis oculi muscle could occur during temporal modified orbicularis repositioning (MORE), we would like to offer some reassurances. While some interruption of the lateral motor components of the orbicularis muscle is possible, our clinical experience in a large number of cases has shown no cases of permanent functional impairment of the orbicularis. This observation is in accordance with the literature. Specifically, Innocenti et al.,2 during the Reidy–Adamson flap-harvesting procedure, noted that even when “most of the orbicularis oculi muscle’s extracanthal innervation source is transected,” there is no clinical evidence of denervation sequelae. This electroneurography study confirmed that extracanthal motor innervation is not the muscle’s primary nerve supply, which is concentrated at the medial palpebral corner.2 This conclusion is reinforced by an important anatomical study by Choi and Kim,3 who demonstrated that orbicularis motility also derives from other nerve fibers reaching its medial portion. This interesting research identified several motor nerve branches originating not only from the zygomatic branch but also from the buccal branch of the facial nerve, which is generally preserved during our procedure (Fig. 1). The same authors classified 3 terminal motor systems composed of these nerve branches: the lower palpebral, upper medial palpebral, and glabellar. All 3 run obliquely along what they called the “medial orbicularis motor line.”Fig. 1.: Photograph from a dissection course showing some of the branches of the facial nerve, with emphasis on the zygomatic branches, which run deep to the zygomaticus major muscle. Note the safety margin between the frontal branch and the incision in the orbicularis oculi muscle.In the context of the temporal MORE, the concept of denervation goes beyond these issues, configuring a new concept that we call “orbicularis oculi selective denervation. In our experience, this selective denervation can even improve crow’s feet, which are primarily caused by orbicularis muscle hyperactivity. We believe that these improvements may derive from the combination of the selective denervation, the subcutaneous dissection, and the subsequent fibrosis between planes. As mentioned in our original article, the temporal MORE technique can also be combined with lower blepharoplasty. Both conjunctival and subciliary approaches may be used and gradually tailored to the patient’s needs. The transconjunctival approach, with direct access to the fat pads, preserves the anterior lamella and is a valid option in cases where excess skin removal is not mandatory. The pinch lower blepharoplasty may be considered a valid ally when limited skin removal (3 to 4 mm) is sufficient, while the transcutaneous approach, with skin flap elevation and fat remodeling, is mandatory for greater skin excision. This gradual approach culminates in a more articulated technique in selected cases, the “extended lower blepharoplasty.” In cases of significant medial midface ptosis, the subperiosteal or supraperiosteal midface lift is recommended to achieve a “direct management” of soft tissues following a more vertical vectorial repositioning, which can outperform the traditional superolateral vector in select patients, as previously described in 2015.4 An additional consideration is the “passive septal tightening” described by Hester et al. in 2006.5 When the orbicularis muscle is stretched and suspended (orbiculopexy), excess fat pads are repositioned into their natural anatomical location. So, we obtain a restoration of the muscle’s supportive role while also reducing the need for fat excision. In our experience, fat preservation does not compromise cosmetic long-term results or increase the recurrence of herniation. For these considerations, we recommend performing lower blepharoplasty only after deep supraperiosteal dissection along the lateral and inferior orbital rim and orbiculopexy. Furthermore, we would like to highlight that excessive orbicularis stretching should be avoided, as it may cause ocular irritation, chemosis, and epiphora. Intraoperative lateral tarsorrhaphy can help prevent these complications in selected cases. Even postoperative tobramycin- and dexamethasone-based eye drops can be useful if these complications occur. In addition, the powerful soft-tissue lift achieved with the temporal MORE technique lends itself to reconstructive purposes. This is the case of anterior lamella retraction/deficit after cosmetic lower blepharoplasty. Temporal MORE may be the key for more middle-third soft-tissue recruitment, which is essential for correcting this kind of complication. This expands the potential indications of the technique, demonstrating that it is not only an effective cosmetic procedure but also a valuable reconstructive tool. We remain available for any further clarifications. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding or other support was received from a sponsor, commercial entity, or third party.