This website is intended exclusively for healthcare professionals and medical device manufacturers.
By accessing this site, you confirm that you belong to one of its of these categories and understand that the information provided is specifically intented for a professional audience.
"PERIORBITAL REJUVENATION IS AMONG THE MOST SOUGHT-AFTER PROCEDURES IN COSMETIC SURGERY"
Professor Simone La Padula is a renowned specialist in Plastic, Reconstructive, and Aesthetic Surgery, practicing at the Federico II University Hospital in Naples, where he is an Associate Professor.
He is also the Director of the Master’s Degree in Microsurgery, the University Diploma in Breast Surgery, and a lecturer in the Master’s Degree in Aesthetic Medicine.
After spending eight years at the Henri Mondor University Hospital in Paris, he perfected advanced techniques in facial, breast, and body contouring aesthetic surgery, as well as breast reconstruction using innovative microsurgical methods such as the DIEP flap.
A dedicated researcher and teacher, Professor La Padula regularly participates in international conferences, publishes in scientific journals, and trains young plastic surgeons.
With a patient-centered approach, he prioritises natural and harmonious results, tailoring each treatment to individual needs. Highly active on Instagram, he also shares his expertise and stays connected with his audience.
Periorbital rejuvenation is among the most sought-after procedures in cosmetic surgery. Patients often focus their attention on the eyelids, without considering that the aging process of the periorbital region results from a combination of multiple interconnected factors.
These factors affect not only the eyelids but also the eyebrows, the lateral canthal region, the lid-cheek junction, and the malar area. The role of the orbicularis oculi muscle (OOM), whose progressive weakening and ptosis are significant contributors, is central to these changes. Many authors have emphasised the importance of addressing the OOM in periorbital rejuvenation. Some have proposed various techniques for orbicularis suspension, while others have described partial muscle resections.
In this article, I present a brow-lifting technique using a subcutaneous temporal approach combined with an OOM flap. This technique, described by Michele Pascali, an Italian surgeon renowned in the field of facial rejuvenation, includes a suborbicular dissection to release the lateral canthal region, the Orbicularis Retaining Ligament (ORL), the Tear Trough Ligament (TTL), and the zygomatic ligament. This method provides significantly better results than a standard temporal lift. I adopted this technique in my practice a few months ago, and the results have been remarkable. More specifically, this is a modified and extended temporal lifting approach, named Temporal MORE (Modified Orbicularis REpositioning) by its creator, Michele Pascali.
Preoperative markings must be performed with the patient standing.
After raising the OOM flap on a preperiosteal plane, the dissection can be extended medially to the lateral orbital rim. This step allows for the complete release of the lateral raphe and the superficial component of the lateral canthal system (canthal ligament).
The superolateral repositioning of the OOM flap enables an ‘‘indirect’’ dynamic canthopexy, capable of raising the canthus by 2 to 3 mm. Similarly, the dissection continues inferomedially along the lower orbital rim, releasing the ORL. In cases of significant hollowing of the nasojugal groove, the dissection can be extended to the TTL.
The dissection then proceeds through the prezygomatic space until the zygomaticus major muscle is visualised following the section of the zygomatic retaining ligament. If a deep plane lift is performed simultaneously, this maneuver is included in the initial steps of that procedure.
The Temporal MORE technique necessarily involves the inclusion of the upper portion of the zygomatic SMAS (up to 1.5–2 cm) in the flap, which becomes a combined MOO/SMAS flap. This flap is suspended superolaterally using several sutures (Vicryl 4/0 or PDS 4/0) to anchor it to the deep tissues.
Three primary sutures are used:
A slight overcorrection is necessary to compensate for the expected relaxation of tissues within 2–3 weeks postoperatively.
The final step involves managing any excess skin. The subcutaneous layer is approximated with interrupted Monocryl 5/0 sutures, and the skin is closed using a continuous Prolene 6/0 suture. In cases of significant tissue traction, excess skin may appear at the lower part of the incision. If this occurs, the incision can be extended toward the tragal region (similar to a cervicofacial lifting incision) to eliminate any “dog ear” formation.
At the end of the procedure, I use a hemostatic “NET” with Prolene 4/0 or 5/0 to prevent hematoma formation, employing the same technique used in cervicofacial deep-plane lifts. These nets are removed 48 hours after surgery.
When an upper blepharoplasty is performed concurrently, it is crucial not to extend the pattern of skin excision too far laterally. The superolateral repositioning of tissues causes a significant shift in the lateral end of the incision. Furthermore, most of the excess skin lateral to the upper eyelid is already addressed by lifting the tail of the brow. Therefore, preoperative marking of the upper lid must be performed with the patient standing, manually suspending the brow to simulate the final result.
For the lower eyelid, skin excess can only be accurately assessed after the repositioning of the MOO/SMAS flap. Elevating the lid-cheek junction and reducing the height of the lower eyelid may cause skin accumulation in this area. In such cases, skin excision may be required.
The management of this excess involves the following steps:
This procedure is performed safely due to the tension provided by the MOO flap after the release of the ORL/TTL complex, which ensures sufficient stability and support for the lower eyelid.
In cases of redundancy or protrusion of the pretarsal portion of the orbicularis muscle, observed in some patients, conservative remodeling of the muscle can be performed to refine the aesthetic outcome. When fat bags are present in the lower eyelid, remodeling may be necessary. In such cases, a transconjunctival approach is preferred and performed before initiating the Temporal MORE technique, ensuring an effective and harmonious correction.
Before
Right side finished & left side untreated
After
One of the key advantages of the Temporal MORE technique is its ability to reposition the lateral canthus without directly addressing the palpebral region. By extending the suborbicular dissection and releasing the superficial component of the lateral canthal system (canthal ligament), the superolateral suspension of the orbicularis flap achieves a dynamic canthopexy effect. This indirect tensioning often eliminates the need for direct suspension of the lateral canthus to the orbital rim.
However, the stability of the lateral canthus and lower eyelid must always be carefully evaluated using standard tests before performing this technique, particularly if combined with a lower blepharoplasty. In cases of significant laxity in these structures, a direct canthopexy is recommended.
If a more significant elevation of the lateral canthus (greater than 2–3 mm) is required, the deep component of the lateral canthal system (canthal tendon) must also be released, and a direct canthoplasty performed.
Dissection extended to the ORL/TTL ligament complex allows mobilisation of the eyelid jowl junction and inner eyelid tissues in a superolateral block. This creates significant tension and vertical shortening of the lower eyelid.
By extending the dissection into the prezygomatic space to release the zygomatic ligament, superolateral mobilisation of the malar soft tissues is achieved. This approach restores the malar prominence in a three-dimensional manner and extends the benefits of the technique to the midface region.
If skin excess persists in the lower eyelid, it can be corrected through a subciliary incision without the need to address the palpebral portion of the MOO. Most defects are already corrected through the lateral approach. When the orbital septum remains attached to the orbicularis muscle, the superolateral traction of the muscle also tightens the septum, thereby reducing the protrusion of postseptal fat pads, in accordance with the principle of ‘‘passive septal tightening’’ described by Hester. Moderate fat bags can thus be treated indirectly.
However, in cases of more pronounced fat bags, a transconjunctival blepharoplasty is preferred and performed prior to initiating the Temporal MORE technique.
No permanent damage to the frontotemporal or zygomatic branches of the facial nerve was observed in this series. However, it is essential to be aware of their anatomical course:
To minimise the risk of nerve entrapment, resorbable sutures (Vicryl 4/0) are used, and the needle is passed parallel to the nerve trajectory within the superficial temporal fascia.
The Temporal MORE technique offers a rapid postoperative recovery. A light compressive dressing is maintained for 24 hours, followed, if necessary, by adhesive strips on the eyelids for one week. Bruising is minimal or absent, allowing patients to quickly return to social activities.
The Temporal MORE technique goes beyond correcting defects of the brows and temporal region, as in a standard temporal lift. It also addresses the lateral canthal region, eyelids, lid-cheek junction, and malar region, which are considered a functional unit in periorbital rejuvenation.
In the hands of experts, this technique has proven to be straightforward, delivering consistent and reproducible results, a rapid postoperative recovery, and a low complication rate. Patient satisfaction has been remarkable, aligning with the assessments of the surgeons involved.
Pascali M, Savani L, Gratteri M, Rega U, Marchese G, Persichetti P. ‘‘Temporal MORE (Modified Orbicularis Repositioning): going beyond the limits of temporal lifting’’. Plast Reconstr Surg. 2024 Sep 17. doi: 10.1097/ PRS.0000000000011752. Epub ahead of print. PMID: 39288448
