Topographic Anatomy of the Inferior Medial Palpebral Artery and Its Relevance to the Pretarsal Roll Augmentation

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The following comments refer to the recent article by Cong et al. (Plast Reconstr Surg. 2016;138:430e–436e).1 Gray wrote that the ophthalmic artery divides into two terminal branches, the frontal artery and the dorsal nasal artery.2 Whitnall noted that the deeper part of the eyelids are supplied by palpebral branches of the nasal artery (medial palpebral artery) and lacrimal artery (lateral palpebral artery). Whitnall wrote the “[medial palpebral arteries] are two vessels which arise, usually with separate origins, from the nasal branch of the ophthalmic just behind the pars lacrimalis muscle and lacrimal sac, and one enters medial end of each lid (Fig. 1).”3 However, the nasal artery from the ophthalmic artery cannot be found in Figures 1 through 3 of the article by Cong et al.
Hayreh classified the mode of origin of the inferior medial palpebral arteries into four types: independent branch, with superior medial palpebral, with dorsal nasal, and absent.4 Cong et al. classified the distribution patterns of the inferior medial palpebral arteries in relation to the superior medial palpebral artery and the supratrochlear artery into four types (Figure 1 of Cong et al.), which is similar to the classification of Hayreh.4 We wanted to know the purpose, meaning, and functions of this new classification, and provide a comparison between the Hayreh and Cong classifications in Table 1. In addition, as complicated classifications can make application difficult, we were interested in the clinical significance of this new scheme. Whitnall3 and Duke-Elder5 wrote: “On entering the lids, each palpebral artery bifurcates into larger marginal and smaller peripheral branch, which run along in relation to the borders of the tarsal plates” (Figs. 1 and 2).3
Figures from Cong et al. show that the “inferior medial palpebral arteries” are curvilinear along the lid margins. The artery that Cong et al. dissected and measured seems to be the “marginal arcade,” because the inferior medial palpebral artery divides into two arcades. We would be grateful if Cong et al. would clarify the description of the structures they dissected as the inferior medial palpebral arteries or the marginal arcade.
Whitnall wrote, “The marginal tarsal arcade lies about 3 mm from the free border of the lid, directly on the tarsal plate and beneath the orbicularis muscle.”3 Cong et al. stated that the inferior medial palpebral arteries were located along the tarsal plate and deep into the pretarsal part of the orbicularis oculi. They recommend that dermal fillers should be placed between the subcutaneous tissue and the pretarsal part of the orbicularis oculi.
We would like to know the difference between Whitnall’s description and the new findings of Cong et al. regarding the depth of the inferior medial palpebral arteries or marginal arcade in the lower eyelid. In Cong et al., the external diameter of the inferior medial palpebral arteries was 0.94 mm (when entering lower lid), tapering to 0.37 mm at the lateral canthus.
In the pretarsal area, it is common for plastic surgeons to inject fillers into the subcutaneous plane, which is relatively avascular compared with the vascularity of the muscular plane. Because of the small external diameter at the lateral area where the cannula is inserted, the possibility of penetrating the vessel, which might cause retrograde flow of the fillers, seems to be less than the possibility of penetrating the larger vessels in other parts of the face.
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