Cosmetic Surgical Anatomy of the Ligamentous Attachments of The

Cosmetic

Surgical Anatomy of the Ligamentous Attachments of the Lower Lid and Lateral Canthus

Arshad R. Muzaffar, M.D., Bryan C. Mendelson, F.R.C.S.Ed., F.R.A.C.S., F.A.C.S., and William P. Adams, Jr., M.D. Dallas, Texas, and Melbourne, Australia

Description of the surgical anatomy of the superficial omy of these areas becomes increasingly man- fascia of the face must include its deep attachments. These ifest. To be of use to the surgeon, anatomic attachments have been mapped out for the forehead, temple, and cheek as retaining ligaments. The deep at- studies should describe the anatomy as the tachments of the orbicularis oculi of the lower lid and surgeon might encounter it in the operating lateral canthus have long been recognized in canthopexy room. To this end, significant and elegant con- surgery but have yet to be properly defined. Six fresh tributions to the literature have been made by cadavers were dissected with histologic support, and the results were correlated with surgical observations. The a number of authors, including Mitz and Pey- 1 2 3 fascia of the deep aspect of the orbicularis is attached to ronie, Bosse and Papillon, Furnas, Thaller et the periosteum of the orbital rim by an orbicularis retain- al.,4 Stuzin et al.,5 Knize,6 Byrd and Andochick,7 ing ligament. This attachment is weakest centrally and and others.8–17 tightest over the inferolateral orbital rim. The retaining It is now well recognized that when the su- ligament fuses with an expanded fibrous attachment beyond the lateral canthus, the lateral orbital thickening, perficial fascial system of the face (superficial which extends over the lateral orbital rim onto the adja- musculoaponeurotic system [SMAS]) is used as cent deep temporal fascia. Aging changes are associated the basis for rejuvenation surgery, specific an- with attenuation of the ligamentous support provided by atomic attachments (ligaments, septa, and ad- the orbital thickening and the orbicularis retaining liga- 17 ment, which then allows inferior displacement of the hesions) to the periosteum and deep fascia lower boundary of the lid and contributes to the typical must be defined and released to allow unre- effects of age in this region. The superficial fascia of the stricted mobilization and redraping of the lateral orbital region has a continuous connective tissue SMAS.18 The definition of these anatomic at- structure linking the temporoparietal fascia and orbicu- tachments in the temple has recently been laris fascia to the lateral canthal tendon by means of the 17 tarsal plate connection. Release of the deep ligamentous published. This study on the lower lid and attachments (lateral orbital thickening and orbicularis lateral canthus, and the subsequent article in retaining ligament) of the orbicularis fascia is important this issue on the anatomy of the midcheek,19 in some canthopexy and in rejuvenation procedures. The represent further investigations from the release allows effective redraping and upward mobilization of the orbicularis of the lower lid and the premalar standpoint of applied surgical anatomy. soft tissues. (Plast. Reconstr. Surg. 110: 873, 2002.) Because the orbicularis oculi is an integral part of the SMAS, the question arises as to what, if any, ligamentous attachment must be As surgical approaches to rejuvenation of the released to effectively redrape the orbicularis midface and periorbital regions become more for midfacial and periorbital rejuvenation. It numerous and complex, the need for precise has been our surgical observation that ade- and detailed descriptions of the surgical anat- quate mobilization of the lower orbicularis oc-

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, and from Melbourne, Australia. Received for publication September 20, 2001; revised November 21, 2001. Presented at the Annual Scientific Meeting of the American Society for Aesthetic Plastic Surgery, New York, May 5, 2001.

873 874 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2002 uli muscle requires the release of a definite the orbicularis and from a subciliary approach. attachment of this muscle to the inferolateral In three other specimens, a temporal approach orbital rim; without specific knowledge about to the lower lid suborbicularis plane was com- this attachment, we had named it the orbicu- bined with an inferior periorbital approach. In laris retaining ligament. These observations each specimen, the arcuate expansion of the were bolstered by the extensive experience of orbital septum and the orbicularis retaining Byrd,7,20,21 who approached the suborbicularis ligament were identified. The distance from plane endoscopically from the temple and who the orbital rim to the ligament was measured. described the importance of the release of this The thickness of the ligament and its length attachment. Regardless of the surgical ap- (the distance from its periosteal attachment to proach, the existence of a stout attachment of the underside of the orbicularis) were mea- the orbicularis to the inferolateral orbital rim is sured along the orbital rim, and the orbicularis beyond clinical question. But what is the anat- oculi was divided at the 8 o’clock position omy of this attachment? (right side) in line with the arcuate expansion. There have been few detailed descriptions of The medial and lateral limits of the retaining the anatomy of the attachments or retaining ligament were also determined. Finally, the di- ligaments of the orbicularis in the lower lid mensions of the lateral orbital thickening and and lateral canthal region. As recently as 1996, the frontal process of the zygoma were Kikkawa et al.22 described an “orbitomalar lig- measured. ament,” which takes origin from the orbital rim Four specimens were submitted for histologic and passes through the orbicularis oculi into analysis: three wedge-shaped en bloc resections the overlying dermis. Pessa et al.16 described a from skin to periosteum of the lower lid- “malar septum,” a thin membrane also origi- midcheek region (subciliary to infrazygomatic) nating from the orbital rim. However, this and a fourth histologic specimen derived from structure is described as inserting into the an entire undissected facial half. All specimens cheek skin approximately “3 cm below the lat- were fixed in formalin. The fourth specimen was eral canthus,” and it seems to be a different decalcified. All sections were stained with hema- structure from that described by Kikkawa et al. toxylin and eosin and trichrome and were re- Given the lack of a satisfactory anatomic de- viewed with a pathologist. scription to account for our clinical observations of the attachment of the orbicularis oculi RESULTS to the orbital rim and the inconsistency of the few reports in the literature, we sought to char- Anatomic Dissections acterize this structure and to define its attach- The orbicularis oculi has a direct muscle ments and relations to the orbital rim, orbicu- attachment to the inferior orbital rim from the laris oculi muscle and fascia, and lateral anterior lacrimal crest out to approximately canthus. the level of the medial corneoscleral limbus. Lateral to this point, the attachment of the METHODS orbicularis to the rim is indirect through the Six fresh cadaver heads ranging in age from orbicularis retaining ligament (Fig. 1). The lig- 48 to 89 years were subjected to dissection and ament spans from the periosteum, just outside histologic examination. Eleven facial halves the orbital rim, to the fascia on the undersur- were dissected; one entire facial half was sub- face of the orbicularis, here separating it into mitted for histologic examination without dis- the preseptal and peripheral parts (Fig. 2). section. Anatomic observations were systemati- The periosteal attachment continues around cally recorded, sketched, and photographically the inferior orbital rim to the lateral canthal documented. These data were correlated with region. The orbicularis retaining ligament was the anatomic observations from hundreds of found to have a variable length at different intraoperative dissections performed in the positions along the inferior orbital rim. course of temple lift, brow lift, and rhytidec- Above the levator labii superioris, the orbic- tomy procedures (B.C.M.). ularis is closely attached to the orbital rim. The Dissection was performed according to a length of this attachment then increases to a standardized protocol using 3.5ϫ loupe mag- maximum centrally, at about the level of the nification. In three specimens, dissection was arcuate expansion of the septum orbitale, here performed from both the inferior margin of measuring between 10 and 14 mm (the dis- Vol. 110, No. 3 / SURGICAL ANATOMY OF FACIAL FASCIA 875

FIG. 1. Dissection within the prezygomatic space. The upper border is indicated by the blue line. Medially, the orbicularis oculi (OO) originates directly from the orbital rim above the origin of the levator labii superioris (LLS). More centrally, the orbicularis has an indirect attachment to the orbital rim by means of the orbicularis retaining ligament (ORL), which courses directly on the orbital side of the zygomatico-facial nerve (ZFN). At the lateral orbital rim, the ligament merges into the lateral orbital thickening. Sub–orbicularis oculi fat (SOOF) lines the undersurface of the prezygomatic orbicularis (pars orbitalis). Zmaj., zygomaticus major muscle; Zmin., zygomaticus minor muscle. tance from the orbital rim to the orbicularis) further laterally until it becomes negligible at and 1.5 to 5 mm in thickness. The length of the the lateral orbital thickening. The laxity of the orbicularis retaining ligament then diminishes retaining ligament creates a V-shaped deformity (Fig. 3). In the lateral canthal region, the orbicularis retaining ligament merges with the lateral orbital thickening, which is a triangular condensation of the superficial and deep fasciae that crosses the frontal process of the zygoma onto

FIG. 2. Concept of the orbicularis retaining ligament (ORL), which indirectly attaches the orbicularis oculi (OO)at FIG. 3. The length of the orbicularis retaining ligament is the junction of its pars palpebrarum and pars orbitalis to the demonstrated by traction. It is negligible medially, increases periosteum of the orbital rim and, consequently, separates to a maximum centrally, and then diminishes laterally. Its the prezygomatic space from the preseptal space. laxity creates a V-shaped deformity (dotted lines). 876 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2002 the deep temporal fascia (Fig. 4). In this region, the retaining ligament is thicker and less distensible. In the five older cadavers aged (77 to 89 years) the lateral orbital thickening measured approximately 11 to 12 mm vertically along the frontal process of the zygoma and 12 to 29 mm in transverse width as it crossed the frontal process (13 to 14 mm wide) and extended onto the deep temporal fascia for 14 to 15 mm. However, in the 48-year-old cadaver, the dimensions of the orbital thickening were considerably greater: 35 mm along the frontal process of the zygoma and 30 mm in transverse width (Fig. 5). These findings are concordant with our clinical observations at surgery that younger patients typically have a greater di- mension of the orbital thickening than do older patients. The orbicularis retaining ligament is a bilaminar membrane (Fig. 6). On the orbital side, the membrane is derived from a reflection of the septum orbitale, whereas the caudal membrane is derived from a continuation of the membrane covering the preperiosteal fat over the zygoma. Thus, the caudal leaflet of the bilaminar membrane that makes up the retaining ligament also forms the cephalad boundary of the prezygomatic glide plane space (Fig. 1) (see companion article).19 Between these membranes is a layer of fat. The thickness of the retaining ligament varies in accordance with the thickness of the intervening fat layer. The orbicularis retaining ligament consis- tently lies directly cephalad, or on the orbital side, of the zygomatico-facial nerve and fora- men (Fig. 1). The nerve is a reliable surgical landmark for the location of the retaining ligament. Access to the ligament may be gained through the prezygomatic space. The orbicularis retaining ligament is in continuity with the lateral orbital thickening at the inferolateral orbital rim immediately below the lateral canthal region. A clinically relevant anatomic relation is evident in this region. Spe- cifically, the retaining ligament, orbital thickening, and lateral palpebral raphe form an FIG. 4. Dissection of the lateral canthal region. The lat- anatomic unit. Moreover, this unit is con- eral orbital thickening (LOT) is a triangular condensation of superficial and deep fascia that crosses the frontal pro- nected to the deep head of the lateral canthal cess of the zygoma onto the deep temporal fascia. The tendon by the orbicularis fascia on the deep orbicularis retaining ligament is thicker and less distensi- surface of the orbicularis oculi muscle and its ble in its lateral part as it merges with the orbital thick- fascial connections to the tarsal plate (Figs. 7 ening. (Center) Complete release of the orbital thickening, showing the triangular shape and dimensions of its base on the frontal process of the zygoma extending onto the deep over an orange background, has a separate orbital attach- temporal fascia (DTF). The deep head of the lateral canthal ment. Zmaj., zygomaticus major muscle; Zmin., zygomaticus tendon (LCT), highlighted by medial forceps traction minor muscle. Vol. 110, No. 3 / SURGICAL ANATOMY OF FACIAL FASCIA 877 orbital rim (Fig. 9). This is in contrast to the lesser dermal attachments of the preseptal orbicularis and the coarser fibrous attachments of the prezygomatic orbicularis to the thicker layer of subcutaneous fat (Fig. 10). Evidence of a fibrous connection between the orbital rim and the orbicularis oculi was also found; however, we were unable to capture a complete cross section of the orbicularis retaining ligament between the rim and the orbicularis in any single histologic section.

DISCUSSION The retaining ligaments of the cheek and their significance in facial rejuvenation surgery FIG. 5. Dimensions of the orbicularis retaining ligament. 2,3,5,17,23–25 The larger light blue outline is the ligament of the youngest have been elegantly described. How- specimen. The dark blue triangle defines the diminished at- ever, the plastic surgery literature does not tachment in the older specimens. include a similarly detailed description of the retaining ligaments or attachments of the orbicularis oculi in the lower lid and lateral canthal region. This deficiency has remained de- spite the mention of a significant attachment of the orbicularis to the orbital rim by several authors in the descriptions of their classic canthopexy techniques.7,20,26–29 The lack of this anatomic detail is also remarkable given the grow- ing importance of orbicularis oculi redraping in rejuvenation surgery of the periorbital and midface regions using dissection in the suborbicularis plane.23,24,30–34 An understanding of lateral canthal anatomy has also become more important because of the increased attention FIG. 6. The orbicularis retaining ligament is a bilaminar given to lateral canthal support in lower lid membrane enclosing a layer of fat of variable thickness. The blepharoplasties of various types, and also be- cephalad lamina is derived from a reflection of the septum orbitale, whereas the caudal lamina is a continuation of the cause of the increased burden placed on the membrane covering the preperiosteal fat over the zygoma. lateral canthus with some of the recent rejuvenation procedures (most particularly, subperi- and 8). Thus, release of the retaining liga- osteal midcheek lifts and laser resurfacing of ment/orbital thickening from the orbital rim the lower lid).26,35-41 periosteum allows movement of all the above As far back as 1975, Hinderer42 described the structures as a unit. The lateral palpebral ra- necessity for a wide undermining of the infero- phe is difficult to identify as an isolated or lateral orbicularis off the orbital rim in his discrete anatomic structure. Rather, it seems to canthopexy technique. Flowers36 mentioned merge into the confluence of fibrous tissue the importance of the “division of tethering that makes up the lateral orbital thickening. bands of orbital septum and caudal reflections In these fresh cadaver specimens, unteth- of the lateral canthal tendon to facilitate easier ered redraping of the preseptal orbicularis oc- upward canthal location” and to secure a last- uli was not possible until the retaining liga- ing canthopexy. Whitaker27 also described the ment and lateral orbital thickening were surgical release of a “distinct band, being a completely released. combination of periosteum and orbicularis muscle, which extends inferiorly and medially Histologic Findings from the lateral canthus,” and whose release is The retinacula cutis fibers between the or- necessary to allow a superior and lateral shift of bicularis oculi and dermis were most concen- the palpebral fissure in canthopexy. These au- trated where they directly overlay the inferior thors all observed an attachment of the orbic- 878 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2002

FIG. 7. The attachments of the orbicularis retaining ligament (ORL) to the orbital rim (including the lateral orbital thickening [LOT]) have been released. This allows the lid to be rotated 180 degrees around the lateral canthal tendon (LCT), which is the only intact attachment. X and X' indicate the lateral extent of the orbital thickening on the deep temporal and temporoparietal fascia (TPF), respectively. consisting of pretarsal fibers. Zide and Jelks46 demonstrated a thickening of the periorbita at the lateral extent of the lateral canthal tendon, whereas Isse47 referred to the thickening of the preperiosteal tissue lateral to the insertion of the lateral canthal tendon as the “precanthal web” and noted that it must be released to modify the lateral canthus. Moss et al.17 described the anatomic relationships of the thick- ened area of the lateral orbital rim periosteum designated the “lateral orbital thickening,” and Knize48 referred to the horizontal condensa- FIG. 8. The superficial fascia, or superficial musculoaponeurotic system, is a continuous unit composed of the tem- tion in the fascia lateral to the lateral canthus poroparietal fascia (TPF) and the orbicularis muscle fascia. It as the superficial leaf of the lateral canthal attaches to the skeleton (1) along the orbital rim, by the tendon. The anatomic details of this region are lateral orbital thickening (LOT) in continuity with the orbic- particularly pertinent to periorbital rejuvena- ularis retaining ligament (ORL); and (2) to the lateral orbital tubercle by means of fibrous connections of the orbicularis tion when using the suborbicularis plane from fascia with the tarsal plates (TP), and from there to the deep the temporal approach7,20,23,24,30,47,49–53 and head of the lateral canthal tendon (LCT). from the traditional lateral face lift approach.25 This study further defined the lateral orbital ularis to the inferolateral orbital rim because of thickening and quantitated its attachment be- the need for its release. tween the orbicularis fascia and periosteum, The description of the anatomy of the lateral and the extension of the attachment onto the canthus in the classic ophthalmology texts43,44 adjacent deep temporal fascia. The orbital provides minimal detail on the lateral palpe- thickening attachment extends further on the bral raphe and the lateral orbital rim perios- deep temporal fascia than on the underside of teum. The lateral palpebral raphe is merely the orbicularis. The ligamentous density of the mentioned as a fibrous intermingling of upper orbital thickening is less than that of some and lower preseptal fibers. Gioia et al.45 clari- specific localized retaining ligaments, such as fied the anatomy of the lateral palpebral raphe the main zygomatic ligaments or the lateral as being located medial to the orbital rim and canthal tendon proper. In addition, it seems Vol. 110, No. 3 / SURGICAL ANATOMY OF FACIAL FASCIA 879 laris. The more distensible central part of the ligament (see discussion of retaining ligament below) does not create a “downward drag,” which is the reason the release along the inferior orbital rim need not extend medial to the pupil.27,36 Moss et al.17 described the lateral orbital thickening as being located immediately su- perolateral to the lateral canthal tendon insertion, where it retains the deep surface of the orbicularis oculi muscle fascia. Furthermore, they described a structure “continuous with- . . .the lateral orbital thickening” that they termed the “periorbital septum” and that “gains origin from three-quarters of the cir- cumference of the orbital rim, extending from the corrugator origin around to the inferome- dial bony origin of the orbicularis oculi.” Be- cause this structure is generically similar to other retaining ligaments of the face, we prefer the term orbicularis retaining ligament for the periorbital septum of the lower lid. The retaining ligament is a distinct and, in

FIG. 9. Histologic findings from the decalcified facial half. The strongest condensation of retinacula cutis fibers is overlying the orbital rim. Deep to the orbicularis, a discrete orbicularis retaining ligament is not seen. that the density of the structure is not uniform; it is weaker peripherally, where it undergoes attrition with aging. This is reflected in the reduction of the peripheral extension of the orbital thickening, which recedes from the deep temporal fascia and persists better where closer to the lateral canthus. Reduction of the lateral orbital rim attachment of the orbicularis would contribute to the increased mobility of the superficial tissues around the lateral canthus and lower temple seen with aging. It is now apparent that the lateral orbital thickening and its inferior extension, the broader-based and more resistant inferolateral part of the orbicularis retaining ligament, are the structures specifically mentioned by several surgeons in their canthopexy techniques. For a FIG. 10. Gross dissection of coarser fibrous attachments between the underside of the subcutaneous fat of the upper surgical release to be effective, it must release cheek and the outer surface of the prezygomatic orbicularis. only the part of the retaining ligament that There is not a smooth fascia covering the superficial surface provides resistance to redraping of the orbicu- of the orbicularis. OO, orbicularis oculi. 880 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2002 part, substantive structure in the form of a orbicularis and the separation of preseptal bilaminar membrane that connects the fascia muscle bundles.33 Such attenuation of the pre- on the underside of orbicularis oculi to the septal orbicularis is associated with a weakened orbital rim periosteum and merges laterally function and reduced ability to contribute to with the lateral orbital thickening. The liga- the support required to maintain the lower lid ment was significantly longer than we had an- fat in its position. This may explain the fre- ticipated, which may have been related to the quent association of bulging lower lid fat in advanced age of our specimens. Lengthening people who have a significant descent of the of this retaining structure allows the descent of lid-cheek junction. bulging orbital fat behind an attenuated sep- The orbicularis retaining ligament is the tum orbitale. It is the orbicularis retaining lig- boundary separating the preseptal space of the ament, not the septum orbitale, which defines lower lid (above) from the prezygomatic space the lower limit of the descent and the shape of (below). Accordingly, when distension of the lower lid fat bulges (Fig. 11). The distension of ligament is present, allowing preseptal fat to the ligament is not uniform across its length. extend into the upper part of the prezygomatic Fat bulges are most prone to develop centrally, space, this constitutes a direct hernia. where the ligament is weakest and becomes The differential laxity of the retaining liga- most distended. The minimal inferior displacement with aging is associated with an altered ment of the bulging fat of the medial lower lid appearance. The greater descent of central lid correlates with the minimal length of the liga- fat and the laxity of the lid-cheek junction form ment here, where it is reinforced by the direct a V-shaped downward angulation, which also orbicularis muscle origin along the medial ex- contributes to the development of the nasoju- tent of the inferior orbital rim. Lateral com- gal groove (Figs. 3 and 12). The descent of the partment fat bulges are initially situated lid-cheek junction produces a redundancy of higher, near the lateral canthus, because the the soft tissue immediately below. This laxity of septum orbitale is least distensible near the the superficial fascia in the roof of the prezy- inferolateral orbital rim. Because the retaining gomatic space contributes to the appearance of ligament is strongest over the inferolateral or- malar mounds (Fig. 13) (see companion arti- bital rim, it further resists the tendency for cle).19 Furnas33 described an “orbit-cheek fold” lateral fat bulges to prolapse over the rim, at (which defines the upper border of the malar least until a more advanced stage of mound) and a “mid-cheek fold” (which defines degeneration. the lower border of the malar mound). He was Because the upper part of the orbicularis is prescient in his hypothesis that the orbit-cheek relatively fixed,51 it is the preseptal segment of fold might be formed “by a line of fusion be- the orbicularis muscle and its fascia that under- tween the superficial and deep layers of facial goes elongation with the downward displace- fascia that in turn attach to the orbital rim.” ment of the lid-cheek junction. This distension This is the level of attachment of the orbicu- accounts for the significant thinning of the laris retaining ligament, first described by

FIG. 11. Comparison between the youthful and aged lid. The blue line overlies the bony orbital rim. In the aged lid, the peripheral extent and shape of the bulging lid fat are determined by the distended orbicularis retaining ligament. The preseptal orbicularis undergoes elongation associated with the extension of the “lid” beyond the orbital rim. Vol. 110, No. 3 / SURGICAL ANATOMY OF FACIAL FASCIA 881 Kikkawa22 as the orbitomalar ligament and brane covering the preperiosteal fat and cau- shown histologically to attach to the overlying dal boundary of the prezygomatic space. dermis. The components of the “orbit-cheek In surgery, once the lateral orbital thicken- fold,” the nasojugal and palpebro-malar ing and the restraining part of the orbicularis grooves, should not be confused with the mid- retaining ligament have been released, the sole cheek or (malar) groove or furrow, which is remaining skeletal attachment of the superfi- the same as the “mid-cheek fold” described by cial fascia (which includes the anterior lamella Furnas. This location correlates with that de- of the lid) is the lateral canthal tendon. The scribed for the termination of the “malar sep- fibrous connective tissue structure of the super- tum” into the cheek skin “approximately 3 cm ficial fascia has a continuity that comprises the below the lateral canthus.”16 It may be that the temporoparietal fascia and the orbicularis mus- “malar septum” is a reflection of the mem- cle fascia, both external to and internal to the orbital thickening, and is linked by the attachment to the tarsal plates and to the deep head of the lateral canthal tendon (Fig. 8). Accord- ingly, after the superficial fascia is completely mobilized from the periosteum of the orbital rim, an effective redraping of the superficial fascia, including the entire orbicularis, can be performed without traction against resistance (Fig. 12). Effective redraping of the orbicularis, made possible by release of the orbital thickening and retaining ligament, allows “clearing” of redundant accumulated lax tissue in the FIG. 12. Aging changes result from laxity and displace- lower lid-cheek region and elevation of the ment of the underlying structures. The grooves overlie liga- ptotic lid-cheek junction. It also counteracts mentous attachments, and the bulges overlie “spaces.” The nasojugal and palpebro-malar grooves overlie the orbicularis the senile tendency for lower lid malposition retaining ligament. The midcheek groove or furrow overlies and scleral show. the zygomatic-cutaneous ligaments. Downward displacement Release of the orbicularis attachment at the of the lid-cheek junction contributes to the development of lateral orbital thickening also allows for modi- malar mounds. On the patient’s left side, the changes are fication of the lateral canthus because of the more advanced because the lid bulge has become confluent with the bulge of the malar mound, with loss of the inter- attachments of the orbicularis fascia to the vening palpebral-malar groove. deep lateral canthal tendon and the continuity

FIG. 13. Surgical application. Intact ligaments of the lateral and inferolateral orbital rim (LOT and ORL) restrict the ability to redrape the orbicularis over this area. Traction, applied through the temporal approach, is resisted by these attachments so that distortion results because the limited movement that does occur is not in the direction of the traction force (right panel). After release of the attachments to the orbital rim, a tension-free and undistorted redraping of the entire orbicularis ensues. The displacement is in the direction of the traction force and affects the tissues medial and lateral to the lateral orbital thickening and the orbicularis retaining ligament.- 882 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2002 of the periorbital SMAS with the anterior la- • Aging of the preseptal orbicularis oculi is mella of the lower lid (Fig. 8). The tarso- associated with considerable distension and ligamentous support of the lower lid may be thinning of this strata, with separation of affected by this redraping of the superficial muscle bundles. fascia. This may occur indirectly, from an un- • The lateral orbital thickening is continuous loading of downward gravitational drag of the with the expanded lateral end of the retain- cheek on a poorly supported lower lid. Alter- ing ligament. natively, a degree of direct improvement on • The orbital thickening is a fibrous fusion the lateral commissure may result from the between the orbicularis fascia of the periph- redraping by means of the previously described eral part of orbicularis oculi and the under- fibrous interconnection through the orbicu- lying deep fascia (periosteum and deep tem- laris fascia to the tarsal plates and lateral can- poral fascia.) thal tendon. Thus, the lateral canthus may be • The orbital thickening extends across the treated without performing a formal canthal entire width of the frontal process of the procedure. Sutures can be placed in the re- zygoma and onto the deep temporal fascia leased superficial part of the orbital thickening for a variable distance. (i.e., the reinforced orbicularis fascia) to fur- • Aging changes of the orbital thickening are ther accentuate the change in the lateral can- associated with a reduction of its area. thus, as described by Byrd and Andochick7 and • There is continuity of the connective tissue Byrd.20 The release associated with this ap- supporting structures medial to the orbital proach also allows the placement of deeper thickening. The orbicularis fascia of the pre- sutures to directly modify the deep lateral can- septal and pretarsal orbicularis continues thal tendon. with the tarsus and the lateral canthal The general principles of SMAS flap surgery tendon. are no less applicable to this area of periorbital • Release of the orbital thickening and the SMAS.18 Accordingly, for orbicularis (SMAS) thicker lateral part of the orbicularis retain- redraping to be effective, there must be a com- ing ligament results in complete detach- plete release of all restraining deep attachment of the superficial fascia from the or- ments between the area requiring correction bital rim. and the point of fixation so that the redraping • Once mobilized, the superficial fascia forms is not placed under tension; hence the need a continuous connective tissue structure, for release of the lateral orbital thickening and namely, the temporoparietal fascia, orbicu- orbicularis retaining ligament. For fixation to laris fascia laterally (pars orbitalis) and over be most effective, it should be close to the area the lid (pars palpebralis), tarsal plate, and requiring correction, which in this situation deep head of the lateral canthus ligament means either the arcus marginalis along the (the sole remaining bony attachment). inner aspect of the orbital rim or the deep • Redraping of the peripheral part of this con- temporal fascia adjacent to the posterior bor- tinuous fibrous supporting structure has a der of the orbital rim. beneficial effect on the more central (lid) part of the structure. CONCLUSIONS Dr. Bryan C. Mendelson 109 Mathoura Road • The orbicularis retaining ligament (previ- Toorak, Victoria 3142 ously termed the orbito-malar ligament or Melbourne, Australia orbicularis retaining septum) is a bilaminar [email protected] septum–like structure attaching the orbicu- REFERENCES laris oculi to the inferior orbital rim. • 1. Mitz, V., and Peyronie, M. The superficial musculo-apo- The attachment of the retaining ligament is neurotic system (SMAS) in the parotid and cheek broader and stronger inferolaterally than area. Plast. Reconstr. Surg. 58: 80, 1976. centrally. 2. Bosse, J., and Papillon, J. Surgical anatomy of the SMAS • Aging changes of the retaining ligament are at the malar region. In Transactions of the 9th Interna- associated with distension, elongation, and tional Congress of Plastic and Reconstructive Surgery. New York: McGraw-Hill, 1987. thinning. Initially, these changes are more 3. Furnas, D. W. The retaining ligaments of the cheek. apparent on the central than on the lateral Plast. Reconstr. Surg. 83: 11, 1989. lid. 4. Thaller, S. R., Kim, S., Patterson, H., et al. The sub- Vol. 110, No. 3 / SURGICAL ANATOMY OF FACIAL FASCIA 883

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