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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 be- yond 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 mobiliza- tion 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 observa- tions 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 defor- mity (Fig. 3). In the lateral canthal region, the orbicularis retaining ligament merges with the lateral or- bital thickening, which is a triangular conden- sation 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.
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