Anatomy of the Eyelids

487 FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 13 (2005) 487–492 Anatomy of the Eyelids a b, Sam P. Most, MD , Steven Ross Mobley, MD *, a Wayne F. Larrabee, Jr, MD, MPH & Superficial topography of the lids & Postseptal orbital fat compartments & Eyelid lamellae & Upper lid retractors & Orbicularis oculi & Lower lid retractors & Orbital septum & Summary & Tarsal plates & References & Neurovascular and lymphatic anatomy of the lids As the variety and complexity of periorbital sur- Eyebrow position is the result of opposing forces. gical procedures increase, so must the facial plastic A ptosis of the eyebrow is a common symptom in surgeon’s understanding of related eyelid anatomy. patients seeking functional or aesthetic brow sur- This article has two general goals: (1) to reacquaint gery. The frontalis muscle is the sole brow elevator. the reader with well-documented studies of eyelid The orbicularis oculi, corrugators, and procerus anatomy, and (2) to review newer concepts of eye- muscles work in concert with the constant force lid anatomy that are relevant to clinical practice. of gravity to contribute to brow descent. Eyebrow hair follicle direction needs to be well understood. This directionality of the brow cilia Superficial topography of the lids is an important consideration when designing The position and form of the eyebrow provide a incisions in the brow and brow hair transplant structural foundation that has a profound impact techniques. Beginning medially, the eyebrow hair on the appearance of the eye below. An exact analy- follicles are all directed more superiorly. Centrally sis of eyebrow position is a critical first step in the and laterally, the upper brow follicles are directed preoperative evaluation of the eyelids. Ideal eye- inferiorly, and the lower brow follicles are directed brow aesthetics have been described differently superiorly [1]. for female patients versus male patients. Typically, Fig. 1 depicts many important anatomic relation- female eyebrows are arched, with a peak whose ships. The lateral canthus is typically 2 to 4 mm horizontal high point is in line with, or slightly superior to the medial canthus. The adult palpe- lateral to, the lateral limbus of the eye [Fig. 1]. At bral fissures average 10 to 12 mm vertically and this highest point, the ideal brow should lay at least 28 to 30 mm horizontally. The distance from the 1 cm above the superior orbital rim. By contrast, lateral canthus to the orbital rim is typically 5 mm. the male brow has been described as less peaked The upper eyelid is positioned at, or 1 to 2 mm and lying more closely to the orbital rim. below, the upper limbus [Fig. 1]. The highest point a Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, University of Washington, Box 354716, 4245 Roosevelt Way NE, Seattle, WA 98105, USA b Division of Otolaryngology, University of Utah Health Sciences Center, 50 North Medical Drive, SOM 3C-120, Salt Lake City, UT 84132, USA * Corresponding author. Division of Otolaryngology, University of Utah Health Sciences Center, 50 North Medical Drive, SOM 3C-120, Salt Lake City, UT 84132. E-mail address: [email protected] (S.R. Mobley). 1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.06.003 facialplastic.theclinics.com 488 Most et al A 8 mm above the lid margin in men and 10 to 12 mm above the lid margin in women. In Asians, the upper lid crease may be lower or absent owing 10 mm to lower insertion of the septum and variable or C absent insertion of the levator aponeurosis into the G upper lid skin [2,3]. 8–11 mm The lower lid margin typically rests at the inferior F limbus. The low point of the lower lid margin is E1 just lateral to the pupil. The malar and nasojugal 5 mm B folds represent the cutaneous insertion of the or- 2–4 mm bitomalar ligament, a distinct bony attachment of E2 D the orbicularis oculi [4]. 5–6 mm 5 mm Intrapalpebral distance is between 10 and 12 mm 3–4 mm on average. This measurement can be divided into the mean reflex distance (MRD) 1 and 2. MRD1 Lateral Medial represents the distance from the center of the pupil up to the inferior edge of the upper eyelid. MRD2 Fig. 1. Topography of the eyelid. (A) The highest point represents the distance from the center of the of the brow is at, or lateral to, the lateral limbus. pupil down to the superior edge of the lower eye- (B) The inferior edge of the brow is typically 10 mm lid. For example, a patient with eyelid ptosis would superior to the supraorbital rim. (C ) Also shown are ranges for average palpebral height (10–12 mm), have a decreased intrapalpebral distance but, more width (28–30 mm), (D) and upper lid fold (8–11 mm, specifically, the MRD1 measurement would be de- with gender and racial differences). Note that the creased. In contrast, a patient with a lower lid lateral canthus is 2 to 4 mm higher than the medial ectropion would have an enlarged intrapalpe- canthus. (E) Intrapalpebral distance measures 10–12 mm. bral distance, corresponding to the increase in the (E1) equals mean reflex distance 1. (E2) equals mean re- MRD2 measurement. Using the MRD1 and MRD2 flex distance 2. (F ) Palpebral width. (G) Upper lid fold terms properly facilitates clear communication be- is 8–11 mm. tween colleagues. of the upper lid margin is just nasal to a vertical line Eyelid lamellae drawn through the center of the pupil. It is important to note this contour in ptosis repair to ensure The structures comprising the layers of the upper a natural-appearing upper lid margin. The position and lower eyelids are traditionally divided into of the upper eyelid crease varies with ethnicity. In anterior, middle, and posterior lamellae. In the the occidental upper lid, the crease is typically 7 to lower eyelid, the anterior lamella is composed of Fig. 2. Orbicularis oculi muscle. The muscle is traditionally divided into orbital and palpebral portions. The orbital portion arises from the anterior aspect of the MCT and the periosteum above and below it. The palpebral portion is further subdivided into pretarsal and preseptal portions, each lying over the tarsal plate or orbital septum, respectively. Anatomy of the Eyelids 489 the skin and underlying orbicularis muscle. The above and below this tendon. The palpebral por- posterior lamella consists of the tarsus, septum, tion is further subdivided into pretarsal and pre- and underlying conjunctiva. The orbital septum septal portions, lying over the tarsal plate and separating the orbital contents from the preseptal orbital septum, respectively [Fig. 2] [5,6]. The pre- structures is the middle lamella, although this no- septal portion arises from two heads. The deep menclature is not as consistently used as the for- head arises from the posterior crest of the lacrimal mer two. fossa as well as the fossa itself. The superficial head arises from the MCT. The pretarsal portion also arises from two heads. The deep head (Horner’s Orbicularis oculi muscle) arises from the posterior lacrimal crest Eyelid skin is extremely thin and nearly devoid of whereas the superficial head arises from the MCT. subcutaneous fat. Deep to the skin lies the orbicu- The superficial heads of the pretarsal and presep- laris muscle. This muscle is traditionally divided tal portions arise from the MCT whereas the deep into orbital and palpebral portions. The orbital heads arise posterior to some portion of the lacri- portion arises from the anterior aspect of the me- mal system. The action of the medial palpebral dial canthal tendon (MCT) and the periosteum portion of the orbicularis oculi is important for Fig. 3. Cross-sectional anatomy of the upper and lower lids. The capsulopalpebral fascia and inferior tarsal muscle , are retractors of the lower lid whereas Müller s muscle, the levator muscle, and its aponeurosis are retractors of the upper lid. Note the preseptal positioning of the retro-orbicularis oculi and suborbicularis oculi fat (ROOF and SOOF, respectively). The orbitomalar ligament arises from the arcus marginalis of the inferior orbital rim and inserts on skin of the lower lid, forming the nasojugal fold. 490 Most et al function of the lacrimal pump mechanism [5].In orbital septum lies deep to the orbicularis muscle. particular, the contraction of Horner’s muscle In the occidental upper lid, the septum typically (which is occasionally defined to include the deep fuses with the levator aponeurosis 2 to 3 mm above head of the preseptal muscle as well) draws the the tarsus, although this point can vary from 0 to eyelids medially and posteriorly, aiding in excretory 10 mm from the superior tarsal edge. The fusion is lacrimal function. Laterally, the pretarsal and pre- more inferior or absent in the Asian lid [2,3]. In the septal muscles merge to from the lateral canthal lower lid, the septum fuses with the capsulopalpe- tendon [5] (or lateral palpebral ligament). bral fascia 5 mm inferior to the tarsus. Weakening The retro-orbicularis oculi fat pad (ROOF) is a of the septum with age results in prolapse of the submuscular fat pad that sits deep to the interdigi- postseptal fat anteriorly. Because the orbital septum tation of the frontalis and orbicularis oculi mus- is weakened and prolapsed but intact, the postsep- cles [Fig. 3] [7,8]. The orbitomalar ligament arises tal fat is described as pseudoherniated [Fig. 4]. from the arcus marginalis of the inferior orbital rim and inserts on skin of the lower lid, passing through the orbicularis [Fig.

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