Cosmetic

Surgical Anatomy of the Ligamentous Attachments in the and Periorbital Regions

Christopher J. Moss, M.B., B.S., F.R.A.C.S., Dip.Anat., Bryan C. Mendelson, F.R.C.S.(E), F.R.A.C.S., F.A.C.S., and G. Ian Taylor, F.R.C.S., F.R.A.C.S., M.D. Melbourne, Australia

This study documents the anatomy of the deep attach- complex system of deep attachments that arise ments of the superficial fasciae within the temporal and from the underlying deep fascia/periosteum. periorbital regions. A highly organized and consistent three-dimensional connective tissue framework supports The subSMAS plane that contains these attach- the overlying skin and soft tissues in these areas. ments is therefore not always a simple cleavage The regional and vessels display constant and plane. This explains why surgical dissection is predictable relationships with both the fascial planes and considerably more complicated in the midfa- their ligamentous attachments. Knowledge of these rela- tionships allows the surgeon to use the tissue planes and cial, temporal, and periorbital regions than in soft-tissue ligaments as intraoperative landmarks for the the . vital neurovascular structures. This results in improved In the , these deep attachments have efficiency and safety for aesthetic procedures in these been defined as the zygomatic, masseteric, and regions. (Plast. Reconstr. Surg. 105: 1475, 2000.) mandibular-cutaneous ligaments.21,22 These lig- aments provide a lateral line of fixation for the mobile tissues of the medial cheek. Release of The patterns of arrangement of the layers of these retaining ligaments is fundamental to the superficial fascia in the cheek,1–9 ,10–13 14 15,16 extended SMAS technique of “deep-plane” sur- scalp, and temple have been well de- 18,19,23,24 scribed. This superficial fascia in the temple, gery. The ligaments act as markers to the position forehead, and periorbital regions meets the 19 definition of a SMAS layer as described in the of the facial branches in the cheek. The midface.1 The superficial fascia thus extends zygomatic and buccal branches emerge from like a mask throughout the whole of the . the masseteric fascia and cross the subSMAS The descriptions of these layers have found plane to the underside of the SMAS. This pas- wide application to aesthetic surgery.17–19 sage occurs just medial to the cheek ligaments. The areolar tissue plane beneath the fibrous The ligaments therefore retain the overlying layer of the superficial fascia of the temple has SMAS and protect the branches as been given numerous names.14,20 A subsuperfi- they cross this glide plane. cial fascial plane is located deep to the galea in In facial rejuvenation surgery, the deep- the upper face, the SMAS in the midface, and plane method achieves a tightening of the me- the platysma in the . The ease of dissec- dial cheek soft tissues. After the retaining liga- tion along this plane in the scalp and forehead ments are released, the superficial fascia can be results from the relative paucity of connective drawn posteriorly. The facial nerve branches tissue attachments between the galea and the are simultaneously identified and preserved underlying deep fascia or pericranium. during surgical ligament release. The superficial fascial layer is retained by a Previous authors have provided a great deal

Dr. Taylor is from the Department of Plastic and Reconstructive Surgery at the Royal Melbourne Hospital. Received for publication June 1, 1999; revised August 27, 1999. Presented at the 30th Scientific Congress of the American Society for Aesthetic Plastic Surgery, in New York, New York, on May 3, 1997. 1475 1476 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 of information on the deep attachments in the proceeded in a caudal direction over the fore- cheek.18,21 Recently, studies have begun to in- and the temporal, periorbital, and facial vestigate deep attachments found in the tem- regions. Loose areolar tissue was gently dis- poral12,25 and periorbital regions.26,27 These ar- sected away, preserving the dense connective eas are therefore the focus of this article. tissue attachments between the deep and su- The origin and pattern of migration of the perficial tissues. The precise locations of these embryonic facial muscles that occur in the mid- attachments were recorded on a standardized face also occur in the upper face.28,29 Accord- worksheet with reference to specific fixed bony ingly, it could be expected that the upper face landmarks. The relationships of the major neu- would display similar tissue and neurovascular rovascular structures to both the connective arrangements. tissue attachments and the fixed skeletal land- The relationships of the facial nerve16,30–32 marks were documented carefully with appro- and sensory nerves33 to the fascial planes in the priate measurements. upper face have received much attention. Al- The cadavers that underwent initial vascular though helpful in identifying the layer of pas- injection were dissected with an identical tech- sage of the facial nerve branches, these studies nique and provided additional information on do not define their exact course. Currently, the relationships between the arterial supply landmarks are widely used in and both the connective tissue layers and their locating the facial nerve.34,35 However, surface attachments. The uninjected specimens pro- anatomy is not sufficiently precise for intraop- vided detailed information on the cutaneous erative dissection when facial nerve branches sensory nerves and fine motor branches of the are involved. facial nerve. This investigation commenced with the hy- pothesis that, as in the cheek, the internal soft- RESULTS tissue ligaments of the temporal and perior- bital regions display a constant anatomy with Arrangement of the Tissue Layers predictable relationships to the temporal The tissues are arranged into two basic layers branches of the facial nerve. The aim of the that may be summarized under the headings of study was therefore to define this not previ- the superficial and the deep fasciae. A contin- ously described anatomy. Although the data uous layer of superficial fascia comprises the reported in this article pertain only to the tem- galea occipitofrontalis, the superficial tempo- poral and periorbital regions, they are derived ral fascia, the SMAS of the zygomatic and from a comprehensive study investigating the cheek regions, and the platysma. This SMAS superficial tissues of the whole face and neck. system receives the insertion of those facial MATERIALS AND METHODS muscles arising directly from bone such as the zygomaticus major and minor; it also envelops This study involved dissection of 22 facial the flat muscles such as orbicularis oculi that halves. All were performed on fresh cadavers of have important attachments around their pe- normal body mass index with ages ranging rimeter to the SMAS layers. from 60 to 78 years. Preserved (formalinized) An easily developed surgical plane exists be- cadavers were excluded because they distorted tween these deep and superficial tissue planes. the delicate connective tissue and facial nerve This subsuperficial fascial plane is a potential anatomy. Of the 22 dissections, 10 were per- space that mainly contains loose areolar or formed following intraarterial vascular injec- fibro-fatty tissue. In predictable locations, dis- 36,37 tion with a lead oxide mixture and 12 were section through this plane is limited by the performed in fresh specimens without arterial fibrous and muscular attachments that retain injection. These data were combined with the the superficial tissues. anatomic recordings from several hundred in- traoperative dissections including open coro- nal brow and temporal lifts and endoscopic Classification of Ligament Morphology temple lifts. The fibrous attachments retaining the SMAS Dissection was performed under 3ϫ loupe layer and skin to the deep tissues may be col- magnification according to a standardized lectively referred to as the ligamentous attach- technique that commenced with a coronal in- ments of the superficial tissues. The individual cision, entered the subgalea plane, and then ligaments have predictable and constant loca- Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1477 tions; however, they vary in the density of their drical arrangement of fibrous tissue that is sur- fibrous tissue. rounded by fatty tissue. True ligaments were Clear description of the ligamentous anat- found in the medial midface and lower face and omy in the superficial tissues of the head and provided the greatest latitude of movement of neck has required the introduction of a num- all the attachments (Fig. 1). True ligaments ber of new terms. The ligaments have been arise from either the deep fascia or the perios- classified according to three morphological teum. They then cross the subSMAS plane to forms: true ligaments, septa, and adhesions the undersurface of the SMAS, where they di- (Fig. 1). vide into numerous branches in a tree-like fash- True ligament. A true ligament is similar to a ion. These branches then distribute the attach- skeletal ligament in that it is a discrete cylin- ment of the ligament to the dermis through a

FIG. 1. Classification of ligamentous morphology. The major tissue planes from deep to superficial include the deep fascia/pericranium, the subSMAS plane, the SMAS/galea, subcu- taneous tissue, and the skin. The diagram shows the three morphologic forms of ligaments that pass through the subSMAS plane to the superficial tissues. These are classified into true ligaments, septa, and adhesions. 1478 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 subcutaneous fascial system, the retinacula cu- and adhesions retain the SMAS plane only, and tis.9,14,38 Examples include the zygomatic and considerable mobility may still occur at more masseteric ligaments (Fig. 1). superficial layers. Aside from the preauricular Septum. A septum is a fibrous wall passing and parotid regions, adhesions were found only between the deep fascia and the undersurface in the forehead and temporal regions. Exam- of the SMAS (Fig. 1). This arrangement permits ples include the temporal (Fig. 1) and the su- mobility only in a plane perpendicular to the praorbital ligamentous adhesions. deep line of attachment of the septum. Most of The deep attachments of the superficial fas- the septa defined within the head and neck are cia in the temporal and periorbital regions located in the temporal and periorbital regions. comprised only septa and adhesions. No true Examples include the inferior temporal sep- ligaments were seen in these regions. tum, the superior temporal septum, and the periorbital septum (Fig. 1). Adhesion. The third form is a low-density The Temporal Ligamentous Adhesion area of fibrous or fibro-fatty adhesion between The temporal ligamentous adhesion (tem- the deep fascia/pericranium and the superfi- poral ligament) supports the region immedi- cial fascia (Fig. 1). Basically a two-dimensional ately superior to the at the junction of structure, an adhesion restricts mobility in all its middle and lateral thirds (Figs. 2 and 3). directions and to the greatest degree of the Located at the intersection of the temporal, three forms. It is important to note that septa frontal, and periorbital regions, it is a well-

FIG. 2. Periorbital and temporal ligamentous attachments with major neurovascular rela- tionships: lateral view. Temporal ligamentous adhesion (TLA), supraorbital ligamentous adhe- sion (SLA), superior temporal septum (STS), inferior temporal septum (ITS), periorbital septum (PS), lateral brow thickening of periorbital septum (LBT), lateral orbital thickening of perior- bital septum (LOT), sentinel vessel (SV), temporal branches of facial nerve (TFN), zygomati- cotemporal nerve (ZTN), zygomaticofacial nerve (ZFN). Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1479

FIG. 3. Periorbital and temporal ligamentous attachments with major neurovascular rela- tionships: anterior view. Temporal ligamentous adhesion (TLA), supraorbital ligamentous ad- hesion (SLA), superior temporal septum (STS), inferior temporal septum (ITS), periorbital septum (PS), lateral brow thickening of periorbital septum (LBT), lateral orbital thickening of periorbital septum (LOT), sentinel vessel (SV), temporal branches of facial nerve (TFN), zy- gomaticotemporal nerve (ZTN), zygomaticofacial nerve (ZFN). 1480 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 4. Right temple. Subject’s nose is to the right. Hairline incision across the forehead with retraction of the flap. The retractor is in the superficial temporal fascia (STF). The scissors are releasing the temporal ligamentous adhesion (TLA) at the anterior end of the superior temporal septum (STS), which separates the frontal periosteum (FP) medially from the deep temporal fascia (DTP) laterally. The superior extension of the temporal ligamentous adhesion is the superior temporal septum (STS). The location of the deep and superficial attachments of the inferior temporal septum (ITS) are defined by the line of the fine blue suture.

FIG. 5. Further elevation of the superficial fascia, deep to the superficial temporal fascia (STF), by releasing the inferior temporal septum. The temple is divided into two parts by the line of attachment of the inferior temporal septum. Above, no vital anatomy is present. In the lower compartment lies the detailed neurovascular anatomy. This contains lobulated fat on the floor. Unnamed minor ligamentous attachments (marked with blue ink) are seen centrally and related to the emerging branches of the zygomaticotemporal nerve (ZTN, yellow beads). The sentinel vessel (SV) crosses the lower temporal compartment inferior to the inferior temporal septum (ITS) just posterior to the frontal process of the zygoma. The green background and green beads display the temporal branches of the facial nerve (TFN) within the fatty layer deep to the superficial temporal fascia, which forms the roof of the triangular compartment. The dotted blue line demarcates the upper border of the supraorbital ligamentous adhesion (SLA). defined keystone structure in that three liga- horizontal mobility of the overlying galeal lay- ments radiate from each of its angles. These ers. The base is located parallel to the arcus are the superior temporal septum, the inferior marginalis of the orbital rim at a distance of 10 temporal septum, and the supraorbital adhe- mm above it. sion (Figs. 4 through 6). The temporal liga- The superior temporal septum. This septum ment arises from the periosteum arises from the periosteum along the superior as an expansion at the anterior end of the temporal line of the and inserts into the superior temporal septum. line of junction between the superficial tempo- The temporal ligament inserts into the su- ral fascia and the galea (Fig. 1). Anteriorly, this perficial fascia at the junction of the superficial line of junction occurs between the superficial temporal fascia and the galea on the deep temporal fascia and the galea lining the deep surface of the (Fig. 4). This surface of the lateral border of the frontalis ligament is approximately 20 mm high and 15 muscle. Whereas it more closely resembles a mm at its base (Fig. 3). It allows 6 mm of septum posteriorly, it becomes a broad adhe- Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1481

FIG. 6. Further elevation of the superficial temporal fascia. The three boundaries of the lower temporal compartment (L.T.C., shaded area) are seen, i.e., the upper border of the zygomatic arch (ZA), the posterior border of the frontal process (FPZ), and the inferior temporal septum (ITS). The smooth surface of the deep temporal fascia above the inferior temporal septum forms the floor of the upper temporal compartment (U.T.C.). SV, sentinel vessel. sion at its anterior termination 30 mm from the lower zygoma they comprise the named zygo- supraorbital rim. This expanded end is the tem- matic (true) ligaments. poral ligamentous adhesion (Figs. 2 and 4). The supraorbital (ligamentous) adhesion. The The inferior temporal septum. This septum density of this fibrous adhesion varies widely. takes an oblique course along a line extending The more dense adhesions maintain a greater from the lateral corner of the temporal liga- restraining effect on the superficial fascia of the ment toward the external acoustic meatus (Fig. brow, thus reducing brow mobility. 1). It comprises criss-crossed fibers that reflect The supraorbital ligamentous adhesion from the deep temporal fascia to their insertion arises from the frontal bone above the orbital into the deepest layers of the superficial tem- rim, extending between the temporal ligament poral fascia (Figs. 7 and 8). and the origin of the corrugator muscle (Fig. The septum is found an average of 27 mm 3). The well-defined inferior border is located above the zygoma at the level of the temporal 6 mm above the deep attachment of the peri- border of the frontal process of the zygoma orbital septum. The upper border of this origin and 21 mm above the superior border of the is less distinct and extended a variable 20 to 40 zygoma at its midportion. The average heights mm above the orbital rim. The ligament is for the level of the division of the deep tempo- condensed around the branches of the su- ral fascia into its deep and superficial leaves are praorbital nerve and the corrugator muscle 37 mm and 27 mm above the zygoma, respec- origin. tively. The division of the deep temporal fascia The supraorbital adhesion supports the into superficial and deep leaves is therefore deep galea which encloses a fat pad and the above the level of the inferior temporal sep- lower frontalis muscle. The adhesion allowed tum. minimal mobility, and therefore retained the The inferior temporal septum forms the su- deep tissues of the lower brow. The corrugator perior border of a triangular fibro-fatty com- and procerus muscles assist in providing an partment between the superficial temporal fas- important dynamic support to the medial cia and the underlying deep temporal fascia brow. Significant mobility of the medial eye- (Fig. 6). Cephalad to this septum is an easily brow can still occur within the tissues superfi- developed dissection plane beneath the super- cial to the superficial fascial layer. ficial temporal fascia. Within the lower tempo- The periorbital septum. This well-defined fi- ral (triangular) compartment, the planes are brous septum gains origin from three-quarters more adherent because of numerous fine, fi- of the circumference of the orbital rim, extend- brous adhesions contained within a variable ing from the corrugator origin around to the amount of adipose tissue. These fibrous inferomedial bony origin of the orbicularis oc- strands have related vessels and cutaneous uli (Fig. 3). It is continuous with two more nerve branches (Figs. 5 and 9 through 12). broad adhesions, which are named the lateral Inferiorly these fibrous attachments become brow and the lateral orbital ligamentous thick- increasingly condensed. At the level of the enings. 1482 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 7. Right temple, shown from above, looking down toward the zygomatic arch. The subject’s orbit is to the left, to the right. Skin hooks are elevating the superficial temporal fascia from the deep temporal fascia to demonstrate the upper temporal compartment. The attachments of the inferior temporal septum (ITS) are marked by the upper blue line on the underside of the superficial temporal fascia (STF) and the lower blue line on the deep temporal fascia (DTF). The tip of the scissors is in the lower triangular compartment. The inferior temporal septum terminates anteriorly by merging with the temporal ligamen- tous adhesion (TLA).

FIG. 8. Same orientation as in Figure 7 after completion of the release of the inferior temporal septum (ITS) and release of the temporal ligamentous adhesion (TLA, triangular adhesion outlined with ink). To the left is the supraorbital ligamentous adhesion (SLA) attached above the supraorbital rim. The released deep attachment of the temporal ligamentous adhesion is continuous with the supraorbital ligamentous adhesion. The scissors are beneath the orbital (internal) surface of the periorbital septum (PS). A nonadherent area devoid of ligamentous attachments exists between the periorbital septum and the temporal/ supraorbital ligamentous adhesions. STF, superficial temporal fascia.

FIG. 9. Dissection continued inferior to the inferior temporal septum (ITS) within the lower triangular compartment of the temple. Note the fatty tissue within this lower compartment compared with the areolar tissue within the upper compartment. The sentinel vessel (SV) is on the left. The scissors are between the medial and lateral branches of the zygomaticotemporal nerve (ZTN), which are protected by fibrous tissue. Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1483

FIG. 10. Dissection of the underside of the roof of the lower temporal compartment. Multiple temporal facial nerve branches (TFN) are contained within a layer of fibrofatty tissue adherent to the deep surface of the superficial temporal fascia (STF). These branches pass perpendicular to the branches of the zygomaticotemporal nerve (ZTN) as they perforate the superficial temporal fascia. SV, sentinel ; ITS, inferior temporal septum.

FIG. 11. Complete elevation of the superficial flap to the boundaries of the lower temporal compartment. The continuous blue line defines the upper border of the zygomatic arch (ZA). The temporal branches of the facial nerve (TFN) are already located in the roof of the compartment at the inferior border of the compartment. They do not cross to the roof within the boundaries of the compartment. Zygomaticotemporal nerve branches (ZTN) do cross the lower compartment and are clearly defined; their fibrous protection has been dissected free. The fine fibrous attachments (X) at the upper border of the zygomatic arch become progressively more concentrated until the lower border of the arch, where a true ligament can be identified. ITS, inferior temporal septum.

FIG. 12. Dissection inferior to the lower temporal space extending over the zygomatic arch (ZA). The ear is seen on the right side. The course of the temporal branches of the facial nerve (TFN, highlighted by green background and indicated by arrows) is defined. These emerge from beneath the lower border of the zygomatic arch (ZA) and pass to the underside of the superficial temporal fascia. In this passage through soft, yellow fat they are protected by definite ligamentous condensations, which attach the superficial temporal fascia to the zygomatic arch. 1484 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 Superiorly, the orbicularis oculi and frontalis anterior zygoma until the defined zygomatic muscles merge in an aponeurosis, each with a ligaments are reached. layer of galeal fascia on their deep surface. The The forehead compartment is limited later- orbicularis oculi fibers passed superficial to ally by the superior temporal septum and infe- those of the frontalis. The periorbital septum riorly by the supraorbital ligamentous adhe- inserts at a T-junction into the deep galea lin- sion. ing the deep surface of the flat facial muscles. The periorbital septum divides the subsuper- The superior arc of the periorbital septum ficial fascial space of the orbital region into two therefore provides an indirect bony origin for compartments: orbital and periorbital (Fig. 2). both the frontalis and the orbicularis oculi The subsuperficial fascial space of the orbital muscles and plays a significant role in restrain- region, located internal to the orbital rim be- ing the brow and upper soft tissues. tween the palpebral portion of the orbicularis At the inferolateral orbital rim, the septum oculi and the orbital septum, contains loose inserts into the deep surface of the orbital areolar tissue only. The superficial fascia itself component of the orbicularis oculi muscle. contains fat within its deepest layers in the Dissected toward its origin at the arcus margi- region of the orbital rim. The subsuperficial nalis, the periorbital septum separates into two fascial compartment of the periorbital region fascial layers. Internal to the orbital rim, the lies external to the rim and contains the attach- periorbital septum continues as the orbital sep- ments between the orbital portion of the orbic- tum; external to the orbital rim, it continues as ularis oculi and the underlying pericranium. the fibrous periosteum. The thin periorbital septum varies from 1 to Relationships between Ligaments and Nerves 3 mm in thickness, with a height of 7 mm (Fig. Facial nerve. The 2 to 4 temporal branches of 8). The lateral orbital thickening is 7 ϫ 10 mm the facial nerve leave the superior pole of the at its base and is located immediately supero- parotid gland by perforating its capsule at the lateral to the lateral canthal tendon insertion. level of the lower border of the zygomatic arch. The smaller lateral brow thickening is 3 ϫ 11 The nerves then cross the subSMAS plane in- mm and arises from a bony crest on the lateral ferior to the zygomatic arch (Fig. 12) to reach supraorbital rim. It does not arise from the the deep surface of the SMAS (Fig. 10). In cross- zygomaticofrontal suture. Both of these liga- ing this mobile plane, the nerve branches are ments insert into and retain the deep surface protected by fibrous condensations passing of the orbicularis oculi muscle fascia. from the zygomatic arch to a fat pad on the deep surface of the superficial temporal fascia. They Fascial Compartments then run in an anterosuperior direction toward The upper face and brow are separated into the insertion of the temporal ligament (Fig. 2). a number of fascial compartments by the ar- At the level of the temporal ligament, the rangement of the temporal (ligamentous) ad- main branches of the temporal nerve divide hesion, the three ligaments that radiate from into numerous filamentous branches. These it, and the periorbital septum (Fig. 2). supply the frontalis, corrugator, and upper or- The inferior temporal septum divides the bicularis oculi muscles through their deep sur- temple into the upper temporal compartment face. The nerve to the corrugator passes in a and the lower temporal compartment (Fig. 6). narrow compartment deep to frontalis, The upper temporal compartment is the po- bounded superiorly by the supraorbital adhe- tential space above the inferior temporal sep- sion and inferiorly by the periorbital septum. tum. Its upper border is the superior temporal The sentinel vein39,40 is located immediately septum. The lower temporal compartment is inferior to the inferior temporal septum (Fig. located below the inferior temporal septum; it 9). The temporal nerve branches display a vari- is bounded inferiorly by the zygomatic arch able relationship to the sometimes duplicated and anteriorly by the frontal process of the sentinel vein. Although the temporal nerve zygoma. The upper compartment has no spe- branches are found both superior and inferior cific structures crossing and is safe for dissec- to this vein, they are predominantly located tion. However, the triangular lower compart- cephalad to the sentinel vein (Fig. 2). Incon- ment contains the temporal branches of the stant smaller nerve branches are found caudal facial nerve.(Fig. 10). There is no well-defined to the sentinel vein. septum limiting inferior dissection over the The inferior temporal septum is therefore a Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1485 reliable and identifiable marker for the loca- scribes a connective tissue that restrains tion of the temporal nerves as it inserts into the bones,42 this definition has subsequently been superficial temporal fascia along a line imme- widened to include “cutaneous retaining liga- diately cephalad to the most superior temporal ments.” These are fibrous attachments anchor- nerve branches (Fig. 5). Dissecting in an infe- ing skin to the underlying deep fascia or peri- rior direction, the release of the inferior tem- osteum and have been described in various poral septum (Fig. 7) exposes the temporal locations including the digits,43,44 the face,18,21 nerves. They are surrounded by loose adipose and the .45,46 tissue and plastered to the deep surface of the Furnas21 introduced the term “retaining lig- superficial temporal fascia by a thin areolar aments” in the face. He documented four cu- fascia (Fig. 10). taneous ligaments in the cheek, naming them Sensory nerves. Each of the major cutaneous the zygomatic, mandibular, platysma-auricular, nerves in the region cross the mobile subsuper- and anterior platysma ligaments. The first two ficial fascia plane in association with a named of these ligaments passed from bone directly ligamentous attachment. into the dermis, whereas the second two passed The supraorbital nerve branches pass along the upper periorbital septum to reach the deep from the superficial fascia (platysma) to the galea. The supraorbital ligamentous adhesion dermis. Traction on the deep end of the cut is condensed along the course of the nerves. ligament dimpled the skin. The ligaments Branches of the infraorbital nerve to the lower fanned out as they approached the dermis and eyelid region follow the inferior periorbital were notably absent in about 10 percent of septum. Where the periorbital septum attaches dissections. 18 to the superficial fascia the respective nerves Stuzin et al. further elaborated on the def- divide into two groups of branches: those to inition of these retaining ligaments, also divid- the eyelid and those to the periorbital tissues. ing them into two groups: the previously de- The supratrochlear nerve is an exception, scribed true osteocutaneous ligaments and a crossing the plane between the of the second group that consisted of a coalescence corrugator muscle. between the deep and superficial fasciae of the The anterior branch of the zygomaticotem- face. This therefore widened the definition of poral nerve is usually related to the lateral retaining ligaments to include defined adhe- orbital ligament; the smaller posterior sions retaining the superficial to the deep fas- branches within the lower temporal compart- cia. These adhesions retain the overlying skin ment are associated with minor fibrous attach- indirectly through a separate system of fibrous ments and fine (Figs. 5 and 11). The septa that extend from the superficial fascia zygomaticofacial nerve emerges through a sin- into dermis.9,14,38 They differ from the discrete gle or duplicate foramen in the zygoma and is osteocutaneous ligaments, which run directly then associated with the inferolateral portion from periosteum to a focal area of dermis. of the periorbital septum. Knize13 recently suggested that, to be consid- The zygomaticotemporal and supraorbital ered a retaining ligament, a structure should cutaneous nerves perforate the superficial fas- insert directly into dermis. However, it is im- cia along the line of the facial nerves branches portant to recognize the vital role of those (Fig. 10). They could therefore be used as other ligaments that attach to the superficial additional markers for the location of the facial fascia yet retain the overlying skin indirectly nerve branches (Fig. 11). through the retinacula cutis. The septa and adhesions in the temporal DISCUSSION and periorbital regions pass to the superficial fascia and exert their effect on the skin, pre- Definition of a Ligament sumably thorough the retinacula cutis. The This study raises the important issue of what true (cutaneous) ligaments branch as they pass exactly is the definition of a “ligament.” The through the superficial fascia to the dermis. Oxford Dictionary41 defines a ligament as “a band The three forms of fibrous attachment de- of fibrous tissue binding bones together or any scribed in this article fulfill the criteria of “lig- membrane keeping an organ in position.” Al- aments of the superficial tissues” and insert though the word ligament traditionally de- into either the superficial fascia or the dermis. 1486 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 Surgical Applications seem that the periorbital septum has not been Connective tissue anatomy. The arrangement described as such before; however, close exam- 12 of the ligamentous fixation between the under- ination of Knize’s histologic studies (Fig. 6 of side of the superficial fascia and the perioste- Knize’s article, middle sagittal section) shows a um/deep temporal fascia provides landmark fascial septum passing from the deep galea to information for the surgeon operating in this the orbital rim. area. The ligamentous attachments demarcate Although there was a condensation of the the anatomic spaces in the forehead, temple, connective tissue in the region of the zygomat- and periorbital regions and localize the facial icofacial suture, we did not find a definite lig- nerve and sensory branches. ament as described in Knize’s article. There This superior temporal septum has been re- was a thickening of the periorbital septum, the ferred to by Knize12 as the “zone of fixation.” At lateral brow thickening, which attaches to the the anterior end of this structure is an expan- orbital rim superior to the zygomaticofacial sion providing strong attachment to the . periosteum medial to the deep temporal fascia. Relationship of the temporal nerves to the liga- This would seem to be what Knize calls the ments. Surgeons have long been cautious orbital ligament; however, our observations dif- about operating in the temple because of the fer in that this temporal ligament does not risk of damaging the temporal branch of the extend to the orbital rim. The supraorbital facial nerve. This concern has prompted nu- ligamentous adhesion has been noted by merous anatomic studies to define the trajec- Knize,12 who describes it as zone B of fixation tory or course of the branches.30–32 However, in the lower 2 cm of the forehead. It would these studies have not fully satisfied the intra-

FIG. 13. Periorbital and temporal ligamentous attachments indicating the required amount of surgical ligamentous release: lateral view. Green, release for lateral brow lift; yellow, additional release required for upper cheek lift through the temple. Temporal ligamentous adhesion (TLA), supraorbital ligamentous adhesion (SLA), superior temporal septum (STS), inferior temporal septum (ITS), periorbital septum (PS), lateral brow thickening of periorbital septum (LBT), lateral orbital thickening of periorbital septum (LOT), sentinel vessel (SV), temporal branches of facial nerve (TFN), zygomaticotemporal nerve (ZTN), zygomaticofacial nerve (ZFN). Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1487 operative requirement of the surgeon in relat- poral compartment can be quite safe in regard ing the nerve to the planes of dissection as they to the facial nerve, provided the ceiling is lifted have referred to external soft-tissue landmarks off the plane of dissection. Further, dissection or to measurements along the zygomatic arch. can then continue readily inferiorly and ante- The temporal ligament and the inferior tem- riorly across the lower temporal space over the poral septum are reliable soft-tissue ligaments body of the zygoma, or to the periorbital at- and provide accurate internal landmarks for tachments. predicting the neurovascular anatomy of the Relationship of the temporal nerves to the sentinel region. vessels. Previous studies39,40 have related the The inferior temporal septum divides the temporal nerve branches to perforating vessels, subsuperficial fascial space in the temple into which enter the superficial temporal fascia 1 cm two separate compartments. The triangular lateral to the superolateral angle of the orbit. lower temporal compartment contained all the De la Plaza has named these the “sentinel vessels “at risk” anatomic structures of the temple. of the lateral wall of the orbit,” and he makes This is significant for the surgeon in that dis- the point that they must be electrocoagulated section can be readily performed within the deep to avoid damage to the temporal nerves. larger upper temporal compartment all the The sentinel vessels provide a landmark for the way to the septum when an abrupt change of temporal branches of the facial nerve during approach is required. The inferior temporal endoscopic forehead dissection.47 septum is readily identified by its criss-crossed Because the relationship between the senti- fibers that provide a barrier to the dissection. It nel veins and the temporal nerve branches is is best defined by blunt dissection. This septum somewhat variable, the vessels should be used varies in thickness between individuals and can as a relative landmark for facial nerve anatomy. be quite fine in some. Sometimes the sentinel vessels are duplicated After operating through this septum it is with tributaries at different vertical levels. Al- imperative that the level of dissection hug the though temporal nerve branches are found floor of the space, that is, directly on the deep just cephalad to the sentinel vessels, some also temporal fascia. This is because the temporal pass caudal to the vessels in an unpredictable branches of the facial nerve course through fashion. the roof of the lower temporal compartment Surgical ligamentous release. Gravitational ag- immediately abutting the inferior temporal ing changes of the brow and also the upper septum. They run parallel to the line of attach- cheek can be corrected by surgical reposition- ment of the inferior septum to this roof. The ing after dissection beneath the superficial fas- temporal branches are at risk here because the cial plane. septum “fixes” the roof of the space close to the As in deep-plane surgery of the cheek, en floor. The branches run within a wafer-thin fat bloc mobilization of the ptotic superficial fas- pad on the underside of the superficial tempo- cia allows it to be repositioned.24,38 An overcor- ral fascia. For the purposes of description, rection of the position of the superficial fascia these nerves should be considered to be in the is required so that the laxity between it and the ceiling, rather than in the roof, of the space. dermis is taken up. The skin position can then Further, these nerves enter the lower temporal be corrected without direct skin traction. compartment already in the ceiling (this oc- The technique of ligamentous release differs curs just caudal to the inferior border of the between the temple and the cheek. In the tem- zygoma), and they remain in the ceiling at all ple, the facial nerve is not in immediate danger times. because it enters the region within the plane of The sentinel vessels and both branches of the superficial fascia and therefore does not the zygomaticotemporal nerve cross the lower cross the plane of dissection. The only area of temporal space, floor to ceiling, related to the potential danger to the nerve is along the line inferomedial surface of the inferior temporal of the inferior temporal septum. This is be- septum. They can also be safely spared at this cause the nerve branches that cross the temple juncture by judicious dissection. The majority immediately caudal to the septum are held by of the facial nerve branches in the ceiling are the septum close to the deep fascia. in the narrow cephalad space between the sen- Accordingly, a swift blunt dissection can be tinel vessels and the inferior temporal septum. performed in the subgaleal plane of the upper Accordingly, dissection through the lower tem- temporal compartment and the forehead with 1488 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 14. Periorbital and temporal ligamentous attachments indicating the required amount of surgical ligamentous release: anterior view. Green, release for lateral brow lift; yellow, additional release required for upper cheek lift through the temple. Temporal ligamentous adhesion (TLA), supraorbital ligamentous adhesion (SLA), superior temporal septum (STS), inferior temporal septum (ITS), periorbital septum (PS), lateral brow thickening of periorbital septum (LBT), lateral orbital thickening of periorbital septum (LOT), temporal branches of facial nerve (TFN), zygomaticotemporal nerve (ZTN), zygomaticofacial nerve (ZFN). the knowledge that blunt dissection should cia as the temporal branches lie immediately cease at the inferior temporal septum. All vital superficial. Once inside the inferior temporal anatomy is inferior to this septum in the lower compartment these branches are kept re- temporal compartment. The inferior septum is tracted out of the field. then judiciously released by sharp dissection The inferior temporal compartment is with small blunt scissors, at all times remaining opened by blunt spreading dissection to pro- directly applied to the surface of the deep fas- tect the zygomaticotemporal nerves. Release of Vol. 105, No. 4 / SURGICAL ANATOMY OF LIGAMENTOUS ATTACHMENTS 1489 the ligaments, other than the inferior temporal brow.10,12 The pathogenesis of this complicated septum, requires sharp dissection. This can be aging process is partly explained by the liga- performed with relative impunity once the mentous anatomy of these regions. The super- temporal branches of the facial nerve are pro- ficial fascial layers of the medial face are tected by the retractor. strongly retained by connective tissue attach- The morphology of the ligaments deter- ments including the temporal ligament, the mines the dissection technique. The cheek at- supraorbital adhesions, and the periorbital sep- tachments are true ligaments, which have a tum. discrete cylindrical nature. After specific re- In the temporal and lateral brow regions, the lease of these localized attachments, no further superficial tissues are restrained by only the dissection is necessary. Unlike the true liga- two temporal septa, which provide less fixation ments of the cheek, the ligaments of the tem- than the many strong medial supports. This ple and forehead are septa and adhesions, and temporal ligament is located above the junc- therefore involve wide areas of attachment be- tion of the lateral and middle thirds of the tween the deep and superficial fasciae. Release eyebrow. Lateral to this the reduction in liga- of these regions therefore involves extensive mentous attachment of the superficial fascia dissection beneath the superficial fascia. Ac- helps explain the earlier ptosis. cordingly, elevation of the lateral brow re- Bryan C. Mendelson, F.R.C.S.(E), F.R.A.C.S., quires more extensive ligamentous release F.A.C.S. than might be expected. Release of only the 109 Mathoura Road temporal ligamentous adhesion and the tem- Toorak 3142 poral septa is insufficient. The supraorbital lig- Melbourne, Australia amentous adhesion and the lateral brow thick- [email protected] ening of the periorbital septum must also be released (Figs. 13 and 14). The supraorbital ACKNOWLEDGMENT ligamentous adhesion usually needs release all The authors express their thanks to Kari Colen for her the way to the supraorbital nerve, being mind- invaluable assistance with the dissections. ful that the lateral branch of the supraorbital nerve is at risk as it approaches the superior REFERENCES temporal septum. If the intended benefit is to 1. Mitz, V., and Peyronie, M. The superficial musculo-apo- include the lateral canthal and upper zygo- neurotic system (SMAS) in the parotid and cheek matic regions, the periorbital release must be area. 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