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Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions

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Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions Cosmetic Surgical Anatomy of the Ligamentous Attachments in the Temple 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 nerves 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 scalp. vital neurovascular structures. This results in improved In the cheek, 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 forehead,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 nerve 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 face. 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 facial nerve 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 neck. 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- head 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 surface anatomy 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.
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