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

Description of the surgical anatomy of the superficial fascia of the face must include its deep attachments. These attachments have been mapped out for the forehead, temple, and cheek as retaining ligaments. The deep attachments of the orbicularis oculi of the lower lid and lateral canthus have long been recognized in canthopexy surgery but have yet to be properly defined. Six fresh cadavers were dissected with histologic support, and the results were correlated with surgical observations. The fascia of the deep aspect of the orbicularis is attached to the periosteum of the orbital rim by an orbicularis retaining ligament. This attachment is weakest centrally and tightest over the inferolateral orbital rim. The retaining ligament fuses with an expanded fibrous attachment beyond the lateral canthus, the lateral orbital thickening, which extends over the lateral orbital rim onto the adjacent deep temporal fascia. Aging changes are associated with attenuation of the ligamentous support provided by the orbital thickening and the orbicularis retaining ligament, which then allows inferior displacement of the lower boundary of the lid and contributes to the typical effects of age in this region. The superficial fascia of the lateral orbital region has a continuous connective tissue structure linking the temporoparietal fascia and orbicularis fascia to the lateral canthal tendon by means of the tarsal plate connection. Release of the deep ligamentous attachments (lateral orbital thickening and orbicularis retaining ligament) of the orbicularis fascia is important in some canthopexy and in rejuvenation procedures. The release allows effective redraping and upward mobilization of the orbicularis of the lower lid and the premalar soft tissues.