Anat Cell Biol.  2010 Mar;43(1):15-24. 10.5115/acb.2010.43.1.15.

Surgical anatomy of the lower eyelid relating to lower blepharoplasty

• Hwang K

• KMID: 2168893
• DOI: http://doi.org/10.5115/acb.2010.43.1.15

Abstract

The aim of this review is to familiarize the reader with the critical lower eyelid anatomy as is related to lower blepharoplasty or a midface lift. The contents include 1) the lacrimal canaliculus in the lower eyelid: the depth and width (diameter) of the vertical portion were 2.58+/-0.24 mm and 0.44+/-0.07 mm, respectively. A vertical portion of the canaliculus was about 1 mm (1.11+/-0.16 mm) deep, and the horizontal portion was about 2~3 mm (2.08+/-2.74 mm) long 2 mm below the mucocutaneous junction, which is where an incision may be made when performing epicanthoplasty. 2) Motor innervation to the lower orbiculis oculi muscle: the pretarsal and preseptal OOMs were innervated by five to seven terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The mean horizontal distance between the lateral canthus and the zygomatic branch was 2.31+/-0.29 cm (range: 1.7~2.7 cm) and the vertical distance was 1.20+/-0.20 cm (range: 0.8~1.5 cm). 3) Sensory innervation of the lower eyelid skin: the majority of the terminal branches (93.8%) of the ION were distributed to the medial to the lateral canthus. Most (99.4%) of the terminal branches of the ZFN were distributed to lateral to the lateral canthus. 4) Retractor of the lower eyelid; capsulopalpebral fascia (CPF): the orbital septum blended with the CPF most closely at 3.7~5.4 mm beneath the lower tarsal border and differently at 3.7+/-0.7 mm on the medial limbus line, 4.3+/-0.8 mm on the midpupillary line and 5.4+/-1.0 mm on the lateral limbus line. 5) Arcuate expansion (AE): The AE was a fibrous band expanding from the inferolateral orbital rim to the medial canthal ligament. A sector (fan-shaped) of the AE originated in the angle of 5 to 80 degrees at the circumference of the inferolateral orbital rim circle, falling within the range of 3 to 5.5 o'clock, and then it tapered and attached to the inferior border of the medial canthal ligament. 6) Suborbicularis oculi fat (SOOF) in the lower eyelid: the SOOF was located in the inferolateral side of the orbit within a range between medial +15 and lateral -89 degrees to a vertical midpupillary line. Histologically, the SOOF was situated deep to the Orbicularis oculi muscle and superficial to the orbital septum and periosteum. The SOOF consisted more of fibrofatty tissue rather than being the pure fatty nature like orbital fat. I hope surgeons can achieve desirable outcomes with the knowledge reviewed in this article.

Keyword

Eyelids; blepharoplasty; regional anatomy; innervation; lacrimal appratus

MeSH Terms

Anatomy, Regional
Blepharoplasty
Eyelids
Facial Nerve
Fascia
Ligaments
Muscles
Orbit
Periosteum

Figure

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  Fig. 1 Histologic sections. V: vertical portion, H1: horizontal portion 1 mm medial to the lacrimal punctum, H2: horizontal portion 2 mm medial to the lacrimal punctum, H3: horizontal portion 3 mm medial to the lacrimal punctum, H4: horizontal portion 4 mm medial to the lacrimal punctum, H5: horizontal portion 5 mm medial to the lacrimal punctum. Arrow: mucocutaneous junction (white line), Arrow head: 2 mm distance from the mucocutaneous junction (Hwang et al., 2005).

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  Fig. 2 The facial nerve innervating the lower eyelid and cheek. (A) An en bloc specimen. The temporal, zygomatic and buccal nerves were dissected and identified from the root of the facial nerve trunk. The resected specimen was turned over. All the pretarsal and preseptal orbicularis oculi muscles (OOMs) were innervated by five to seven terminal branches, which approached the OOM fibers at an angle of approximately 90 deg (original magnification ×10 before 37% reduction).(B) Higher magnification shows five to seven terminal branches that approached the OOM fibers at an angle of approximately 90 deg. T: temporal branch, Z: zygomatic branch, B: buccal branch (Hwang et al., 2001).

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  Fig. 3 Schematic representation of the critical zone, which is delineated by a circle with a radius of 0.5 cm, and its center is 2.5 cm away from the lateral canthus at an angle of 30 deg (Hwang et al., 2001).

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  Fig. 4 Plane of the infraorbital nerve (ION) and zygomaticofacial nerve (ZFN) course. The ION and ZFN run superficially to the periosteum within and beneath the epimysium of the orbicularis oculi muscle (OOM) and then perpendicularly through the OOM and they are distributed to the skin. N: nerve, OS: orbital septum (Hwang et al., 2008).

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  Fig. 5 The majority of the terminal branches (93.8%) of the infraorbital nerve (ION, blue dots) are distributed medial to the lateral canthus and most of the terminal branches (99.4%) of the zygomaticofacial nerve (ZFN, red dots) are lateral to the lateral canthus (Hwang et al., 2008).

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  Fig. 6 Three parasagittal sections on the medial limbus (M), the midpupillary line (C) and the lateral limbus (L). 10 µm section, Masson-trichrome stain, ×10 magnification. The head of the capsulopalpebral fascia (CPF) splits open superiorly and inferiorly and then it wraps around the inferior oblique muscle (IO) and meets anteriorly. The CPF inserted in to the inferior border of the tarsus, and then it merges with the anterior border of the inferior tarsal muscles (TM). The orbital septum (OS) blended with CPF most closely at 3.7~5.4 mm beneath the lower tarsal border: and differently at 3.7±0.7 mm on the medial limbus line, 4.3±0.8 mm on the midpupillary line and 5.4±1.0 mm on the lateral limbus line. A distinct bundle of capsulopalpebral fiber was seen about 3 mm below the lower border of the tarsal plate, 2.9±0.6 mm on the medial limbus line, 2.9±0.6 mm on the midpupillary line and 3.1±0.9 mm on the lateral limbus line (Hwang et al., 2006).

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  Fig. 7 Topography of the AE . The AE from the inferolateral orbital rim at 5 to 80 degrees (3 to 5.5 o'clock) is 22.5±5.4 mm. A fan shaped AE tapers and is attached to the medial canthal ligament. The width is 2.5±1.1 mm at the midpoint and 8% of the vertical orbital dimension (Hwang et al., 2010).

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  Fig. 8 Gross dissection. (A) A skin incision 1 cm away from the orbital rim. (B) Dissection down to the orbicularis oculi muscle O. (C) O is separated from the orbital septum S. (D) S is detached from the underlying capsulopalpebral fascia and is reflected downward to expose the orbital fat (F). The central and lateral fat appeared to be divided by the Arcuate expansion (AE, arrow). (E) A common membrane without septation enveloped the central and lateral fat deep to the AE. (F) After removal of the orbital fat. The AE is a sector of fibrous bands between the inferolateral orbital rim and inferior border of the medial canthal ligament. Reproduced with permission (Hwang et al., 2010).

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  Fig. 9 Dimensions of the SOOF. The length of the SOOF horizontal part is almost equal to a transverse orbital dimension. The height of the SOOF vertical part was about three fourth (b×3/4) of the vertical orbital dimension and the width of the vertical part was one fourth (a/4) of a transverse orbital dimension (Hwang et al., 2007).

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  Fig. 10 Section and Histology. (Center) Schema of sections: SOOF is located deep to the OOM and superficial to the orbital septum and periosteum. The SOOF consists more of fibrofatty tissue than pure fatty tissue like the orbital fat. OM: orbicularis oculi muscle, OS: orbital septum, CPF: capsulopalpebral fascia (Hwang et al., 2007).

Reference

1. Aiache A. The suborbicularis oculi fat pads: an anatomic and clinical study. Plast Reconstr Surg. 2001. 107:1602–1604.

2. Aiache AE, Ramirez OH. The suborbicularis oculi fat pads: an anatomic and clinical study. Plast Reconstr Surg. 1995. 95:37–42.

3. Black EH, Gladstone GJ, Nesi FA. Eyelid sensation after supratarsal lid crease incision. Ophthal Plast Reconstr Surg. 2002. 18:45–49.

4. Bosniak SL. Cosmetic blepharoplasty. 1990. New York: Raven Press;59–65.

5. Codner MA, Hanna MK. Nahai F, editor. Applied anatomy of the eyelids and orbit. The art of aesthetic Surgery: principles and techniques. 2005. St Louis: Quality Medical Publishing;634–638.

6. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg. 1988. 81:677–687.

7. Dortzbach RK. Ophthalmic plastic surgery. 1994. New York: Raven Press;23.

8. Duke-Elder S. System of Opthalmology. 1961. vol II. St Louis: C.V. Mosby;459.

9. Dutton JJ. Atlas of clinical and surgical anatomy. 1994. Philadelphia: W.B. Saunders;95–96.

10. Ellis E, Zide MF. Surgical approaches to the facial skeleton. 1995. Baltimore: Williams & Wilkins;12–13.

11. Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Opthalmol. 1982. 100:1313–1318.

12. Hornblass A. Oculoplastic, orbital and reconstructive surgery. 1988. Baltimore: Williams & Wilkins;9–10.

13. Hwang K, Choi HG, Nam YS, Kim DJ. Anatomy of arcuate expansion of capsulopalpebral fascia. J Craniofac Surg. 2010. 21:239–241.

14. Hwang K, Kim DJ, Hwang SH. Anatomy of lower lacrimal canaliculus relative to epicanthoplasty. J Craniofac Surg. 2005. 16:949–952.

15. Hwang K, Kim DJ, Hwang SH, Chung IH. The relationship of capsulopalpebral fascia with orbital septum of the lower eyelid: an anatomic study under magnification. J Craniofac Surg. 2006. 17:1118–1120.

16. Hwang K, Lee DK, Lee EJ, Chung IH, Lee SI. Innervation of the lower eyelid in relation to blepharoplasty and midface lift: clinical observation and cadaveric study. Ann Plast Surg. 2001. 47:1–7.

17. Hwang K, Nam YS, Choi HG, Han SH, Hwang SH. Cutaneous innervation of lower eyelid. J Craniofac Surg. 2008. 19:1675–1677.

18. Hwang SH, Hwang K, Jin S, Kim DJ. Location and nature of retro-orbicularis oculus fat and suborbicularis oculi Fat. J Craniofac Surg. 2007. 18:387–390.

19. Klatsky S, Manson PN. Numbness after blepharoplasty: the relation of the upper orbital fat to sensory nerves. Plast Reconstr Surg. 1981. 67:20–22.

20. Lim WK, Rajendran K, Choo CT. Microcsopic anatomy of the lower eyelid in Asians. Ophthal Plast Reconstr Surg. 2004. 20:207–211.

21. Lockwood CB. The anatomy of the muscles, ligaments, and fascia of the orbit, including an account of the capsule of tenon, the check ligaments of the recti, and of the suspensory ligament of the eye. J Anat Physiol. 1885. 20:1–25.

22. Manson PN, Clifford CM, Su CT, Iliff NT, Morgan R. Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg. 1986. 77:193–202.

23. McGraw BL, Adamson PA. Postblepharoplasty ectropion. Prevention and management. Arch Otolaryngol Head Neck Surg. 1991. 117:852–853.

24. Mendelson BC. Fat preservation technique of lower-lid blepharoplasty. Aesthet Surg J. 2001. 21:450–459.

25. Sultanov MIu. X-ray anatomy of lacrimal canaliculi. Vestn oftalmol. 1995. 111:28–30.

26. Ramirez OM, Santamarina R. Spatial orientation of motor innervation to the lower orbicularis oculi muscle. Aesthet Surg J. 2000. 20:107–113.

27. Scobee RG. The fascia of the orbit; its anatomy and clinical significance. Am J Ophthalmol. 1948. 31:1539–1553.

28. Standring S. Gray's anatomy. 2005. 39th ed. Edinburgh: Elsevier;684–685.

29. Stuzin JM. Discussion. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg. 1999. 103:1044–1055.

30. Tanaka Y, Matsuo K, Yuzuriha S, Shinohara H, Kikuchi N, Moriizumi T. A transverse ligament located anterosuperiorly in the lower orbital fat space restricts lower eyelid retraction in the Mongoloid eye. J Plast Reconstr Aesthet Surg. 2008. 61:603–609.

31. Whitnall SE. The anatomy of the human orbit and accessory organs of vision. 1932. London: Humphrey Milford;225–226.

32. Williams PL. Gray's Anatomy. 1995. 38th ed. New York: Churchill Livingstone;1188.

33. Zarem HA, Resnick JI. Minimizing deformitiy in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg. 1993. 20:317–321.