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Clinical Anatomy of the Periocular Region

Pari N. Shams, BSc, MRCP, FRCOphth1 Santiago Ortiz-Prez, MD2 Naresh Joshi, FRCOphth1
1 Oculoplastic and Craniofacial Service, Department of

Ophthalmology, Chelsea and Westminster Hospital, London, United Kingdom 2 Department of Oculoplastic, Institut Clinic Oftalmologia, Hospital Clinic, Barcelona, Spain Facial Plast Surg 2013;29:255 263.

Address for correspondence Pari N. Shams, BSc, MRCP, FRCOphth, Department of Ophthalmology, Chelsea and Westminster Hospital, 369 Fulham Road, London, United Kingdom SW10 9NH (e-mail: pari.shams@gmail.com).

Abstract
Keywords

The primary function of the eyelids is to protect the globe through voluntary and re ex eyelid closure. They also play an important role in maintaining good vision by providing important elements of the precorneal tear lm, the most important refractive surface of the eye, and helping to distribute the tear lm evenly over the surface of the eye. Additionally the lacrimal pump function of the eyelids acts to propel the tears to the medial canthus, to enter the lacrimal drainage system. We aim to provide the reader with a comprehensive and up-to-date overview of periocular anatomy; however, the reader is encouraged to refer to recent reviews and peer reviewed articles and to textbooks of oculoplastic surgery for greater detail and understanding of the anatomy of the periocular region.110

the superior corneal limbus in children and 1.5 to 2 mm below it in adults. The lower eyelid margin rests at the inferior corneal limbus. When operating on the lateral canthus, it is worth remembering that the normal lateral canthal angle lies 2 to 3 mm higher than its medial counterpart.

The Skin
There is a marked transition from the thin eyelid skin to the thicker skin of the eyebrow and cheek. The redundancy and elasticity of the eyelid skin and other eyelid structures allow for primary closure of large defects of up to 30% of the eyelid in older patients. Increased redundancy and laxity of eyelid skin and muscle with age is known as dermatochalasis. Prominence of the lower eyelids may result from prolapse of the orbital fat, malar bags, or hypertrophic or overriding orbicularis oculi muscle. Eyelid skin is the thinnest in the body, often less than 1 mm thick, and unique in having no subcutaneous fat. The upper eyelid skin crease is created by attachments from the super cial aspect of the levator aponeurosis into the orbicularis muscle and the subcutaneous tissue. The skin crease, although variable in height and subject to gender and racial differences, usually lies 5 to 6 mm above the eyelid

Super cial Topography of the Eyelids

The interpalpebral ssure or palpebral aperture measures 10 to 11 mm vertically in young adults and decreases to 8 to 10 mm with advancing age (Fig. 1). The peak of the upper eyelid usually lies just nasal to the midline of the pupil. The horizontal length of the ssure is 31 1 mm. The upper and lower eyelids meet at an angle of 60 degrees medially and laterally. In primary position, the upper eyelid margin lies at

Issue Theme Periocular Aesthetic Rejuvenation; Guest Editor, Naresh Joshi, FRCOphth

Copyright 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0033-1349365. ISSN 0736-6825.

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anatomy eyelid periocular oculoplastic surgery brow midface orbital septum facial nerve

The aims of this article are twofold: (1) to provide the facial plastic surgeon with a comprehensive and up-to-date overview of periocular anatomy including the brow, midface, and temporal region and (2) to highlight important anatomical relationships that must be appreciated in order to achieve the best possible functional and aesthetic surgical outcomes.

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Fig. 1 The topography of the eyelids in relation to one another and the globe.

Fig. 2 The anatomy of the pretarsal, preseptal, and orbital parts of the orbicularis oculi, the other brow depressors (corrugator and procerus), the brow elevator (frontalis), and other periocular muscles.

margin centrally in males and 7 to 8 mm in females (Fig. 1). When marking the desired position of the upper lid skin crease, note that the crease descends to within 3 to 4 mm of the eyelid margin medially and 5 to 6 mm laterally. The lower eyelid skin crease is 3 to 4 mm blow the eyelid margin centrally and 5 to 6 mm laterally. In Asian patients, the upper lid skin crease is typically poorly developed or absent because the orbital septum inserts onto the levator aponeurosis in a lower position. This anatomical arrangement allows the preaponeurotic fat to extend further into the eyelid. These are condensations of brous tissue, known as retaining ligaments, that run from deeper structures to the overlying dermis and help to anchor the skin and mobile soft tissues to the underlying skeleton. The orbital retaining ligaments are located over the zygomaticofrontal suture and over the malar eminence. With aging fascial and ligamentous laxity, in combination with dermal elastosis, there is descent of all soft tissues of the face contributing to the characteristic brow ptosis, submalar hollowing, and the prominence of the nasolabial fold.

Orbicularis Oculi
The orbicularis oculi may be divided into the orbital and palpebral parts, with the latter being divided further into the preseptal and pretarsal portions (Fig. 2). The palpebral portion functions in voluntary and involuntary eyelid closure, and the orbital portion is used in forced eye closure. The orbital portion overlies the bony orbital margins. It arises from insertions on the frontal process of the maxillary bone, the orbital process of the frontal bone, and the medial canthal tendon. Its bers pass around the orbital rim to form a continuous ellipse without interruption at the lateral canthus and insert just below the points of origin. The muscle bers extend superiorly to interdigitate with the frontalis muscle and corrugator supercilii muscle, laterally to cover the anterior temporalis fascia, and inferiorly to cover the origins of the lip elevators. The palpebral portion of the orbicularis muscle overlies the mobile eyelid from the orbital rims to the eyelid
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margins. The muscle bers pass circumferentially around each eyelid, xed medially and laterally at the canthal tendons. The bers of the preseptal orbicularis originate perpendicularly along the upper and lower borders of the medial canthal tendon, arc around the eyelids, and insert along the lateral horizontal raphe. An overriding preseptal orbicularis muscle in the lower eyelid is associated with epiblepharon. The weight of the skin fold and the orbicularis muscle may rotate the lower eyelid margin inward, creating an entropion. The pretarsal portion of the muscle originates from the medial canthal tendon via separate super cial and deep heads, arc around the lids, and inserts onto the lateral canthal tendon and raphe. Additional bundles of thin muscle bers run along the upper and lower eyelid margins. These are referred to as muscles of Riolan. Contraction of these bers aids in the lacrimal pump mechanism. Medially, the deep heads of the pretarsal bers fuse to form a prominent bundle of bers, the Horner muscle, which extends just behind the posterior limb of the canthal tendon and inserts onto the posterior lacrimal crest. As the Horner muscle passes to the posterior lacrimal crest, it is joined by the medial horn of the levator aponeurosis, the posterior layer of the orbital septum, and the medial rectus check ligament. Contraction of the Horner muscle draws the eyelids (especially the lower) medially and posteriorly. The resulting lateral pull on the lacrimal sac creates a relative negative pressure within the sac and draws the tears from the canaliculi into the sac. An avascular fascial plane composed of loose connective tissue exists between the orbicularis muscle and the orbital septum-levator aponeurosis fascial complex, which extends to the margin of the eyelid at the gray line. The gray line is also referred to as the muscle of Riolan and represents the pretarsal orbicularis muscle on the eyelid margin. The gray line itself marks the anatomical separation of the anterior skinmuscle lamella from the posterior tarsoconjunctival lamella. This postorbicularis fascial plane allows bloodless surgical dissection down to the septum and approach to the superior and inferior orbital margins.

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Clinical Anatomy of the Periocular Region

The postorbicularis fascial plane also allows slight movement between the orbicularis muscle and the underlying orbital septum while maintaining an integrated lamellar structure. Surgical disruption of the brous connections within the postorbicularis fascial plane can cause an inferior slippage of the anterior lamella. This can be prevented by xating the orbicularis muscle and skin edges to the levator aponeurosis during the skin closure.

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The Orbital Septum

The orbital septum is a thin, brous, multilayered sheath that begins at the arcus marginalis along the orbital rim (Fig. 3); it represents a continuation of the orbital fascial system. The orbital septum can be readily identi ed during surgery by noting the rm resistance to traction applied to it because of its attachment to the arcus marginalis. Distal bers of the orbital septum merge into the anterior surface of the levator aponeurosis. The point of insertion usually is 3 to 5 mm above the tarsal plate, but it may be as much as 10 to 15 mm above it. In the lower eyelid the septum fuses with the capsulopalpebral fascia several millimeters below the tarsus (Fig. 4). In young patients, the orbital septum is usually relatively thick and quite easily identi ed at surgery. In contrast, the orbital septum may be very thin and dehiscent in older patients. Functionally, the septum may act as a barrier to infection and hemorrhage. The orbital septum is continuous with the inner layers of the periorbita. Within the orbit, the periorbita lines the bony orbital walls and is composed of an outer layer of periosteum and an inner layer continuous with the orbital fascia. These layers separate at the arcus marginalis, and the outer periosteum continues over the orbital margins as the periosteum of the forehead and facial bones. In the upper eyelid the inner

fascial layer separates into two layers at the arcus marginalis. The super cial layer continues over the brow where it is continuous with the deep fascia over the frontalis muscle and the galea aponeurotica above the eyebrow. The deep layer becomes the orbital septum in the upper eyelid. In the lower eyelid the inner fascial layer extends into the eyelid as the orbital septum. Medially, the septum attaches to the anterior and posterior lacrimal crests, and laterally it inserts into the lateral canthal tendon and also passes behind the tendon inserting onto the lateral retinaculum together with the lateral horn of the levator aponeurosis.

Periocular Fat Compartments

Fat is located within the eyelid, subbrow, and orbital compartment. Eyelid fat is interconnected and contiguous with deeper orbital fat and both serve as a protective cushion for the globe and facilitate movement of the globe. Because the eyelid fat pads are in direct communication with the deep extraconal fat of the orbit, caution must be exercised when handling orbital fat in the anterior orbit. Traction on the fat pad may injure deep orbital vessels causing orbital hemorrhage. The central preaponeurotic fat pad is an important surgical landmark, as it lies immediately posterior to the orbital septum and anterior to the levator aponeurosis in the upper lid (Fig. 3) and lower lid retractors in the lower eyelid (Fig. 4). Fine connective tissue septa extend anteriorly from the capsule of preaponeurotic fat to the orbital septum and posteriorly to the levator aponeurosis. The preaponeurotic fat pad is yellow as compared with the whiter, more brous medial fat pad. The medial fat pad is derived from orbital fat deep to the levator muscle and is more vascular because of the location of the palpebral arterial arcade that courses through it. The lacrimal gland lies lateral to the central preaponeurotic fat pad, isolated within its own fascial sheath. If the latter becomes lax, the gland can prolapse into the lateral aspect of
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Fig. 3 Sagittal cross section through the upper eyelid. Abbreviations: PAFP, preaponeurotic fat pad; ROOF, retro-orbicularis oculi fat.

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Fig. 4 Sagittal cross section through the lower eyelid. Abbreviation: SOOF, suborbicularis oculi fat.

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lopalpebral fascia in the lower eyelid without rst separating the orbital septum will result in lower eyelid retraction. Suturing the orbital septum without adequate traction of the eyelid in the opposite direction also risks shortening resulting in lagophthalmos or eyelid retraction. The midfacial fat compartments include the SOOF and malar fat pads. These fat compartments are bound to the orbicularis muscle by the super cial muscular aponeurotic system (SMAS) of the cheek. In the aging lower eyelid, pseudoherniation of orbital fat may result in contour irregularities. The SOOF can become apparent with the gravitational descent seen in the midface with aging and contributes to the aesthetic deformity of the lower lids. Malar bags may also develop from descent of the malar fat pad.

The tarsal plates are made up of dense brous tissue and provide the main structural integrity to the eyelids. The upper and lower tarsal plates are 25 mm in length horizontally and 1 to 1.5 mm in thickness, and centrally the vertical height of the tarsal plate varies from 8 to 12 mm in the upper lid and 3.5 to 4 mm in the lower eyelid. The medial and lateral aspects of the tarsal plates taper to 2 mm in height as they pass into the medial and lateral canthal tendons. The posterior surface of both tarsal plates is covered by conjunctiva. Only 4 to 5 mm of tarsus is needed for upper eyelid stability, when the tarsus is used in eyelid reconstruction. Within the tarsal plates, 20 to 30 vertically aligned meibomian glands lie, which are multilobulated holocrine sebaceous glands, opening onto the posterior eyelid margin behind the gray line and secreting the lipid layer of the precorneal tear lm.

The Canthal Tendons

Medially, the tarsal plates pass into brous bands that form the crura of the medial canthal tendon. These lie between the orbicularis muscle anteriorly and the conjunctiva posteriorly. The superior and inferior crura fuse to form a common tendon that inserts via three limbs, anterior, posterior, and superior. The anterior limb inserts onto the orbital process of the maxillary bone in front of and above the anterior lacrimal crest. It provides the major support for the medial canthal angle. The posterior limb arises from the common tendon near the junction of the superior and inferior crura and passes between the canaliculi. It inserts onto the posterior lacrimal crest just in front of the Horner muscle. The posterior limb directs the vector forces of the canthal angle backward to maintain close approximation with the globe. The superior limb of the medial canthal tendon arises as a broad arc of bers from both the anterior and posterior limbs. It passes upward to insert onto the orbital process of the frontal bone. The posterior head of the preseptal orbicularis muscle inserts onto this limb, and the unit forms the soft tissue roof of the lacrimal sac fossa. This tendinous extension may provide vertical support to the canthal angle but it also appears to

Fig. 5 The fat compartments of the upper and lower eyelid and their relationship to adjacent structures.
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the eyelid where it must be differentiated from preaponeurotic fat by its rm, pink, vascular, lobulated structure to avoid perioperative injury. Although the so-called fat pads of the lower eyelid are not distinct anatomic entities, they have been divided into three clinically useful divisions: medial, central, and lateral (Fig. 5). The medial and central fat pads are divided by the inferior oblique muscle, and the boundaries of the middle and lateral fat pads are de ned by the arcuate expansion, which extends from Lockwoods ligament to the inferolateral orbital margin. A small lobule from the precapsulopalpebral fat pad extends superiorly between the orbital septum and the lateral canthal tendon, known as the Eisler pocket, which is thought to act as a bursa to the lateral canthal tendon during eyelid movements. A deep plane of fat, the retro-orbicularis oculi fat (ROOF), lies posterior to the orbital part of the orbicularis muscle superiorly over the superior orbital margin (Fig. 3) and inferiorly the suborbicularis oculi fat (SOOF) lies over the inferior orbital margin (Fig. 4). Subbrow fat can form a redundant upper eyelid skin fold and undergoes gravitational descent during aging. In females, the eyebrow is generally arched and above the level of the supraorbital rim. The male eyebrow is atter and at the level of the supraorbital rim. The position of the eyebrow can affect the height and excursion of the upper eyelid and must be considered in a patient being evaluated for ptosis repair or blepharoplasty. Resection of the ROOF in conjunction with aesthetic blepharoplasty can soften and atten heaviness and bulkiness in the lateral upper orbital and brow region. It is extremely important not to confuse an extension of the brow fat pad into the postorbicularis fascial plane of the upper eyelid with the preaponeurotic fat pads. If the orbital septum is incorrectly identi ed as the levator aponeurosis, an inadvertent advancement of this septal layer will result in marked lagophthalmos. Likewise advancement of the capsu-

The Tarsal Plates

Clinical Anatomy of the Periocular Region

play a signi cant role in the lacrimal pump mechanism. It is the posterior arm of the medial canthal tendon inserting into the posterior lacrimal crest that must be repaired meticulously when a lower eyelid has been avulsed to avoid an anterior malposition of the lower eyelid. Laterally, the tarsal plates pass into not very well-developed brous strands that become the crura of the lateral canthal tendon. The lateral canthal tendon is a distinct entity separate from the orbicularis muscle; it measures 1 mm in thickness, 5 to 7 mm in length, and 3 mm in width at the point where the superior and inferior crura unite but it broadens to a width of 6 to 7 mm as it inserts into the lateral orbital tubercle 1.5 mm inside the lateral orbital margin. The lateral horn of the levator aponeurosis blends with the superior border of the lateral canthal tendon. The insertion of these brous strands extends posteriorly along the lateral orbital wall, where it blends with strands of the lateral check ligament from the sheath of the lateral rectus muscle. Along with the lateral canthal tendon complex, the inferolateral bers of the Whitnall superior suspensory ligament and the lateral portion of the Lockwood inferior suspensory ligament insert onto the lateral tubercle, forming the lateral retinaculum. The lateral canthal tendon and the lateral horn of the levator aponeurosis extend superiorly to a position 4 to 5 mm below the frontozygomatic suture line forming a broad tendonlike insertion. Division of the superior crus of the lateral canthal tendon can be associated with signi cant morbidity due to the proximity of important adjacent structures (i.e., the lateral horn of the levator, the Whitnall ligament, and the lacrimal gland). The inferior crus of the lateral canthal tendon is divided during the course of a lateral tarsal strip procedure and in the management of an acute orbital hemorrhage.

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The Eyelid Retractors

The upper eyelid retractor muscles include the levator palpebrae superioris (LPS) muscle and the superior tarsal muscle, called the Mller muscle, in the upper eyelid. The LPS is a skeletal muscle innervated by the oculomotor nerve (third cranial nerve), whereas the inferior tarsal muscle and the Mller muscle are both composed of smooth muscle and sympathetically innervated. The LPS muscle arises from the lesser wing of the sphenoid bone just above the annulus of Zinn and superolateral to the optic canal. The muscle is 35 mm in length. At its origin it is 4 mm in width, widening to 8 mm in the midsection of the orbit. As the muscle passes forward, it lies in intimate contact with the superior rectus muscle (Fig. 3). The levator and the superior rectus muscles are connected by ne brous strands of the superior orbital fascial system, which function as check ligaments but permit coordinated movement of the upper eyelid with vertical ocular movements. Immediately posterior to the superior orbital margin, the LPS muscle widens to 18 mm where a condensation of horizontally oriented connective tissue is seen running along the muscle sheath in a horizontal direction known as the Whitnall superior transverse ligament. The Whitnall ligament marks

the junction where the LPS changes from a skeletal muscle to a brous sheath, the levator aponeurosis. The levator aponeurosis continues inferiorly 15 to 20 mm to insert onto the superior two-thirds of the anterior tarsal surface but also send bers to the septum, the pretarsal orbicularis muscle, and the skin, which act to prevent overhang of these structures on elevation of the eyelid and form the upper lid skin crease. The dehiscence of the levator aponeurosis therefore results in a superior displacement of the skin crease. The Whitnall ligament attaches to the trochlear fascia and superior oblique tendon medially and sends brous connections to the medial retinaculum. It attaches laterally to the fascia surrounding the orbital portion of the lacrimal gland and at the frontozygomatic suture. The ligament is rmly attached to the levator muscle sheath medially and laterally but only very loosely attached to the levator muscle centrally. A very thin sheet of fascia passes from the Whitnall ligament to insert into the superior orbital margin. The Whitnall ligament appears to function as a check ligament against posterior movement of the levator and superior rectus muscles. The Whitnall ligament forms a circumorbital fascial ring in conjunction with the Lockwood ligament. During ptosis surgery the Whitnall ligament should be maintained intact wherever possible. If the Whitnall ligament is severed, the levator muscle can prolapse. This loss of support results in the need for a greater resection than would otherwise be required. The ligament can also be used as an internal sling during ptosis surgery. The levator aponeurosis widens to form the medial and lateral levator horns as it passes inferiorly from the Whitnall ligament. The medial and lateral levator horns help to distribute the forces generated by the levator muscle along the levator aponeurosis, allowing the central aspect of the eyelid to elevate to the greatest extent. The medial horn is more tenuous, accounting for a lateral shift of the superior tarsus in older patients. The lateral horn is a better-de ned structure and separates the lacrimal gland into orbital and palpebral lobes. The lateral levator horn inserts onto the lateral orbital tubercle of the zygomatic bone and joins the bers of the capsulopalpebral fascia of the lower eyelid. The medial horn of the levator aponeurosis inserts onto the posterior limb of the medial canthal tendon and the posterior lacrimal crest. The lateral levator aponeurosis horn is divided during levator recession procedures for upper eyelid retraction. The levator horns should be preserved during ptosis surgery to advance the dehisced levator aponeurosis but may need to be divided to allow adequate levator resection of the dysgenic LPS in congenital ptosis. The Mller muscle is joined to the overlying levator aponeurosis by a very loose avascular connective tissue layer, allowing separation of these structures during ptosis surgery. The origin of the Mller muscle is from the under surface of the levator muscle, 20 to 22 mm above the superior tarsal border at the origin of the aponeurosis. The Mller muscle runs inferiorly posterior to the levator aponeurosis. It measures 8 to 12 mm in length and has a variable thickness of 0.1 to 0.5 mm. The Mller muscle inserts onto the anterior edge of the superior border of the tarsus.
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arises from the Lockwood ligament. This is situated just posterior to the CPF and functions to retract the fornix inferiorly during downgaze. The conjunctiva contains a series of small accessory lacrimal glands as well as mucous-secreting goblet cells. At the medial canthus lies the caruncle, containing multiple sebaceous glands and hair follicles, and a vertical fold of conjunctiva, the plica semilunaris, immediately lateral to it. Access to the medial orbital wall can be gained via the transcaruncular approach, through the plane between the caruncle and the plica semilunaris.

Full excursion of the upper eyelid from depression to full elevation is 15 to 20 mm, which is primarily the action of the LPS, with the Mller muscle responsible for 2 mm. The muscles of the forehead and brow also play a role in elevating the eyelid; the frontalis muscle is the primary elevator of the forehead and brow and innervated by the seventh cranial nerve, the facial nerve; the corrugator muscle draws the head of the eyebrows to the nose and is responsible for vertical furrows on the bridge of the nose. Depression of the head of the eyebrow is a result of contraction of the procerus muscle, which can result in horizontal furrows in the skin of the glabellar region of the forehead overlying the bridge of the nose. When examining patients with upper eyelid ptosis, it is important to immobilize the forehead and eyebrows to accurately measure the severity of the ptosis. The lower eyelid retractors are composed of the capsulopalpebral head, capsulopalpebral fascia (CPF), and the smooth muscle bers, also known as the inferior tarsal muscle analogous to the Mller muscle described previously. The capsulopalpebral head originates from the inferior rectus muscle fascia and as it passes anteriorly from its origin, it splits to envelop the inferior oblique muscle and reunites as the inferior transverse or Lockwood ligament (Fig. 4). Thin fascial extensions from the Lockwood ligament pass forward to unite with the Tenon capsule and the inferior fornix conjunctiva with additional bers coursing forward as the CPF. The thinner anterior part of the CPF joins the orbital septum, 4 to 5 mm below the inferior border of the tarsal plate, and the suborbicularis fascial layer and extends to the anterior lamellae of the lower eyelid through the orbicularis oculi muscle. This anterior layer does not attach to the inferior margin of the tarsus but passes forward to the subcutaneous tissues forming the lower eyelid skin crease. The posterior and thicker part of the CPF consists of dense bers containing scattered smooth muscle bers and inserts into the lower tarsal plate. The main role of this posterior layer is to pull the lower eyelid inferoposteriorly. In the Asian lower lid, the line of fusion of the orbital septum to the CPF is often higher, or indistinct, with anterior and superior orbital fat projection, and overriding of the preseptal orbicularis oculi over the pretarsal orbicularis.

Sensory Nerve Supply of the Eyelids

Branches of the ophthalmic and maxillary divisions of the trigeminal nerve provide the sensory innervation of the eyelids (Fig. 6). The upper eyelid is innervated by the supraorbital, supratrochlear, and lacrimal nerves. The medial aspect of the upper and lower eyelids is supplied by the infratrochlear nerve. Branches of the infratrochlear nerve also supply parts of the adjacent eyebrow, forehead, and nose. The lateral aspect of the upper eyelid and temple is supplied by the zygomaticotemporal branch of the maxillary nerve. The central aspect of the lower eyelid is supplied by infraorbital nerve, a branch of the maxillary nerve, and the lateral aspect of the lower eyelid is supplied by the zygomaticofacial branch of the maxillary nerve.

Vascular Supply to the Eyelids

A network of vessels derived from two major sources, the internal and the external carotid arteries, richly vascularizes the eyelids (Fig. 7). Collateralization between the internal and external systems contributes to the rapid wound healing and the low incidence of infection following eyelid surgery. The internal carotid arterial supply is from the supraorbital, supratrochlear, and dorsal nasal branches, which are terminal branches of the ophthalmic artery medially and the lacrimal

The Conjunctiva
The conjunctiva is a mucous membrane composed of nonkeratinizing strati ed squamous epithelium, clinically divided into palpebral, forniceal, and bulbar portions. The bulbar conjunctiva is loosely attached to the globe and the palpebral portion rmly adheres to the posterior surface of the tarsal plates (Figs. 3 and 4). It is also closely applied to the Mller muscle in the upper lid and the equivalent smooth muscle bers in the lower lid and continues into the forniceal portion. The superior fornix is situated 10 mm above the superior corneal limbus. The superior fornix is supported by a ne brous suspensory ligament, which arises from the fascia of the levator muscle and the superior rectus muscle. The inferior fornix is situated 8 mm below the inferior corneal limbus and is supported by a ne suspensory ligament that
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Fig. 6 The sensory innervation of the eyelids and periorbital region.

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vascular and a pericranial ap can be used to reconstruct deep medial canthal defects in conjunction with a fullthickness skin graft. The pericranium can be lifted from the underlying bone very easily, and the space thus created is avascular. This space is accessed for endoscopic browlift surgery.

The Brow
The frontalis muscles are paired extensions of the galea aponeurotica and insert into the supraorbital dermis by interdigitating with the orbicularis oculi muscle. The super cial and deep galea layers continue to the upper palpebral margin as the anterior and posterior sheaths of the frontalis and orbicularis muscles. A fat pad develops within a split in the posterior muscle sheath at the brow. The galea is continuous with the super cial temporal fascia laterally, which is continuous with the SMAS inferiorly. At the temporal crest there is a fusion plane between the galea, temporalis, and periosteum. The depressors of the brow are the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi muscles. The procerus muscles originate from the upper lateral cartilages and nasal bones and insert into glabellar skin at the medial edges of the frontalis. Contraction produces transverse wrinkling at the radix of the nose. The corrugator muscle has both a transverse and an oblique head. The procerus, depressor supercilii, and the oblique head of the corrugators muscle originate from the superomedial orbital rim and share a parallel course before inserting into the dermis under the medial eyebrow. The transverse head of the corrugator supercilii muscle originates from the medial-superior orbital rim and inserts into the dermis just superior to the middle third of the eyebrow. This transverse head of the muscle moves the entire eyebrow medially, producing both vertical and oblique glabellar skin creases. The procerus supercilii muscle and the oblique head of the corrugator supercilii muscle produce oblique glabellar skin lines. The orbital portion of the orbicularis oculi muscle interdigitates with the corrugators medially and is continuous around the lateral canthus into the zygomatic area. Contraction of the orbicularis results in downward displacement of the lateral brow. Contraction of the medial head of the orbital portion depresses the level of the medial eyebrow but does not uniformly contribute to the formation of oblique glabellar skin lines. The sensory nerves of the forehead are the supraorbital and supratrochlear nerves. These nerves typically exit from the supraorbital notch or foramen; however, in up to 10% of cases one or both of these nerves may arise from a true foramen 1 to 2 cm superior to the orbital rim are at risk of injury. The supraorbital nerve splits into a deep branch, which passes between the galea and periosteum, and a super cial branch, which enters the frontalis 2 to 3 cm above the supraorbital rim. The supratrochlear nerve enters the substance of the corrugator and then the frontalis. The motor nerve of the forehead is the temporal branch of the facial nerve.
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Fig. 7 The vascular anatomy of the eyelids and periorbital region.

artery laterally. Two medial palpebral arteries arise from the ophthalmic artery as the superior and inferior marginal arcades and pass horizontally and laterally, one to supply the upper lid and one to supply the lower lid, lying on the anterior tarsal surface 4 mm and 2 mm from the upper and lower eyelid margin, respectively. In the upper lid, a peripheral arcade arises from the marginal arcade and lies on the anterior surface of the Mllers muscle, just above the superior tarsal border. Laterally, the lacrimal artery pierces the orbital septum to give rise to two lateral palpebral arteries, which pass medially, one to the upper eyelid and one to the lower eyelid, and anastomose with the marginal arcades. The facial artery, the super cial temporal artery, and infraorbital artery are branches of the external carotid artery. The facial artery continues up to the medial canthal region as the angular artery, anastomosing with the dorsal nasal artery. The super cial temporal artery supplies the eyelid via the transverse facial and zygomatic branches. The infraorbital artery, a terminal branch of the maxillary artery, exits the infraorbital foramen to anastomose with vessels of the lower eyelid. The lymphatic drainage from the lateral two-thirds of the upper eyelid and the lateral one-third of the lower eyelid drains laterally and inferiorly into the deep and super cial parotid and submandibular lymph nodes. Lymph from the medial one-third of the upper eyelid and the medial twothirds of the lower eyelid drains medially and inferiorly into the anterior cervical lymph nodes. Extensive disruption of these lymphatic channels results in lymphedema.

The Scalp
The central scalp consists of ve layers: skin, subcutaneous brofatty tissue, galea aponeurotica, loose areolar tissue, and pericranium. The galea aponeurotica links the frontalis and occipitalis muscles. The subgaleal plane is relatively avascular and the forehead can be peeled forward in this plane after making a bicoronal scalp incision. The pericranium is very

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Fig. 8 The fascial planes of the temporal region and the path of the frontal branch of the facial nerve in this region. Abbreviation: DTF, deep temporalis fascia.

The Temporal Region

Generally, there are nine layers in the temporal region (Fig. 8), including the skin, the subcutaneous tissue, the super cial temporal fascia (temporoparietal fascia), the loose areolar layer, the super cial layer of the deep temporal fascia, the super cial temporal fat pad, the deep layer of the deep temporal fascia, the deep temporal fat pad, and the temporalis muscle. The super cial temporal fascia in the temporal region is the most super cial layer beneath the subcutaneous tissue. It is continuous with the galea superiorly, the frontalis muscle anteriorly, and the SMAS inferiorly. It contains the frontal branch of the facial nerve and the super cial temporal artery. Deep to the super cial temporal fascia is a loose areolar fascial layer, otherwise known as the intermediate temporal fascia or subaponeurotic plane. Deep to this fascia is the deep temporal fascia that covers the temporalis muscle. It is easily recognized by its thick white glistening surface and can be con rmed by making a small cut in the fascia to expose the underlying temporalis muscle. For an endoscopic browlift the dissection from the temple to the orbital margin should be made along this layer, with the frontal branch of the facial nerve lying protected above this layer in the super cial temporal fascia. A few centimeters above the zygomatic arch, the deep temporal fascia splits into two layers: the super cial and the deep layers of the deep temporal fascia. These insert onto the anterosuperior and posterosuperior aspects of the zygomatic arch, respectively. Between these two layers lies the temporal fat pad.

Fig. 9 Branches of the facial nerve

The Facial Nerve

The facial nerve supplies most of the muscles of facial expression and motor function of the eyelids. The two branches of the nerve, the upper (temporozygomatic) and the lower (cervicofacial) branches, pass within the substance of the parotid gland before dividing into the main distal branches. The upper division divides into the frontotemporal and zygomatic branches (Fig. 9), which innervate the
Facial Plastic Surgery Vol. 29 No. 4/2013

frontalis muscle, superior orbicularis muscle, transverse head of the corrugator supercilii muscle, and superior end of the procerus muscle. The lower cervicofacial division gives rise to the buccal, mandibular, and cervical branches, which innervate muscles of the lower face and neck. At the anterior border of the parotid gland, these branches lie on the surface of the masseter muscle deep to the parotidomasseteric fascia. The temporal nerve is the smallest of the branches, has the fewest number of interconnections, and in the majority of individuals is a terminal branch, often showing the least degree of recovery following a facial palsy. The frontotemporal branch of the facial nerve divides into two to four branches that exit the parotid gland within the parotid-masseteric fascia and continue within the intermediate temporal fascia across the zygomatic arch. The frontotemporal branch becomes super cial once it crosses the zygomatic arch where the nerve is most vulnerable to injury. Between 1.5 to 3.0 cm above the superior border of the zygomatic arch and 0.9 to 1.4 cm posterior to the lateral orbital rim the frontotemporal branches transition from the intermediate temporal fascia to run on the undersurface of the super cial temporal fascia before entering the frontalis or orbicularis oculi muscle. A series of bridging vessels, including one larger sentinel vein, are encountered between the super cial and deep temporal fascia during the dissection in the temporal region. These bridging vessels point to the frontal branch of the nerve as it courses through the super cial temporoparietal fascia. In the temple, the nerve runs within the super cial temporoparietal fascia and supplies the frontalis muscle, the superior bers of the orbicularis muscle, the procerus and corrugator supercilii muscles (Fig. 8). It is important to stay on the glistening bers of the deep temporal fascia deep to the temporoparietal fascia to avoid injury to the nerve during surgical dissections in this area. In the brow region, the frontal branch runs 2 cm above the brow.

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Clinical Anatomy of the Periocular Region

The zygomatic branch of the facial nerve supplies the inferior orbicularis oculi muscle, inferior end of the procerus muscle, depressor supercilii muscle, oblique head of the corrugator supercilii muscle, and medial head of the orbicularis oculi muscle.

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SMAS and Midface Anatomy

The SMAS is a super cial continuous bromuscular layer of the face and neck, which invests and interlinks all the super cial muscles of facial expression. The SMAS can be divided and repositioned or plicated to augment or contour the elevation of the malar fat pad. It extends from the malar region superiorly to become continuous with the galea aponeurotica, inferiorly to join the platysma, and laterally to invest in the parotid fascia. In the temporal region, the SMAS blends into the super cial temporoparietal fascia. The SMAS invests the super cial mimetic muscles, including the platysma muscle, orbicularis oculi muscle, occipitofrontalis muscle, zygomaticus muscles, and the levator labii superioris muscle. The SMAS attaches to the skin via ligamentous extensions. It varies in thickness and becomes much thinner and less distinct as it extends toward the nasolabial fold. The malar fat pad is a collection of fat overlying the malar eminence, which lies on and within the anterior surface of the SMAS. In the lower part of the face, the facial nerve branches are deep to the SMAS and innervate the facial muscles on their undersurface. The deep facial muscles are an exception to this rule: the levator anguli oris, the buccinator, and the mentalis are all innervated on their super cial surface. These facial nerve branches are protected if a dissection is kept super cial to the SMAS in this location. The malar soft tissues are suspended from the malar eminence and maxilla by the zygomatic retaining ligaments laterally and buccomaxillary ligaments medially. The malar prominence descends inferomedially with aging to deepen the nasolabial crease and expose the lateral orbital rim. It is composed of a subcutaneous malar fat pad with underlying orbicularis oculi muscle. Deep to this is the SOOF, which is

intimately associated with the periosteum of the infraorbital rim and maxilla and the insertions of the zygomaticus major and minor muscles. Motor nerve supply to the muscles of the midface comes from the zygomatic and buccal branches of the facial nerve traveling along the deep surface of the muscles. Sensory innervation of the midface comes from the second division of the trigeminal nerve, the infraorbital nerve, which exits the infraorbital foramen, and the zygomaticotemporal branch of the trigeminal nerve that exits through the body of the zygoma. The zygomaticotemporal nerve supplies the lateral temple region of the scalp and is encountered in a midfacial dissection, although it is rarely visualized.

Summary
Understanding the anatomy of the periocular region is a prerequisite to successful oculoplastic and oculofacial surgery and essential in minimizing adverse outcomes.

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