COSMETIC

The Orbicularis Retaining Ligament of theMedial Orbit: Closing the Circle

Ashkan Ghavami, M.D.Joel E. Pessa, M.D.Jeffrey Janis, M.D.

Rohit Khosla, M.D.Edward M. Reece, M.D.

Rod J. Rohrich, M.D.

Dallas, Texas

Background: There exists some ambiguity regarding the exact anatomical limitsof the orbicularis retaining ligament, particularly its medial boundary in boththe superior and inferior orbits. Precise understanding of this anatomy is nec-essary during periorbital rejuvenation.Methods: Sixteen fresh hemifacial cadaver dissections were performed in theanatomy laboratory to evaluate the anatomy of the orbicularis retaining liga-ment. Dissection was assisted by magnification with loupes and the operatingmicroscope.Results: A ligamentous system was found that arises from the inferior andsuperior orbital rim that is truly periorbital. This ligament spans the entirecircumference of the orbit from the medial to the lateral canthus. There existsa fusion line between the orbital septum and the orbicularis retaining ligamentin the superior orbit, indistinguishable from the arcus marginalis of the inferiororbital rim. Laterally, the orbicularis retaining ligament contributes to thelateral canthal ligament, consistent with previous studies. No contribution to themedial canthus was identified in this study.Conclusions: The orbicularis retaining ligament is a true, circumferential “peri-orbital” structure. This ligament may serve two purposes: (1) to act as a fixationpoint for the orbicularis muscle of the upper and lower eyelids and (2) to protectthe ocular globe. With techniques of periorbital injection with fillers and bot-ulinum toxin becoming ever more popular, understanding the orbicularis re-taining ligament’s function as a partitioning membrane is mandatory for avoid-ing ocular complications. As a support structure, examples are shown of howmanipulation of this ligament may benefit canthopexy, septal reset, and brow-liftprocedures as described by Hoxworth. (Plast. Reconstr. Surg. 121: 994, 2008.)

There exist several possibilities for manipula-tion of the orbicularis retaining ligament forperiorbital rejuvenation. Despite its poten-

tial significance, there is some controversy in theliterature as to the actual dimensions of this struc-ture, specifically, as to its medial limit in both thesuperior and inferior orbits.

The description of the orbicularis retainingligament is an interesting story, with suggestions ofits existence being present in the literature severaldecades ago. To be historically accurate, Hargiss1

offered the first description of fascia from theinferior rim traveling to cheek skin in 1963, laterreferred to as suborbicularis fascia by Puttermanin 1973.2 It was Raul Loeb who was the first to

anatomically document a “septum that separatesthe orbital area from the nasal and cheek areas”during his technique of orbital fat transpositionpublished in 1981.3 Without referring to it as such,Loeb was very likely releasing the orbicularis re-taining ligament to transpose fat beneath the orbitcheek crease.

Loeb ascribed a protective role to this mem-brane; he felt it prevented spread of nasal infec-tion to the face and eyes. Pessa performed dyeinjection studies that supported this concept of aprotective role.4 Kikkawa et al. looked at this areafrom the perspective of possible superficial mus-culoaponeurotic system attachments to the orbit,and labeled this membrane the orbitomalar liga-ment in 1996.5

From the Department of Plastic Surgery, University of TexasSouthwestern Medical Center.Received for publication June 2, 2006; accepted August 16,2006.Copyright ©2008 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000299941.62645.4e

Disclosure: The authors have no financial interestin any company or licensing agreement that relatesto this research.

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Muzaffar et al. are credited with applying thecurrently accepted nomenclature “orbicularis re-taining ligament” to this structure in 2002, in keep-ing with its origin from bone and insertion tomuscle.6 Their study, combined with the previousanatomical treatise by Moss et al.,7 added an enor-mous amount of information to the understand-ing of this anatomy. These studies were the first toshow a membrane in the superior orbit, to define itscontribution to the lateral canthus as a lateralorbital thickening, and to identify its exact archi-tecture as a bilaminar structure, the last observa-tion having eluded all previous investigators.

Despite these studies, some anatomical ques-tions remain. One question is whether the orbic-ularis retaining ligament spans the entire circum-ference of the orbit as suggested by lower lidstudies,4,5 or whether it only partially encircles theorbit as shown by other authors.6,7 The exact originof the orbicularis retaining ligament along theorbital rim has not been mentioned, nor has itsrelationship to the orbital septum and arcus mar-ginalis been clarified. The following fresh cadaverstudy was performed to address these questions.

MATERIALS AND METHODSSixteen fresh hemifacial cadaver dissections

were performed in the anatomy laboratory. Noneof these specimens had sustained soft-tissuetrauma or had previous facial surgery, with theexception of lens implants. A preliminary dye in-jection test was performed to confirm the positionof the orbicularis retaining ligament in the supe-rior orbit, dye diffusion having been used in theinferior orbit in previous work.4 There were fivemale and three female cadavers in this study, withan age range from 19 to 91 years. Orbital dissec-tion was performed by leaving a rim of pretarsalskin in the upper and lower eyelids to maintain theintegrity of the lid margin.

Dissection proceeded from lateral to medial inboth the upper and lower orbits. This sequence ofdissection was used because it is easiest technicallyto identify the orbicularis retaining ligament at thelateral orbital rim. The orbicularis retaining liga-ment was identified in its suborbicularis locationusing the vertical spread technique. The ligamentwas traced medially along the orbital rims andidentified at its insertion near the medial canthus.The relationship of the orbicularis retaining lig-ament to the orbital septum, arcus marginalis,corrugator muscles, and orbital rim was noted.

Gross anatomical dissection was performedwith loupe magnification. Magnification of 3.5�to 5� was used for identification of the ligament.

The Zeiss operating microscope (Carl Zeiss,Oberkochen, Germany) was used for high-powerdissection of the orbicularis retaining ligamentalong the orbital rim and to closely confirm itsrelationship to the orbital septum. Photographicdocumentation was achieved with the Canon dig-ital 20D system (Canon, Tokyo, Japan) and a50-mm macro lens; images were scanned into Pho-toshop CS2 (Adobe Systems, Inc., San Jose, Calif.).

RESULTSSixteen facial halves were dissected assisted by

loupe and microscopic magnification. The cir-cumferential nature of the orbicularis retainingligament was consistent in every specimen. Theorbicularis retaining ligament was noted to becontinuous from the medial orbit to the lateralorbit in both upper and lower eyelids (Fig. 1, above,left and below). The orbital septum can be seen toinsert onto the inferiormost part of the orbital rim;the orbicularis retaining ligament inserts 2 to 3mm above this point (Fig. 1, above, right).

The orbicularis retaining ligament was alwaysnoted to be distinct from the orbital septum (Fig.2, left); the two merge onto the orbital rim at thethickening called the arcus marginalis. In the su-perior orbit, two membranes were occasionallynoted, in accordance with the previously de-scribed bilaminar nature of the orbicularis retain-ing ligament.6

Dissections of the lateral half of the upper andlower orbits confirmed the previously noted in-sertion of the orbicularis retaining ligament intothe lateral canthus. The lateral orbital thickeningwas noted to arise from the orbicularis retainingligament and to be confluent with the superficiallateral canthal ligament, in accordance with find-ings described by Moss et al.7 Observations fromour dissections indicated that the orbicularis re-taining ligament was more lax and greater inlength laterally (Fig. 2, right), whereas medially itwas a more taut, shorter structure (Fig. 2, left).Therefore, medially it may function as a support-ive “hammock” for the brow depressor muscles.Ancillary dye studies confirmed previous work thatconfirmed that the orbicularis retaining ligamentdisplays relative impermeability.4

DISCUSSIONThis study clarifies three points regarding the

orbicularis retaining ligament: (1) the orbicularisretaining ligament is a circumferential, perior-bital structure; (2) the orbicularis retaining lig-ament of the superior orbit has similar imper-meability characteristics as has been shown in

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the inferior orbit; and (3) the orbicularis re-taining ligament of the superior orbit arises 2 to3 mm above the orbital rim in the mid orbit.These seemingly minor points have importantramifications for clinicians.

It may seem of academic interest only whetheror not the orbicularis retaining ligament acts as apartitioning membrane. However, if botulinumtoxin is injected directly at the lower edge of theinfraorbital rim, the patient may develop elevatorparalysis and eyelid ptosis (Fig. 3, left). If, in con-

trast, botulinum toxin is injected several millime-ters above the inferior edge of the rim (above theorigin of the orbicularis retaining ligament), le-vator dysfunction is much less likely (Fig. 3, right).In this scenario, the function of the orbicularisretaining ligament as a partitioning membranebecomes important to the practicing clinician, asdoes knowledge of the precise origin of this liga-ment in reference to the edge of the supraorbitalrim. Figures 4 and 5 shows this anatomy in a sche-matic fashion.

Fig. 1. (Above, left) Predissection photograph of an 88-year-old man. The dissection technique to approachthe orbicularis retaining ligament is similar to what is used clinically in the operating room. The orbicularisretaining ligament is most easy to identify laterally using the vertical spread technique, after which it canbe traced medially along the orbital rims. (Below) Schematic depicting the orbicularis retaining ligament(ORL) as a “circumferential” structure of the orbit that follows the orbicularis oculi muscle (OOM) fibers, andis associated with the lateral orbital thickening (LOT). (Above, right) The orbicularis retaining ligament of themedial orbit is seen clearly in both the superior and inferior orbits. The orbicularis retaining ligament isseparate from the orbital septum. The orbicularis retaining ligament spans the entire circumference of theorbits from the medial to lateral canthus.

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As a retaining ligament, enough informationexists to begin using the orbicularis retaining lig-ament in surgical techniques. Muzaffar et al. sug-gested release of the orbicularis retaining liga-ment and lateral orbital thickening for proper

redraping of the orbicularis muscle during mid-face lift.6 This idea, the concept that orbicularismuscle can be repositioned more effectively afterrelease of the orbicularis retaining ligament, en-ables the technique of orbicularis retaining liga-

Fig. 2. (Left) The orbicularis retaining ligament in a 91-year-old man illustrates how this structure isseparate from the orbital septum (OS). The orbital septum has an origin on the inferior edge of the orbitalrim. The orbicularis retaining ligament has a higher origin 2 to 3 mm superior to the inferior rim edge. Thefusion point of the orbicularis retaining ligament (ORL) and the orbital septum is referred to simply as thearcus marginalis (AR), which is nothing more than the common fusion line of these structures and peri-osteum from the bones that form the orbital aperture. The medial orbicularis retaining ligament is shortand taut. (Right) The orbicularis retaining ligament is long and lax laterally, which may partially explainthe phenomenon of “lateral hooding.”

Fig. 3. (Left) If one only palpates the inferior edge of the supraorbital rim and injects neuroparalytic agent,this may lead to levator paralysis. This needle entrance point is below the origin of the orbicularis retainingligament at the mid orbit. (Right) Proper needle placement, above the origin of the orbicularis retainingligament, ensures that injected fluid is partitioned away from the levator mechanism. Understanding of this anat-omy is important when one considers any periorbital injection, whether it be neuroparalytic agents or fillers.

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ment release to be applied creatively in manyother ways.

Canthopexy by release and resuspension ofthe orbicularis retaining ligament has been usedby Hoxworth.8 This obviates the need to disruptthe lateral canthal tendon (Fig. 6). Once the or-bicularis retaining ligament has been releasedfrom the inferior orbital rim, the overlying orbic-ularis muscle is essentially free: it can be placedunder any amount of tension desired. In situationswhere canthal position is unaffected, such asectropion or lamellar scarring, Hoxworth’s tech-nique of orbicularis retaining ligament releaseand fixation without canthal disruption mayprovide an alternative method of securing thelower lid.8

The above technique can be performed simul-taneously with fat transposition of the lower eyelid.The orbicularis retaining ligament can be simplytransected to allow for intraorbital fat to fill thesuborbital hollow (Fig. 7). Almost by definition,once the orbicularis retaining ligament is transected,the position of the orbital septum has to be reset,because the orbicularis retaining ligament is theinferior (caudal) anatomical boundary of lowereyelid fat (Fig. 7, left). Hamra described his ap-proach using release of the arcus marginalis,which is a fusion plane along the orbital rim.9Recently, Barton et al. have critically evaluated thistechnique, its indications, and its long-termresults.10 Knowledge of orbicularis retaining liga-

Fig. 5. A schematic as viewed from the lateral orbital rim toward thenasal bones with the orbicularis oculi muscle (OOM) suspended byhooks to demonstrate the length and size differential between thelateral and medial orbicularis retaining ligaments (ORL). The lateralorbicularis retaining ligament is longer than the medial in both thesuperior and inferior orbits. Note the relationship between the orbic-ularis retaining ligament, the corrugator supercilii muscle (CSM), andthe lateral orbital thickening (LOT).

Fig. 4. Schematic drawing of the relationship of the orbital sep-tum and the orbicularis retaining ligament. The orbicularis re-taining ligament arises from orbital rim several centimetersabove the inferior edge. The arcus marginalis is really nothingmore than a fused area of the orbital septum, orbicularis lig-ament, and periosteum, and lies between these two struc-tures. OOM, orbicularis oculi muscle; ORL, orbicularis retainingligaments.

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Fig. 6. (Left) The orbicularis retaining ligament can be released to resuspend underminedorbicularis muscle during blepharoplasty. Before orbicularis retaining ligament release, thelower lid is relatively immobile. (Right) Without disruption of either the lateral canthal tendonor the lateral orbital thickening, simple release of the orbicularis retaining ligament from theinferior orbital rim allows for lid repositioning under any degree of tension. The orbicularisretaining ligament is fairly dense tissue laterally, and can be incorporated into the suture foradded support. (Photograph and technique courtesy of Ronald E. Hoxworth, M.D.)

Fig. 7. (Left) Orbicularis retaining ligament (ORL) release and fat transposition is possible with orbicularisretaining ligament transaction in the lower lid. The orbicularis retaining ligament is noted beneath the dis-section scissors. The orbital septum has not been opened. Transection of the orbicularis retaining ligamentwas performed along the line shown. (Right) Completed orbicularis retaining ligament transection and fatrepositioning is shown. This procedure is anatomically straightforward, because after identifying the orbitalseptum (OS), the next structure caudal has to be the orbicularis retaining ligament. A vertical spread tech-nique is very useful for accurate dissection of this ligament from the orbital rim to the orbicularis muscle.(Photograph and technique courtesy of Ronald E. Hoxworth, M.D.)

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ment anatomy makes release and fat repositioninga relatively straightforward technique. In addition,the anatomy of the orbicularis retaining ligamentis reflected onto the overlying soft tissue and canbe visualized with knowledge of its anatomical de-tail and its boundaries (Fig. 7, right).

It may be that significant advances in browlifting may arise by manipulation of the orbicularisretaining ligament. It may be that some of thesplaying of the medial brows noted with conven-tional techniques may be ameliorated by leavingthe medial orbicularis retaining ligament intact inthis region. We observed the orbicularis retainingligament to be short and taut medially, increasingits “retaining” effect on the medial brow and thecorresponding muscles (orbicularis oculi and cor-rugator supercilii muscles) (Fig. 5). Laterally, theorbicularis retaining ligament is long and appearsto be redundant beyond the temporal crest line,where there is a paucity of muscular support to thebrow (Figs. 2, right and 5). These interesting an-atomical variations between the superomedial andsuperolateral orbicularis retaining ligament in theupper orbit may explain why lateral hooding occursreadily with aging and medial hooding does not.Again, with knowledge of the anatomy, it is clear thatany approach to the corrugators through the uppereyelid has to transect the orbicularis retaining liga-ment (Fig. 8).

Release of the lateral orbicularis retaining lig-ament through an upper eyelid incision has beenperformed, and it can be effectively released andits position reset through a direct brow techniqueor with endoscopic brow techniques.8 Lateral or-bicularis retaining ligament release may be im-portant in brow lifting for two reasons: (1) it re-leases the attachment of the brow to the orbitalrim and (2) it sets the stage for orbicularis retain-ing ligament fixation to accurately reposition theeyebrow. It may be that the longevity of endo-scopic brow procedures can be improved by or-bicularis retaining ligament release, as advocatedby Hoxworth8 and as shown in ongoing clinicalstudies.

CONCLUSIONSSeveral additional anatomical points are de-

scribed relating to the orbicularis retaining liga-ment. These anatomical details become importantwhen one considers surgical procedures in theperiorbital region. As a functional barrier, knowl-edge of the precise anatomy is important whenperforming injection techniques. Understandingof the role this ligament plays as a retaining struc-

ture may lead to improved techniques in botheyelid and brow rejuvenating procedures.

Joel E. Pessa, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical Center5323 Harry Hines Boulevard

Dallas, Texas 75390-9132joel.pessa@utwsouthwestern.edu

ACKNOWLEDGMENTSThis article would not have been possible without the

efforts of Melinda Mora of the University of Texas South-western Medical Center Willed Body Program, whosededication and hard work has facilitated all of this work.Kind thanks to Holly Smith for suggestions and recom-mendations for this article that have only served to helpmake it better, and to Kim Hoggatt-Krumwiede for ele-gant illustrations and attention to detail.

REFERENCES1. Hargiss, J. L. Surgical anatomy of the eyelids. Trans. Pac. Coast

Otolaryngol. Ophthalmol. Soc. 44: 193, 1963.2. Putterman, A. M. Baggy eyelids: A true hernia. Ann. Oph-

thalmol. 5: 1029, 1973.

Fig. 8. The anatomical limits of the orbicularis retaining liga-ment of the upper (ORLS) and lower (ORLI) orbits are illustrated bythe dotted line. This ligament spans the entire orbit. It is interest-ing to note that skin at the lateral canthus overhangs the lateralorbital thickening, where orbicularis is more densely attached tobone (lateral arrow). The orbicularis retaining ligament in the in-ferior orbit reflects its shape onto the skin as the orbit cheekcrease, which is simply the submuscular fusion point of the or-bicularis retaining ligament with orbicularis oculi muscle. Medi-ally, a double indentation is occasionally seen that correspondsto the orbicularis retaining ligament of the medial orbit.

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3. Loeb, R. Fat pad sliding and fat grafting for leveling liddepressions. Clin. Plast. Surg. 8: 757, 1981.

4. Pessa, J. E. The malar septum, the anatomical basis of malarmounds. Presented at the American Society for AestheticPlastic Surgery meeting, Dallas, Texas, April 1994.

5. Kikkawa, D. O., Lemke, B. N., and Dortzbach, R. K. Relationsof the superficial musculoaponeurotic system and charac-terization of the orbitomalar ligament. Ophthal. Plast. Recon-str. Surg. 12: 77, 1996.

6. Muzaffar, A. R., Mendelson, B. C., and Adams, W. P. Surgicalanatomy of the ligamentous attachments of the lower lid andlateral canthus. Plast. Reconstr. Surg. 110: 873, 2002.

7. Moss, C. J., Mendelson, B. C., and Taylor, G. I. Surgicalanatomy of the ligamentous attachments in the temple andperiorbital regions. Plast. Reconstr. Surg. 105: 1475, 2000.

8. Hoxworth, R. E. Lower lid suspension by orbicularis retain-ing ligament release and fixation with preservation of thelateral canthal ligament. Personal communication, 2006.

9. Hamra, S. T. Arcus marginalis release and orbital fat pres-ervation in midface rejuvenation. Plast. Reconstr. Surg. 96:354, 1995.

10. Barton, F. E., Jr., Ha, R., and Awada, M. Fat extrusion andseptal reset in patients with the tear trough triad: A criticalappraisal. Plast. Reconstr. Surg. 113: 2115, 2004.

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