ARTICLE | FACIALAESTHETICS |
with the lid retractor structures near the lid margins, thus acting as a diaphragm. Although usually depicted diagrammatically as a discrete layer immediately posterior to the orbicularis oculi muscle, the orbital septum is a multilaminated structure that is part of the anterior orbital connective tissue framework. The septum has a laxity consistent with the mobility of the eyelids.
Figure 3 Laser blepharoplasty of the upper eyelids and skin resurfacing of the lower lids: (A) before and (B) after treatment
Ligaments, levators and retractors The orbicularis retaining ligament attaches the orbicularis oculi to the inferior orbital rim; it is broader and stronger inferolaterally than centrally. The expanded lateral end of the orbicularis retaining ligament is continuous with the orbital thickening. The orbital thickening is a fibrous fusion between the orbicularis fascia covering the peripheral part of the orbicularis oculi, and the underlying deep fascia (i.e. to the periosteum and the deep temporalis fascia). The orbital thickening extends across the entire width of the frontal process of zygomatic bone and onto the deep temporal fascia for a variable distance. With age, the retaining ligament becomes distended and thinned, with the changes being greater centrally than laterally. During surgery, the detachment of the orbital thickening and the lateral part of the retaining ligament will completely release the superficial fascia from the orbital rim. The levator palpebrae superioris (LPS), which is the
Figure 4 Laser blepharoplasty of the upper eyelids and skin resurfacing of the lower lids; (A) before and (B) after treatment
fibrous tissue and are responsible for the structural
integrity of the lids. Their posterior surfaces adhere to the conjunctiva. The medial canthal tendon, which is also called the
medial palpebral ligament, is linked with the orbicularis oculi muscle and lacrimal system. The lateral canthal tendon (lateral palpebral ligament) is formed by dense fibrous tissue arising from the tarsi and passes laterally deep to the orbital septum to insert into the lateral orbital tubercle. The orbital septum is a connective tissue structure that attaches peripherally at the periosteum of the orbital margin (the arcus marginalis); it centrally fuses
main retractor of the upper eyelid, arises at the orbital apex from the undersurface of the lesser wing of the sphenoid bone. The levator muscle and superior rectus muscle share a developmental origin and are connected by fibrous attachments. The LPS proceeds anteriorly for 40 mm and ends in an aponeurosis approximately 10 mm behind the orbital septum. The levator complex changes direction from a horizontal to a more vertical direction at the superior transverse ligament (Whitnall’s ligament). The levator aponeurosis spreads laterally and medially to form lateral and medial horns. The medial horn attaches to the posterior lacrimal crest. The lateral horn divides the lacrimal gland into orbital and palpebral lobes before attaching to the lateral orbital tubercle. The aponeurosis fuses with the orbital septum prior to reaching the level of the superior tarsal plate border. At the inferior edge of this fusion, some aponeurotic fibres descend to insert into the lower third of the anterior surface of the tarsal plate. An anterior extension from this fusion inserts into the pre-tarsal orbicularis oculi muscle and overlying skin, forming the upper-lid skin crease.
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November/December 2012 |
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