the tear trough and lid/cheek junction: anatomy and...

COSMETIC

The Tear Trough and Lid/Cheek Junction:Anatomy and Implications for Surgical CorrectionNicholas T. Haddock, M.D.

Pierre B. Saadeh, M.D.Sean Boutros, M.D.

Charles H. Thorne, M.D.

New York, N.Y.; and Houston, Texas

Background: The tear trough and the lid/cheek junction become more visiblewith age. These landmarks are adjacent, forming in some patients a continuousindentation or groove below the infraorbital rim. Numerous, often conflictingprocedures have been described to improve the appearance of the region. Thepurpose of this study was to evaluate the anatomy underlying the tear trough andthe lid/cheek junction and to evaluate the procedures designed to correct them.Methods: Twelve fresh cadaver lower lid and midface dissections were per-formed (six heads). The orbital regions were dissected in layers, and medicalphotography was performed.Results: In the subcutaneous plane, the tear trough and lid/cheek junctionoverlie the junction of the palpebral and orbital portions of the orbicularis oculimuscle and the cephalic border of the malar fat pad. In the submuscular plane,these landmarks differ. Along the tear trough, the orbicularis muscle is attacheddirectly to the bone. Along the lid/cheek junction, the attachment is ligamen-tous by means of the orbicularis retaining ligament.Conclusions: The tear trough and lid/cheek junction are primarily explainedby superficial (subcutaneous) anatomical features. Atrophy of skin and fat is themost likely explanation for age-related visibility of these landmarks. “Descent”of this region with age is unlikely (the structures are fixed to bone). Bulgingorbital fat accentuates these landmarks. Interventions must extend significantlybelow the infraorbital rim. Fat or synthetic filler may be best placed in theintraorbicularis plane (tear trough) and in the suborbicularis plane (lid/cheekjunction). (Plast. Reconstr. Surg. 123: 1332, 2009.)

The terms “tear trough” and “lid/cheek junc-tion” are ubiquitous at plastic surgery meet-ings and in the literature. There is general

agreement that these landmarks become morevisible with age. Disagreement exists, however, re-garding the anatomical explanation for theselandmarks and which procedure is best to dis-guise, improve, or correct them.

The tear trough,1 also known as the nasojugalgroove,2 is the natural depression extending in-

ferolaterally from the medial canthus (Fig. 1).When this external landmark is deep enough to beunsightly in the eyes of the patient or the surgeon(usually because of the aging process), it is knownas the “tear trough deformity.” The tear trough isshort (no more than 3 cm in length) and termi-nates approximately in the midpupillary line. Ex-tending laterally from this point, below and ap-proximately parallel to the infraorbital rim, isanother indentation that becomes more obviouswith age. This groove has been variably referred toas the palpebromalar groove3 or, by some, thelid/cheek junction (Fig. 1). A tear trough defor-mity and a well-demarcated lid/cheek junction,along with visible bulging of orbital fat, may stim-ulate a patient to seek periorbital aestheticsurgery.4

Various anatomical explanations for the teartrough deformity have been provided in the

From the Institute of Reconstructive Plastic Surgery, NewYork University School of Medicine, and Houston Plasticand Craniofacial Surgery.Received for publication April 4, 2008; accepted September16, 2008.Presented at the 40th Anniversary Meeting of the AmericanSociety for Aesthetic Plastic Surgery, in New York, New York,April 19 through 24, 2007.Reprinted and reformatted from the original article publishedwith the April 2009 issue (Plast Reconstr Surg. 2009;123:1332–1330).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318269c70f

Disclosure: None of the authors has a conflict ofinterest.

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literature.1,2,5–7 These include (1) an attachment ofthe orbital septum to the arcus marginalis at theorbital rim, (2) the gap between the levator labiisuperioris alaeque nasi muscle and the orbicularisoculi muscle, and (3) loss of facial fat in the troughor herniation of fat superior to the trough.

Despite numerous descriptions of the perior-bital and midface fascial system, contradictory an-atomical explanations also exist for the deepeningof the lid/cheek junction.3,8–13 Some have sug-gested that the lid/cheek junction descends withage.14–17 Studies by Lambros18 using photographsof the same patients over time, however, demon-strate that the lid/cheek junction does not actuallydescend with age.

How can there be such a lack of consensusregarding the anatomical cause, and behaviorover time, of such important landmarks? Palpa-tion of the tear trough and lid/cheek junction inthe upright patient makes one thing clear: theexplanation for their existence has nothing to dowith the orbital rim or the arcus marginalis. Thetear trough and lid/cheek junction extend wellbelow the orbital rim.

Given the diversity of anatomical explana-tions, it is not surprising that numerous and oftenconflicting surgical and injectable procedureshave been described as treatments for the teartrough deformity and the lid/cheek junction.Treatments for the tear trough include alloplasticimplants, release of the orbicularis oculi muscleorigin, transposition of pedicled orbital fat, graft-ing of fat by injection, and injection of other ma-terials such as hyaluronic acid fillers.1,2,7,17,19–25 Pro-

posed treatments for the deepening lid/cheekjunction are even more diverse and include mid-face lifting, redraping, and cephalic traction onthe orbicularis muscle; transposition of pedicledorbital fat; and injection of either fat or othermaterials.14–17,19,23–29 In addition, traditional treat-ment for orbital fat herniation, namely, orbital fatexcision, may disguise the tear trough deformity andthe lid/cheek junction interface to some extent.

The anatomical study reported in this articlewas designed to answer the following question:What exactly are the tear trough and lid/cheek junc-tion, from an anatomical point of view? After an-swering this primary question, it was hoped that thefollowing questions might be addressed secondarily:Why do these external landmarks become more ob-vious with age? In which anatomical plane is surgicalintervention most likely to succeed? Which of theprocedures heretofore described to correct the teartrough and deepening lid/cheek junction make themost anatomical sense?

METHODSTwelve fresh cadaver lower lid and midface dis-

sections were performed (six heads; three malethree female cadavers). The ages of the cadaverswere noted, the anatomical components of the re-gion were examined, and photographs were taken.A representative cadaver is shown in Figure 2.

Dissection was performed carefully, layer bylayer, to evaluate whether there were multiple an-atomical contributions to the overlying surface

Fig. 1. The tear trough deformity, or nasojugal groove, is thenatural depression extending inferolaterally from the medialcanthus (black arrow). The lid/cheek junction, or palpebromalargroove, extends around the lateral half of the inferior orbit (whitearrows).

Fig. 2. A representative fresh cadaver (53-year-old male).

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anatomy. Attention was directed to the thicknessof the skin, the amount of subcutaneous fat, theorigin and configuration of the orbicularis oculimuscle, and the attachments between the orbic-ularis oculi muscle and the underlying bone.

RESULTSAll cadavers were older than 50 years. There

was no distinction between the anatomy of the teartrough and the adjacent lid/cheek junction in thesubcutaneous plane. Rather, they were continu-ous and correlated in every case with the junctionbetween the palpebral (or preseptal) and orbitalportions of the orbicularis oculi muscle.

Additional features contributed to the visibil-ity of these landmarks. The skin overlying the pal-pebral orbicularis (eyelid skin) was thin, with nosubcutaneous fat. The skin over the orbital orbic-ularis (cheek skin), in contrast, was thicker and wasseparated from the underlying orbicularis muscle bythe malar fat pad. The cephalic border of the malarfat pad was located, in every case, precisely at thejunction of the palpebral and orbital portions of theorbicularis oculi muscle (Fig. 3).

The tear trough, and the underlying anatom-ical features that explain it, begin at the medialcanthus and extend inferolaterally away from theorbital rim, terminating 4 to 6 mm caudal to thearcus marginalis at the orbital rim. The gap be-tween the orbital portion of the orbicularis andthe levator labii superioris alaeque nasi muscle,thought by some to explain the tear trough, wasalways inferomedial to the tear trough and did not

contribute to the overlying surface anatomy (Figs.4 and 5).

Although the anatomy of the tear trough andits lateral continuation, the lid/cheek junction,were identical in the subcutaneous plane, this wasnot the case deep to the orbicularis muscle. Alongthe tear trough, there was no dissectible anatom-ical plane deep to the orbicularis. Rather, the pal-

Fig. 4. Subcutaneous anatomy with malar fat reflected. The ma-lar fat pad (single white arrow) has been reflected laterally, expos-ing the junction of the palpebral and orbital components of theorbicularis oculi muscle, which precisely corresponded to thetear trough deformity (black arrow) and the lid/cheek groove(double white arrow).

Fig. 5. Relationship between the orbicularis oculi muscle andthe levator labii superioris alaeque nasi muscle. In no case did thetear trough deformity (white arrow) correlate with the junctionbetween the orbicularis oculi and the levator labii superioris alae-que nasi (black arrow).

Fig. 3. Subcutaneous anatomy of the tear trough and lid/cheekjunction. The cephalic border of the malar fat pad correspondsprecisely with the tear trough medially (black arrow) and the lid/cheek groove laterally (double white arrow). The palpebral por-tion of the orbicularis (single white arrow) lacked overlying fat andthe reflected eyelid skin was thin (far left).

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pebral portion of the orbicularis was rigidly at-tached to the maxilla where it takes origin (Fig. 6).Laterally, however, along the lid/cheek junction,the attachment between the orbicularis muscleand the underlying bone was ligamentous (theorbicularis retaining ligament). In this region,there was a dissectible plane deep to the orbicu-laris muscle.

The orbicularis retaining ligament was at-tached to the underlying zygoma caudal to the arcusmarginalis at the orbital rim (Fig. 7). The orbicularisretaining ligament was furthest from the rim in themidpupillary line (4 to 6 mm) and terminated closerto the rim near the lateral canthus (2 to 4 mm). Torepeat, the orbicularis retaining ligament did notarise from the infraorbital rim but, like the cutane-ous landmark overlying it, was several millimeterscaudal to the rim.

Finally, attenuation of the orbital septum ac-companied by orbital fat herniation was transmittedthrough the relatively lax palpebral orbicularis, fur-ther accentuating the tear trough. This was espe-cially evident medially, where the strong orbital or-bicularis attachments originate. Table 1 summarizesthe findings, comparing the tear trough anatomy tothe lid/cheek junction anatomy. Figures 8 through11 illustrate these findings.

DISCUSSIONThe anatomical features that explain the ex-

ternal landmarks known as the tear trough and

lid/cheek junction exist in three different planes:at the skin level, at the subcutaneous plane, and atthe suborbicularis plane. In the subcutaneousplane, the tear trough and lid/cheek junction cor-relate with the junction of the palpebral and or-bital portions of the orbicularis muscle. Along thetear trough, there tends to be a particularly obvi-ous cleft between the two portions of the orbicu-laris muscle. In addition, there is virtually no fatbetween the skin and the muscular junction, ac-counting for its visibility as a cutaneous landmark.Further contributing to external visibility is thefact that the eyelid skin above the landmark andthe cheek skin below the landmark have distinctlydifferent textures and thicknesses. In addition, themalar fat pad begins precisely at the same mus-cular junction, providing further definition.

In the suborbicularis plane, the tear troughand the lid/cheek junction differ. Along the teartrough, the palpebral portion of the orbicularisoculi muscle is rigidly attached to the bone, withno dissectible anatomical plane deep to the mus-cle. It was not technically possible to dissect abovethe periosteum and below the muscular attach-ment. Along the lid/cheek junction, however, theorbicularis muscle has a ligamentous attachmentto the bone by means of the orbicularis retainingligament. Unlike the tear trough region, there isa plane deep to the muscle into which material canbe injected or surgical dissection performed. Al-though there appeared to be one main orbicularisretaining ligament, there were several weaker lig-amentous attachments between the orbital rimand the attachment of the main orbicularis re-taining ligament.

Fig. 6. Submuscular anatomy of the tear trough. Deeper dissec-tion revealed that the origin of the orbital orbicularis (black ar-row) was an obliquely oriented, dense muscular attachment aris-ing from the maxilla, projecting inferiorly and laterally wellbelow (4 to 6 mm) the orbital rim and corresponding preciselyto the tear trough and the overlying junction between thepalpebral and orbital portions of the orbicularis oculi muscle.

Fig. 7. Laterally, the orbicularis retaining ligament was identi-fied (black arrow) and corresponded with the lid/cheek junctionand the overlying junction between the palpebral and orbitalportions of the orbicularis oculi muscle.


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Flowers described a set of factors contributingto the formation of the tear trough deformity,including (1) descent of the cheek with the junc-tion of cheek skin and eyelid skin occurring at alower point than usual; (2) a muscular defect be-tween the orbicularis muscle and angular head ofthe quadratus labii superioris muscle; (3) underde-velopment of the suborbital malar complex (he-

miexophthalmos); and (4) a progressive loss of facialfat with age. Flowers focused his efforts on develop-ing alloplastic implants designed to fill varying de-grees of tissue inadequacy.1 In a related observation,Freeman noticed that the formation of the nasojugaldeformity was associated with the inferior migrationof the sub–orbicularis oculi fat pad.21,22

Loeb described three theoretical malforma-tions that cause what he termed the nasojugalgroove. These include (1) fixation of the orbitalseptum at the level of the inferomedial portion ofthe arcus marginalis; (2) the existence of a trian-gular gap limited by the lateral portion of theangular muscle on one side and the medial por-tion of the orbicularis oculi muscle on the other;

Table 1. Anatomical Features that Characterize the Tear Trough and Lid/Cheek Junction Divided andCompared on the Basis of Each Tissue Dissection Layer

Tissue Dissection PlaneAnatomical Features Explaining the

Tear TroughAnatomical Features Explaining the

Lid/Cheek Junction

Skin Thinner over palpebral orbicularisoculi, thicker over orbital orbicularisoculi

Thinner over palpebral orbicularisoculi, thicker over orbital orbicularisoculi

Immediately deep to skin No subcutaneous fat over palpebralorbicularis oculi

No subcutaneous fat over palpebralorbicularis oculi

Junction of palpebral (preseptal) andorbital portions of the orbicularisoculi muscle

Junction of palpebral (preseptal) andorbital portions of the orbicularisoculi muscle

Superior border of the malar fat pad(begins abruptly)

Superior border of the malar fat pad(begins abruptly)

Suborbicularis Origin of the palpebral portion of theorbicularis oculi from the maxilla,extending obliquely from the medialcanthus to a point 4–6 mm belowthe orbital rim

Orbicularis retaining ligament, fibrousstructure extending from theorbicularis muscle to the zygomabelow the orbital rim (4–6 mm)

Orbital septum Orbital fat herniation accentuates teartrough and lid/cheek junction

Fig. 8. Artist’s drawing depicting the orbicularis oculi musclejunction and the origin of the muscle from the maxilla (yellowline). The cleft between the palpebral and orbital portions of themuscle explains the presence of the tear trough (medial) andthe lid/cheekjunction(lateral). The muscle junction also corre-sponds precisely to the superior border of the malar fat pad.Note that the orbital rim (dotted line) is located several milli-meters cephalad to the tear trough and lid/cheek junction.

Fig. 9. Drawing of the orbicularis muscle junction with the malarfat pad removed.


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and (3) the absence of fat tissue from the centraland medial fat pads subjacent to the orbicularisoculi muscle in the area below the groove. Loebalso noted that this natural sulcus may be incon-spicuous until neighboring fat pads grow andexaggerate the defect. To manage these spatialderangements, Loeb described a number of treat-ment options, including (1) transplant of free fatgrafts; (2) sliding fat from the medial and centralhypertrophic fat pads; and (3) liposuction of ex-cess fat on the cheek region.2,5

According to Codner and Ford, the teartrough deformity overlies the muscular triangleformed by the orbicularis oculi, the levator labiisuperioris, and the levator alaeque nasi muscles.They also point out that, with age, there is post-septal fat herniation and prezygomatic fat ptosisthat accentuates the defect.6 Barton et al. referredto the tear trough triad: (1) herniation of orbitalfat, (2) tight attachment of the orbicularis alongthe arcus marginalis, and (3) malar retrusion.7

Regarding the issue of apparent descent ofthe lid/cheek junction, Lambros has pointed outthat the lid/cheek junction is in fact stable over

time and the perception of descent is relatedto age related tissue contrasts and not actualmovement.18 Much of the apparent descent is at-tributable to herniation of the orbital fat followingorbital septal and preseptal orbicularis oculi mus-cle attenuation.30 These shadows exaggerate thetear trough deformity and palpebromalar groove.Furthermore, skin atrophy leads to darkeningof the preseptal skin, causing an increase in con-trast and therefore an accentuated lid/cheekjunction.18 Our study suggests that the tear troughdeformity is not related to facial “descent,” thearcus marginalis, the orbital rim, or the junctionof the levator labii superioris alaeque nasi muscleand the orbicularis oculi muscle.

In patients with a deep tear trough combinedwith a deep lid/cheek junction, the two landmarksform a near continuous indentation several mil-limeters below the infraorbital rim. Muzaffar et al.described the anatomy of the lateral lower eyelid,specifically focusing on the orbicularis retainingligament.9 Our findings were consistent with theseobservations with the exception that the orbicu-

Fig. 10. Medial cross-sectional illustration demonstrating theorigin of the orbicularis muscle from the maxilla, several millime-ters below the orbital rim and the arcus marginalis. Externally, thetear trough landmark corresponds to this bony attachment. Thetear trough indentation is accentuated by bulging orbital fat andthe superior border of the malar fat pad.

Fig. 11. Lateral cross-sectional illustration demonstrating theorbicularis retaining ligament extending from the orbicularismuscle junction to the underlying zygoma. Externally, the lid/cheek junction landmark corresponds to this bony attachment.The lid/cheek junction is accentuated by bulging orbital fat andthe superior border of the malar fat pad.


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laris retaining ligament originated from a point 4to 6 mm below the orbital rim and never the rimitself. In contrast to our findings, Ghavami et al.8described the origin at the infraorbital rim and 2 to3 mm above the supraorbital rim. They depicted theorbicularis retaining ligament as a circumferential“periorbital” barrier with fixation to the orbicularisoculi muscle. We emphasize that medially there is noorbicularis retaining ligament. Rather, the attach-ment between the orbicularis and the bone is direct,with no evidence of a ligament.

Several, often conflicting, procedures havebeen described to improve the appearance of thetear trough and lid/cheek region, including mid-face lifts, orbicularis redraping, orbital fat trans-position, and the injection of fat and hyaluronicacid fillers.

The traditional treatment for the bulgingeyelid fat is fat resection.31 In recent years, someauthors have recommended limiting or avoid-ing eyelid fat removal,7,14,17,20,26,32–37 but contro-versy remains over the benefits of fat mobiliza-tion and repositioning. Various methods of fatrestoration have been proposed.32,33,37

In an attempt to soften the orbital rim, Hamradescribed an extension of Loeb’s technique, inwhich the arcus marginalis is released and the her-niated fat is draped over the entire length of theorbital rim and secured to the periosteum.17 Bartonet al. and Eder reproduced this technique.7,34

Goldberg suggested a benefit of repositioningthe fat in the subperiosteal location with a de-creased chance of a visible demarcation.35,38,39

Kawamoto and Bradley found that dissectionthrough the supraperiosteal suborbicularis planewas possible and noticed that in comparison to thesubperiosteal plane there was better filling of thenasojugal groove.20 Our study does suggest thatany fat transposition procedures would have toinclude release of the orbicularis retaining liga-ment and medial orbicularis muscle and place-ment of the fat at least as far below the rim as thoseattachments.

Hester et al. introduced the concept of trans-palpebral midface lifting to treat “descent” of thelid/cheek junction. They originally used a subcili-ary incision but modified the technique in favor ofa lateral endoscopic approach because of lowereyelid complications.15,26–28

Alternative less invasive approaches to ablatethe tear trough deformity have been developed.Coleman applied a lipostructure fat transplanta-tion technique to fill the defect,23,24 and othershave attempted similar techniques of tissueinjection,40 and combined traditional blepharo-

plasty with fat grafting.41 Kane injected hyaluronicacid (Restylane; Q-Med, Uppsala, Sweden) super-ficially to elevate the surface from the orbitomalarligament and add volume to the trough,25 whereasLambros described injection in the orbicularis oc-uli muscle or at the periosteum to correct the teartrough deformity.42

It is appealing to design surgical proceduresthat are physiologic (i.e., that seem to reverse theprocess that created the deformities they are cor-recting). For example, transposition of fat over theorbital rim often improves the tear trough, but itis not physiologic. The procedure is not returningfat to the place it originated. The ideal and mostphysiologic treatment for these landmarks wouldappear to be in the superficial plane between theskin and the underlying muscle. The problem isthat the skin is extremely thin and interventions inthis plane may leave contour irregularities. Mid-face lifting may improve the appearance of thelower orbit in some patients, but it is not physio-logic either; that is, the lid/cheek junction doesnot descend so lifting it is less appealing. As aes-thetic surgeons, however, our interventions neednot be physiologic, provided they work. Injectionof fat grafts or synthetic fillers may be more safelyplaced in a deeper plane, although it is less phys-iologic and has only an indirect effect on the ex-ternal landmarks. Along the lid/cheek junction,the material (fat or filler) can be injected deep tothe orbicularis muscle. Along the tear trough,however, it is important to appreciate that there isno plane deep to the muscle. Any attempts toplace fat or filler deep to the muscle along the teartrough are probably, in actuality, placing the ma-terial within the muscular origin of the orbicularis.

CONCLUSIONSOur study suggests that the tear trough defor-

mity is not related to facial descent, the arcusmarginalis, the orbital rim, or the junction of thelevator labii superioris alaeque nasi muscle andthe orbicularis oculi muscle. The tear trough andlid/cheek junction extend significantly below theorbital rim and are explained primarily by ana-tomical features in the subcutaneous plane. Spe-cifically, these landmarks overlie the junction be-tween the palpebral and orbital portions of theorbicularis oculi muscle and are made more ob-vious by the absence of subcutaneous fat, a differ-ence in skin quality, and the presence of the malarfat pad whose cephalic border is immediately cau-dal to the lid/cheek junction and the tear trough.The two landmarks differ in their attachment tothe bone. Along the tear trough, the muscle is


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rigidly attached to the bone. Along the lid/cheekjunction, the orbicularis retaining ligament at-taches the muscle to the bone. The anatomicalfindings in this study have led to the followingsecondary conclusions/impressions:

1. Atrophy of the skin and underlying subcuta-neous fat is the most likely explanation forthe increasing visibility of the tear troughand lid/cheek junction with age.

2. It is unlikely that there is age-related descentof these structures because they are fixed tothe bone.

3. Because descent is not an etiologic factor,midface lifting (a significant procedure withcomplications) may not be the best solution.

4. Any surgical intervention aimed at correc-tion of the tear trough and lid/cheek junc-tion must extend significantly below the in-fraorbital rim because these deformitiesextend at least 4 mm below the arcus mar-ginalis at the rim.

5. Although the cause is atrophy, especially offat, injection of material above the muscle isfraught with hazard. Injected fat frequentlydoes not resorb and is difficult to removewithout creating a greater deformity. Theremay be a role for the injection of filler in thissuperficial plane, but we have no experiencewith that procedure. It seems likely that thefiller would also be visible or cause discolor-ation.

6. Treatment may be best directed to the sub-orbicularis plane in the case of the lid/cheek junction and intraorbicularis plane inthe case of the tear trough, not because it isa physiologic correction but because thetreatment is less likely to result in a visibledeformity. The term “intraorbicularis” planeis used to emphasize that there is no planedeep to the muscle in the tear trough intowhich to inject anything.

Charles H. Thorne, M.D.Institute of Reconstructive Plastic Surgery

New York University Medical CenterTH 169, 550 First Avenue

New York, N.Y. 10016

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the tear trough and lid/cheek junction: anatomy and...

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