Article

Location and Nature of Retro-Orbicularis Oculus Fat and Suborbicularis Oculi Fat

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Abstract

The aim of this study is to elucidate the anatomic location and histologic nature of the retro-orbicularis oculus fat (ROOF) and suborbicularis oculi fat (SOOF) around the orbital area. Seventeen hemifaces of 12 Korean adult cadavers were used. ROOF and SOOF were observed in all specimens. ROOF was located in a supraorbital area within a range of between a medial +41 and a lateral -39 degrees to a vertical midpupillary line. The shape is crescent and almost symmetric when folded in half. The horizontal length of ROOF was approximately two thirds of a transverse orbital dimension. The height was approximately one third of a vertical orbital dimension. SOOF was located in the inferolateral side of the orbit within a range between a medial +15 and a lateral -89 degrees to a vertical midpupillary line. The SOOF looks like a hockey stick head. The SOOF is divided into two parts, horizontal and vertical. The length of the SOOF horizontal part is almost equal to a transverse orbital dimension (a). The height of the SOOF vertical part was approximately three fourths (bx3/4) of the vertical orbital dimension (b), and the width of vertical part was one fourth (a/4) of a transverse orbital dimension (a). Most of the SOOF vertical part was outside the lateral orbital rim, and the horizontal part was below the infraorbital rim. Histologically, ROOF and SOOF were situated deep to the orbicularis oculi muscle and superficial to the orbital septum and periosteum. ROOF and SOOF consisted more of fibrofatty tissue than the pure fatty nature of orbital fat. The findings in this study might be conducive to the practice of blepharoplasty and midface lift.

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... The suborbicularis oculi fat (SOOF) was defined as a fat pad lying supraperiosteally beneath the orbicularis oculi muscle (OOM) and below the lateral half of the infraorbital rim above the zygoma. 1 The hockey stick-shaped head of SOOF is located at the inferolateral side of the orbit within a range of +15 degrees medial and −87 degrees lateral to a caudal vertical mid-pupillary line. 2 It has an average horizontal length of 48 mm and an average vertical height of 27 mm. 2 Previous studies described that the midfacial fat compartments (malar and SOOF) are connected to the orbicularis oculi muscle and the facial bone by the superficial musculoaponeurotic system (SMAS). 3 The lack of a clear definition of the SMAS structure allowed the authors to conclude that SMAS inserts in the orbicularis oculi muscle (OOM) connection to the facial bone. ...
... The suborbicularis oculi fat (SOOF) was defined as a fat pad lying supraperiosteally beneath the orbicularis oculi muscle (OOM) and below the lateral half of the infraorbital rim above the zygoma. 1 The hockey stick-shaped head of SOOF is located at the inferolateral side of the orbit within a range of +15 degrees medial and −87 degrees lateral to a caudal vertical mid-pupillary line. 2 It has an average horizontal length of 48 mm and an average vertical height of 27 mm. 2 Previous studies described that the midfacial fat compartments (malar and SOOF) are connected to the orbicularis oculi muscle and the facial bone by the superficial musculoaponeurotic system (SMAS). 3 The lack of a clear definition of the SMAS structure allowed the authors to conclude that SMAS inserts in the orbicularis oculi muscle (OOM) connection to the facial bone. ...
... 6 Nevertheless, the lack of a clear definition of SOOF has allowed controversial opinions and interpretation concerning the anatomical location and morphology of this structure. 2,11 The aim of this study was to perform histomorphological analysis and three-dimensional (3D) reconstruction of the meshwork of the SOOF structure and its connection to the SMAS, the OOM, the intraorbital fat and the skin. The hypothesis of this investigation was that SOOF is a fat pad with morphological architecture that is similar to that of the SMAS underlying the OOM. ...
Article
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The aim of this study was to reveal the histomorphological connections among the suborbicularis oculi fat (SOOF), the orbicularis oculi muscle (OOM), the superficial musculoaponeurotic system (SMAS), the infraorbital fat and the skin. Full graft tissue blocks of the infraorbital region with the skin, SMAS, OOM and SOOF were collected post mortem from one female and two male formalin-fixed body donors. Serial histological sections were made, stained and digitized. Digitalization and three-dimensional (3D) reconstruction of the histological meshwork were performed. SOOF was revealed as a fibro-adipose tissue underlying the OOM, which was strictly separated from the intraorbital fat pad by the orbital septum. SOOF, OOM and SMAS were connected by fibrous septa derived from the SOOF, traversing the OOM with division into multiple muscular bundles, continuing above the muscular plane by forming the SMAS and ending with skin insertion. In the infraorbital region, two different types of SMAS bordering the infraorbital fold have been recognized. Muscle cells have been demonstrated in the SMAS fibrous septa of both SMAS types. Together with the OOM, the SMAS and the skin, SOOF forms an anatomical functional unit. Muscular contraction of the OOM could be transferred by the SMAS to the skin level, producing periorbital mimic expression. The 3D reconstruction facilitates the comprehension of the morphological structure, its connections and space correlations in the infraorbital area. The morphological and topographical peculiarities of the infraorbital structures make it possible to conclude that surgical interventions in this area need to be elaborated and individualized.
... The SOOF consists more of fibrofatty tissue than pure fatty tissue like the orbital fat. OM: orbicularis oculi muscle, OS: orbital septum, CPF: capsulopalpebral fascia (Hwang et al., 2007.) fi brous band expanding from the inferolateral orbital rim to the medial canthal ligament. ...
... SOOF is an elusive entity and can only be visualized from the suborbicularis space during a skin-muscle fl ap procedure in lower blepharoplasty (Aiache 2001). In Hwang's recent paper (Hwang et al., 2007), the SOOF was observed in all specimens. Th e SOOF was located in the inferolateral side of the orbit within a range between medial +15 and lateral -89 degrees to a vertical midpupillary line. ...
... I hope surgeons can achieve desirable outcomes with the knowledge the SOOF horizontal part is almost equal to a transverse orbital dimension. The height of the SOOF vertical part was about three fourth (b×3/4) of the vertical orbital dimension and the width of the vertical part was one fourth (a/4) of a transverse orbital dimension (Hwang et al., 2007). Anat Cell Biol 43:15~24, 2010 23 reviewed in this article. ...
Article
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The aim of this review is to familiarize the reader with the critical lower eyelid anatomy as is related to lower blepharoplasty or a midface lift. The contents include 1) the lacrimal canaliculus in the lower eyelid: the depth and width (diameter) of the vertical portion were 2.58±0.24 mm and 0.44±0.07 mm, respectively. A vertical portion of the canaliculus was about 1 mm (1.11±0.16 mm) deep, and the horizontal portion was about 2~3 mm (2.08±2.74 mm) long 2 mm below the mucocutaneous junction, which is where an incision may be made when performing epicanthoplasty. 2) Motor innervation to the lower orbiculis oculi muscle: the pretarsal and preseptal OOMs were innervated by five to seven terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The mean horizontal distance between the lateral canthus and the zygomatic branch was 2.31±0.29 cm (range: 1.7~2.7 cm) and the vertical distance was 1.20±0.20 cm (range: 0.8~1.5 cm). 3) Sensory innervation of the lower eyelid skin: the majority of the terminal branches (93.8%) of the ION were distributed to the medial to the lateral canthus. Most (99.4%) of the terminal branches of the ZFN were distributed to lateral to the lateral canthus. 4) Retractor of the lower eyelid; capsulopalpebral fascia (CPF): the orbital septum blended with the CPF most closely at 3.7~5.4 mm beneath the lower tarsal border and differently at 3.7±0.7 mm on the medial limbus line, 4.3±0.8 mm on the midpupillary line and 5.4±1.0 mm on the lateral limbus line. 5) Arcuate expansion (AE): The AE was a fibrous band expanding from the inferolateral orbital rim to the medial canthal ligament. A sector (fan-shaped) of the AE originated in the angle of 5 to 80 degrees at the circumference of the inferolateral orbital rim circle, falling within the range of 3 to 5.5 o'clock, and then it tapered and attached to the inferior border of the medial canthal ligament. 6) Suborbicularis oculi fat (SOOF) in the lower eyelid: the SOOF was located in the inferolateral side of the orbit within a range between medial +15 and lateral -89 degrees to a vertical midpupillary line. Histologically, the SOOF was situated deep to the Orbicularis oculi muscle and superficial to the orbital septum and periosteum. The SOOF consisted more of fibrofatty tissue rather than being the pure fatty nature like orbital fat. I hope surgeons can achieve desirable outcomes with the knowledge reviewed in this article.
... Entre la porción orbitaria del músculo orbicular y el periostio de los bordes orbitarios superior e inferior existen dos paquetes de tejido adiposo conocidos como ROOF (retroorbicularis oculi fat) y SOOF (suborbicularis orbital fat), respectivamente (17,18) . El ROOF, también conocido como cojinete graso de la ceja, puede ser hipertrófico y extenderse al plano que hay entre el músculo orbicular y el septum orbitario para formar la grasa preseptal (19) . ...
... No obstante, algunos autores sugieren que la grasa preseptal del párpado inferior es una estructura independiente y compartimentalizada, que es menor a la grasa orbitaria (postseptal) y se encuentra solamente en la porción lateral del párpado inferior. Estos autores se refieren a ese paquete graso como compartimento graso pretarsal (Figura 5) (17,21) . ...
Article
El conocimiento preciso de la anatomía de la órbita es importante para la realización de procedimientos quirúrgicos y no quirúrgicos o mínimamente invasivos en dermatología. Al ser una región facial con una red vascular compleja, dependiente del sistema carotídeo externo e interno, debe ser abordada de forma cautelosa, teniendo en cuenta las zonas de riesgo para complicaciones.
... 30 Deep fat compartments ( Figure 3B) include deep medial cheek fat, buccal fat, medial and lateral suborbicularis oculi fat (SOOF), and retro-orbicularis oculi fat (ROOF). 11,23,31,32 These compartments comprise fat lobules that are larger, more loosely arranged, and tend to occur in a more chaotic pattern. 30 Deep fat is immobile as it is firmly anchored to the underlying bone and helps to provide contour, support of overlying fat compartments, and a gliding plane for muscle movement. ...
... Superficial fat compartments (A) are separated by fascia and septae that meet at adjacent compartments, where retaining ligaments reside, with each component found in varied amounts, proportions, and arrangements in different regions of the face. 24,29,92 Deep fat compartments (B)comprise retro-orbicularis oculus fat, lateral and medial suborbicularis oculus fat, buccal fat, and deep medial cheek fat, which has medial and lateral parts.23,25,31,32 ...
Article
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The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. This evidence-based paper aims to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the “inside out”; that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy are presented, including remodeling of the facial skeleton, atrophy or repositioning of fat pads, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.
... For our study, we employed the nomenclature described by Stuzin et al 1 and found that the temporal branch ran along the undersurface of the superficial temporal fascia, in accordance with their original description and the majority of studies. [1][2][3][4][5][6][7][8][9][11][12][13][14][15][16][17][18][19][20][21]22 The ROOF is defined by May et al 23 as "a layer of fibrofatty soft tissue deep to the orbicularis oculus muscle, superficial to the orbital septum and orbital rim, and extending medially from the superior orbital nerve and laterally to a varying distance over the lateral upper orbit." To further characterize the fat pad, Hwang et al 21 correlated the size of the fat pads to the size of the orbit. ...
... The horizontal component's length is almost equal to the transverse orbital dimension, and the height of the vertical component is three-fourths of the vertical orbital size. 21 Our cadaver dissection confirmed the locations of the ROOF and SOOF and their relationship to the temporal nerve branches. The ROOF existed in a loose areolar plane deep to the superficial temporal fascia, with the temporal nerve branch directly superficial to it. ...
Article
Full-text available
A great number of studies have reported on the temporal branch anatomy and its relationship to the fascial layers and various fat pads of the temporal region, but no article has included information on the relationship of the temporal nerve to the retro-orbicularis oculi fat (ROOF) and/or the suborbicularis oculi fat (SOOF). The authors report the results of a series of human cadaver temporal nerve dissections, with particular attention paid to its relation to the ROOF and the SOOF. The results of a literature review and a subsequent open browlift are also reported to confirm the results of the cadaver study. Dissection was performed on 15 fresh human cadavers, for a total of 29 hemifaces. The course and relationships of the temporal nerve branch to the fascia, fat pads, and landmarks in the temporal region were noted and detailed. A thorough review was also performed for 23 articles, to compare the author's anatomical findings with data in the previous literature. During cadaver dissection, the temporal branch was found to lie on the undersurface of the superficial temporal fascia. In the supraorbital area, the ROOF existed in the loose areolar plane or deep layer of the superficial temporal fascia, with the temporal nerve branch directly superficial to it. The temporal branch passed lateral to the SOOF in its superiomedial course at the level of the zygoma. These findings were later confirmed during an in vivo open browlift as well. The ROOF was formerly unrecognized as an important sentinel marker for possible injury to the temporal nerve branch during browlift. However, this cadaver study and its accompanying literature comparisons show that browlift dissection, whether endoscopic or open, should aim to keep the ROOF fat in the superficial plane, ensuring that the nerve branch is safe from iatrogenic injury.
... Sometimes, orbital fat transposition is not enough to fill the depression in the tear trough area and fat injection is needed. 14,32,33 SOOF is normally inferolateral to the infraorbital rim 34 and is absent in the medial part. The elevation and suture of buccal fat to this infraorbital rim decreases the need for fat tissue in this area. ...
Article
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Background Despite traditional facelift and transtemporal endoscopic facelift techniques are used in treatment of mid face ptosis, they do not have a big impact on the midface area. Lower blepharoplasty techniques are effective to provide rejuvenation on nasojugal area, midface ptosis and tear trough deformity. Additionally, it is also possible to correct the lower face area and jowls with lower blepharoplasty. Objectives To define effect of vertical space lift in tear-trough, midcheek groove, midface and lower face. Methods A retrospective study was carried out on 23 patients who had surgeries between January 2018 and January 2021. The buccal fat is suspended and anchored to the medial infra orbital rim with a superomedial vector and the midface flap anchored to the lower and lateral orbital rim with a superomedial and superolateral vector. The average follow-up period was 12 months. Results A high degree of satisfaction has been achieved in the feedback of questionnaires. Results showed that there is a significant improvement in nasojugal deformity, malar ptosis, mid-cheek grove, and jowls. Conclusions While transcutaneous lower blepharoplasty provides an opportunity for rejuvenation of the lower eyelid and midface area, vertical space lift allows the surgeon to work on the midface, lower face and jowls area except the neck. Choosing appropriate technique according to area that needs to be corrected increases success rate.
... The maximal height indicated by Moss et al was lateral of the orbital midline and inferior to the lateral temporal adhesion; 2 Hwang et al placed this more central in relation to the orbit and related to the position of the ROOF lateral to the emergence of the SOA beneath the lateral two-thirds of the brow. 7 The margins of the ROOF are the inferior frontal septum superiorly (as the lower border of the temporal and supraorbital ligamentous adhesions as described by Moss et al 2 ), the orbicularis retaining ligament inferiorly, and the SOA medially 6 ( Figure 2). ...
... To reduce the heaviness of the upper eyelid, part of the orbicularis oculi muscle and the orbital fat are usually resected during plastic surgery, but this method is not entirely suitable for all patients. 2,3 The anatomical structure of the upper eyelid of different people is not exactly the same. In the upper eyelid, the retro-orbicularis oculus fat (ROOF) is defined as "a layer of fibrofatty soft tissue deep to the orbicularis oculus muscle, superficial to the orbital septum and orbital rim, and extending medially from the superior orbital nerve and laterally to a varying distance over the lateral upper orbit". ...
Article
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Background: Puffy upper eyelids are normal in Asians, and full-incision blepharoplasty is commonly performed to remove some orbital fat to ameliorate the problem, but not all patients would exhibit obvious improvement. Local retro-orbicularis oculus fat (ROOF) is a layer of fibrofatty soft tissue that lies much deep into the orbicularis oculi in the upper eyelid, which is an important factor in the formation of puffy upper eyelids. This study was carried out to evaluate the clinical application (including the evaluation of photographs for the thickness of upper eyelid) of upper blepharoplasty combined with ROOF resection for correcting puffy upper eyelids. Method: A total of 65 patients (5 males, 60 females) with puffy upper eyelids recruited from October 2015 to October 2016 were included in the study. Full-incision blepharoplasty combined with partial ROOF resection was performed on all patients. The thickness of soft tissue in the upper eyelid was measured by ultrasound biomicroscopy preoperatively and at 12 months postoperatively. Result: All patients underwent surgery successfully, and 62 patients (124 eyes) were followed up for 12-15 months (mean 13.8 ± 2.7 months). Before the surgery, the thickness of the ROOF was 0.35 ± 0.12 mm on the left and 0.42 ± 0.08 mm on the right. Twelve months postsurgery, the thickness of the ROOF was 0.18 ± 0.03 mm on the left and 0.20 ± 0.02 mm on the right. During the follow-up period, all patients were satisfied with the esthetic effect, and no severe postoperative complications were observed. Conclusion: Puffy upper eyelids can be corrected effectively by local ROOF resection in esthetic blepharoplasty.
... The smooth, full, three-dimensional shape created by the subcutaneous and deep fat pads characterizes the eyebrow. 12,13 This contour covers the orbital rim and extends variably into the eyelid space itself. By projecting the skin forward, the three dimensional volume essentially elevates the eyelid skin out of the orbital space in a similar way that a full balloon stretches and smoothes the rubber surface. ...
Article
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Background: The eyebrow region presents challenges for filling: the skin is thick, the three-dimensional anatomy is complex and there is a predisposition towards fat atrophy and skeletonization with aging. Hyaluronic acid gel fillers are well known for their use in the periorbital region. We report our long-term experience with eyebrow filling over a period of five years.Methods:Twenty cases of periorbital eyebrow filling with hyaluronic acid gel fillers were followed up over a period of five years. The eyebrow filling was customized based on the patient's anatomical features in a three-dimensional plane. Standardized photographs before and after the procedure in standard lighting conditions were evaluated.Results:Hyaluronic acid gel fillers were tolerated well in the eyebrow region. There were no cases with blue-gray dyschromia or prolonged edema as is the case with lower eyelid injections. The eyebrow gained volume and looked fuller immediately after the injection. There were three cases with excessive eyebrow puffiness noted on a long-term follow-up which may be the accumulated filler weighing the eyebrow. No other adverse events were noted.Conclusion:The eyebrow anatomy is a complex three-dimensional structure. Deflation in the eyebrow area along with the superior sulcus occurs with aging. Filling the eyebrow with hyaluronic acid gel fillers is a useful tool in the armamentarium of the cosmetic facial surgeon and can be used in isolation in select patients or as an adjunct to surgical rehabilitation. We believe the fillers last longer and are well tolerated in the eyebrow region due to the complex anatomy specific to this region.
... Deep depots include sub-orbital, retro-orbital, and buccal adipose pads. Being important for facial reconstruction, they are detailed in plastic surgery literature (Aiache and Ramirez, 1995;Hwang et al., 2007;May et al., 1990;Stuzin et al., 1990). Superficial depots are numerous and distribute broadly under the facial skin. ...
Article
Adipose tissue depots can exist in close association with other organs, where they assume diverse, often non-traditional functions. In stem cell-rich skin, bone marrow, and mammary glands, adipocytes signal to and modulate organ regeneration and remodeling. Skin adipocytes and their progenitors signal to hair follicles, promoting epithelial stem cell quiescence and activation, respectively. Hair follicles signal back to adipocyte progenitors, inducing their expansion and regeneration, as in skin scars. In mammary glands and heart, adipocytes supply lipids to neighboring cells for nutritional and metabolic functions, respectively. Adipose depots adjacent to skeletal structures function to absorb mechanical shock. Adipose tissue near the surface of skin and intestine senses and responds to bacterial invasion, contributing to the body's innate immune barrier. As the recognition of diverse adipose depot functions increases, novel therapeutic approaches centered on tissue-specific adipocytes are likely to emerge for a range of cancers and regenerative, infectious, and autoimmune disorders.
... The vertical height of the eyebrow fibroadipose tissue is 1 to 1.5 cm superior to the orbital rim, approximately one third of the vertical orbital dimension. [15][16][17][18] In this study, sagittal HRU images were obtained along the midpupillary axis, with the ultrasound probe centered at 0.5 cm cephalad to the superior orbital rim. This section included layers of dermis fat, orbital orbicularis oculi muscle, ROOF, and the lateral corrugator muscles intercalated within the multiple galeal fat layers. ...
Article
Clinical, radiographic, and molecular studies have shown that patients with thyroid-associated orbitopathy exhibit volumetric expansion of eyebrow tissues. This clinicopathologic entity has been termed thyroid-associated periorbitopathy. The goal of this study was to determine whether high-resolution ultrasonography could be used to reliably quantify thyroid-associated periorbitopathy. Institutional review board approval was obtained. The internal case-control study consisted of 12 subjects with unilateral-asymmetric thyroid-associated orbitopathy. High-resolution ultrasonography using a 15-MHz probe (Logiq p6) was performed by a single operator. Measurements were obtained 0.5 cm cephalad to the superior orbital rim at the midpupillary sagittal level. For each subject and tissue layer thickness (total tissue, dermis fat, retro-orbicularis oculi fat), the measured values on the less affected side were subtracted from those on the more severely diseased side. Summary statistics were used to analyze results. High-resolution ultrasonography effectively demonstrated asymmetric expansion of total eyebrow tissue (p < 0.0001) and retro-orbicularis oculi fat (p = 0.0003). No significant difference in dermis fat thickness was found between the 2 sides (p = 0.2). Hertel exophthalmometry measurements were statistically different between the 2 sides (p = 0.002). This study demonstrates that high-resolution ultrasonography independently confirms previously published studies of retro-orbicularis oculi fat expansion in patients with thyroid-associated orbitopathy. Compared with CT, MRI, and tissue biopsy, high-resolution ultrasonography is a more practical and cost-effective way to quantify and track thyroid-associated periorbitopathy over time. With its potential for real-time tissue assessment, high-resolution ultrasonography may be best suited for future studies of the dynamic relationship between globe and periorbital structures.
... A thorough understanding of the anatomy of each region treated with HA is important and is especially crucial with these injections, as the septum may dip below the bony infraorbital margin. [86][87][88][89] Hyaluronic acid binds to water, 90,91 which may result in significant edema in the retroseptal soft tissues with only a tiny amount of misplaced filler. Good technique involves treating deep to the orbicularis muscle and orbitomalar septum and carefully approaching this area from below to avoid retroseptal injection 69,81 or injection anterior to the orbitomalar septum, 85 which may cause premalar edema. ...
Article
Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.
... 37,38 The distance from the skin to the fascia of the orbital part of orbicularis oculi muscle is about 5 mm, based on studies of the anatomy of the orbicularis muscle and surrounding tissue in two human cadavers at the Institute of Basic Medical Sciences, Department of Anatomy, University of Oslo, Norway ( Fig. 2), and literature research. [43][44][45] Location of the PPG probe on the orbital part of orbicularis oculi muscle in the test subjects was 15 mm beneath the lower lid on a vertical line intersecting the pupil when looking straight ahead. The probe was attached to the skin with medical adhesive tape and covered with black-colored adhesive tape to avoid stray light from the glare source. ...
Article
Eye strain during visually demanding computer work may include glare and increased squinting. The latter may be related to elevated tension in the orbicularis oculi muscle and development of muscle pain. The aim of the study was to investigate the development of discomfort symptoms in relation to muscle activity and muscle blood flow in the orbicularis oculi muscle during computer work with visual strain. A group of healthy young adults with normal vision was randomly selected. Eye-related symptoms were recorded during a 2-h working session on a laptop. The participants were exposed to visual stressors such as glare and small font. Muscle load and blood flow were measured by electromyography and photoplethysmography, respectively. During 2 h of visually demanding computer work, there was a significant increase in the following symptoms: eye-related pain and tiredness, blurred vision, itchiness, gritty eyes, photophobia, dry eyes, and tearing eyes. Muscle load in orbicularis oculi was significantly increased above baseline and stable at 1 to 1.5% maximal voluntary contraction during the working sessions. Orbicularis oculi muscle blood flow increased significantly during the first part of the working sessions before returning to baseline. There were significant positive correlations between eye-related tiredness and orbicularis oculi muscle load and eye-related pain and muscle blood flow. Subjects who developed eye-related pain showed elevated orbicularis oculi muscle blood flow during computer work, but no differences in muscle load, compared with subjects with minimal pain symptoms. Eyestrain during visually demanding computer work is related to the orbicularis oculi muscle. Muscle pain development during demanding, low-force exercise is associated with increased muscle blood flow, possible secondary to different muscle activity pattern, and/or increased mental stress level in subjects experiencing pain compared with subjects with minimal pain.
... [18][19][20][21] The vertical height of the eyebrow fibroadipose tissue is 1 to 1.5 cm superior to the orbital rim-approximately one-third of the vertical orbital dimension. 22 In our study, we defined the cephalad extension as a horizontal plane 0.5 cm from the supraorbital notch, with its lateral projection at an adequately higher level from the rim to contain the entire ROOF structure. This compartment included the orbital component of the orbicularis oculi, frontalis, and the lateral corrugator muscles embedded in the multiple galeal layers. ...
Article
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The eyebrows and eyebrow fat pads, key structures in upper facial aesthetics, are particularly vulnerable to age-related changes. In this study, the authors compare the impact of aging on the eyebrows and eyebrow fat pad volume in men and women through three-dimensional (3D) volumetric analysis. Electronic medical records of patients seen at the Jules Stein Eye Institute in the Division of Orbital and Ophthalmic Plastic Surgery between 2005 and 2010 were reviewed. Patients were included if they had undergone investigative imaging of the orbit for unilateral pathology. Computed tomography (CT) scans of patients with Graves disease diagnosis, extensive orbital trauma, and/or previous eyebrow surgery were excluded. A total of 52 CT scans (24 men and 28 women) were retained for analysis. A 3D reconstruction software was used to analyze the scans and calculate volumes of the retroorbicularis oculi fat (ROOF), galeal fat (ROOF and subcutaneous fat), and soft tissue muscles. Galeal and brow fat volumes showed a significant positive trend toward enlargement in women (P values of .01 and .05, respectively). Although men showed a tendency toward fat enlargement with age, this was not statistically significant. Soft tissue-muscle volume decreased significantly in aging women (9.32 mm(3)/y) (P = .02). Data indicated that soft tissue volume in men tended to increase with age (3.92 mm(3)/y) but not significantly (P = .36). Neither total volume nor brow thickness appeared to change significantly in women (P = .56, P = .73). In men, total volume and brow thickness showed weak evidence of increasing with age (P = .12, P = .22). Linear regressions of Hertel measurements with and without sex interaction showed no statistically significant trend between the amount of proptosis and the galeal or brow fat. Although overall eyebrow volume does not change with age, the relative contribution of fat and soft tissue to the total volume does seem to change. This pattern also differs between males and females. As women age, the fat volume increases and the soft tissue volume decreases. In men, the shift from soft tissue volume to fat volume is less pronounced. Although many clinicians have been drawn to the concept of fat volume deflation as a key element of facial aging, this study does not support this perspective in the eyebrow fat pad. An increasingly refined understanding of the dynamics of facial aging is mandatory for clinical diagnosis and will likely provide the framework from which to develop more innovative treatment options.
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It is crucial for a facelift surgeon to have a comprehensive understanding of ageing-related changes on the volume, elasticity, and relative position of various facial tissues and layers. These changes lead to an alteration in the surface topography, contour, and ultimately shape of the face. The depressions and sagging of tissues created as a result of ageing then has a bearing on one's perceived age. This article describes the various layers of the face and neck affected by ageing. The fat compartments, superficial musculoaponeurotic system (SMAS), potential facial spaces, facial ligaments, and facial nerve are discussed in detail. Safe and effective execution of facelift requires a thorough understanding of the intricate relationship between the various layers of face and neck, in particular the path of facial nerve, as it negotiates between these layers. The emphasis of this article is on integrating this knowledge to generate practical tips for safe dissection, effective tissue movement, and repositioning during various type of facelift procedures.
Article
Background The ageing in the mid-face involves volume deficiency in multiple anatomical units, including the zygomatic arch, infraorbital region, medial and lateral cheek and nasolabial fold (NLF). Hyaluronic acid (HA) is extensively used in the minimally invasive procedures of mid-face rejuvenation. ObjectivesMD CodesTM is proposed to perform combined treatment of multiple sites to reduce treatment variability and increase clinician success rates. Although the detailed procedure of this technique, aesthetic effects and complications have been disclosed, its anatomical information has yet to be discussed. This paper elaborated on the static and dynamic anatomical characteristics of MD CodesTM through cadaveric dissection and ultrasound imaging.Methods Anatomical dissection and ultrasound imaging help us look back on the injection methods and anatomical principles of MD CodesTM.ResultsThe treatment is threefold: (1) the bolus injections, for lifting purposes, are performed at the most depressing point along the zygomatic arch, zygomatic eminence, the prominent optimal point in the zygomatic region, the most depressed point of upper NLF with 0.2–0.3 ml HA. (2) The linear injections, featuring facial contouring refinement, are performed at the deep fat pad of the medial cheek and infraorbital region with 0.4 ml HA. (3) The linear injections, featuring volume replacement, are performed at the subcutaneous fat layer of lateral cheek and NLF with 0.8 and 0.4 ml HA.ConclusionsMD CodeTM is led by the principle of “less dosage and better effect”, and a special injection sequence is formulated based on the anatomical characteristics. Ultrasound is a useful tool to make for a dynamic anatomical understanding of MD CodeTM and visualize the anatomical information such as layers and thicknesses.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Article
The lower eyelid tear trough deformity is a common cosmetic concern which is the result of multiple anatomic changes in the lower eyelid, usually resulting from age. A sound understanding of the underlying anatomy is vital to inform surgeons about the ideal treatment options for rejuvenation of this region and to minimize the risk of complications. Cadaveric studies provide unique insight into underlying anatomic changes. Here we review the relevant published cadaveric studies relating to the tear trough deformity and its treatment.
Chapter
Fat graft to correct deflation occurring with aging has become a workhorse in the modern facial rejuvenation. Fat can be grafted in particles of different sizes according to each specific indication. Generally speaking bigger fat lobules are used to increase or reconstruct deep fat compartments while smaller grafts, as micro graft, are indicated for the treatment of the more superficial ones. Presence of ADSC from the stromal vascular fraction (SVF) increases the taking of the graft and also improves the quality of the skin. Even if the use of sharp needle to inject the fat has been described blunt cannula are preferred for the injection due to their higher safety especially in terms of prevention of embolism. The specific indications for each fat compartment are presented and the possible complications are listed at the end of the chapter.KeywordsAgingFat graftAnatomyRejuvenationMicrograftStem cellCannulaAdipocyteSoft tissue-fat compartments
Article
Background: In East Asians, a common method to ameliorate puffy eyelids is to resect excess orbital fat and the orbicularis. However, in some patients satisfactory improvement cannot be achieved, owing to thick submuscular fibroadipose tissue (SMFAT) and minimal orbital fat. The SMFAT lies between the orbicularis and the orbital septum and can also be found in the pretarsal area. It is responsible for puffy eyelids and slackening of the tissue post-removal. In this study, we combined extended SMFAT resection with the ladder suture technique to correct puffy SMFAT eyelids. Method: 76 patients with thick SMFAT and minimal orbital fat were recruited. The thick SMFAT, which included the soft tissue near the artificial fold and the pretarsal area soft tissue, was resected. The ladder suture technique was performed by positioning the stitch 1mm below the orbicularis margin after skin flap margin puncture. The aesthetic effect was evaluated preoperatively and at 12 months postoperatively. Results: The pre-operative thickness of the SMFAT and full- layers of the eyelid were 0.27 ± 0.03 mm and 2.01 ± 0.11 mm, respectively. One year post-surgery, the thickness was 0.08 ± 0.02 mm and 1.68 ± 0.14 mm, respectively (p < 0.05). The post-operative upper eyelash lift-up angle and the eyelash exposure length were significantly increased on both sides compared to pre-surgery (p < 0.05). No patients experienced complications. Conclusion: Extended SMFAT resection combined with the ladder suture technique can effectively correct puffy SMFAT eyelid without complications.
Article
Background: Novel imaging methods have provided new insights into the layered anatomy of the forehead. This study seeks to critically reevaluate the layered anatomy of the forehead by using ultrasound imaging and cadaveric dissection to provide an accurate anatomical description that can be used to guide safer surgical and minimally invasive frontal procedures. Methods: This study used ultrasound imaging in a sample of 20 volunteers (12 female and eight male volunteers; aged 35.25 ± 4.2 years; body mass index, 24.28 ± 3.5 kg/m2) and cadaveric dissections of 16 body donors (12 female and four male body donors; aged 72.76 ± 9.5 years) to reevaluate the layered anatomy of the forehead. Layer-by-layer dissections and ultrasound-based measurements of the frontal structures guided conclusions. Results: The following layered arrangement was identified: layer 1, skin; layer 2, superficial fatty layer; layer 3, suprafrontalis fascia; layer 4, orbicularis oculi and frontalis muscle (same plane); layer 5, a homogenous layer of fat [preseptal fat (in the upper eyelid), retro-orbicularis fat (deep to the orbicularis oculi muscle), and retro-frontalis fat (deep to the frontalis muscle); layer 6, subfrontalis fascia; layer 7, preperiosteal fat within the prefrontal space in the lower forehead and deep compartments in the upper forehead; and layer 8, periosteum. Conclusions: The results of this study add to the current understanding of the layered arrangement of the forehead. The combination of ultrasound imaging and cadaveric dissections provided evidence for a continuous fatty layer deep to the frontalis muscle.
Article
Background : Many people are characterised by a swollen appearance and loose skin of upper eyelids, especially Asians. Retro-orbicularis oculus fat (ROOF) lying in the lateral canthus area is a critical factor of the bulkiness formation. Although several approaches have been reported, most of them intend to remove orbicularis muscle and preaponeurotic fat through a double-eyelid incision, leaving ROOF untreated. Consequently, an unnatural eyelid fold is formed and the lateral supraorbital region remains bloated. Methods : 67 patients underwent sub-brow skin excision combined with ROOF resection. The key point was to excise the loose skin and thick ROOF through an incision along with the lower 1/3 of the eyebrow. Surgical outcomes were evaluated 6 months postoperatively by the heights of the designed line from the palpebral margin to the pupil center (HPPC), medial cornea (HPMC) and lateral canthus (HPLC). The pinch test, photographs and complications were also recorded. Results : The preoperative average HPPC, HPMC and HPLC were 9.68 ± 1.73, 7.68 ± 1.24 and 6.82 ± 1.12 mm while the postoperative average measurements were 7.25 ± 0.51, 5.99 ± 0.54 and 5.54 ± 0.61 mm, respectively. The result of pinch test was improved and postoperative scarring was unconspicuous. Two patients had transient numbness in the eyebrow region that subsided within seven days. Two patients had slight asymmetry of eyebrow position but did not need a second operation. Conclusions : Sub-brow skin excision combined with ROOF resection is an effective technique for improving upper eyelid bulkiness and skin excess with low revision rates.
Article
Objective: This study aims to analyze the anatomical location and continuation between the retro-orbicularis oculi fat (ROOF) and sub-superficial musculoaponeurotic system fat (subSMAS fat; named "innominate fascia") by comparing their layered structures, thereby letting us suggest a safe minimally invasive procedure guideline for the forehead and temple. Methods: Ultrasonographic scanning was performed from the upper medial eyebrow to the lateral side of the superior temporal line in 109 volunteers. Hematoxylin and eosin staining was performed on five specimens at the same area as ultrasonographic scanning. Then, four embalmed cadavers were dissected from the orbicularis oculi, frontalis muscle, superficial temporal fascia, and SMAS to confirm the location and continuation pattern of the ROOF and subSMAS fat. Results: On ultrasonography and histological images, there was a continuous fatty layer from the ROOF to the subSMAS fat. When dissecting, the ROOF, which was located deep below the frontalis muscle, also continued to the subSMAS fat, passing through the superior temporal line in the upper temporal region. Conclusions: This study confirmed that the subSMAS fat is an anatomical fat structure that is continuous with the ROOF. Since the subSMAS fat layer is known as a less vascular area, it is considered a safer layer to avoid serious complications, and injecting accurately into the subSMAS fat layer has been a goal of clinicians. Based on this study, a cannula will safely approach the subSMAS fat through the ROOF injection that named "forehead-downward approach."
Article
Objective The authors sought to determine the efficacy of periumbilical fat block grafting to the orbital retro-orbicularis oculi fat (ROOF) layer to correct sunken-upper eyelids in Asians. Methods All patients complained about upper-eyelid hollowness and a variety of deformities. Invasive double-eyelid procedures were performed, and periumbilical fat blocks were grafted for these patients. The core procedure of this approach was to make a separation between the orbicularis oculi muscle and septum to expose the retro-orbicularis oculi fat (ROOF) and fixate the fat grafts to the desired region of ROOF.ResultsFrom February 2018 to October 2019, the novel technique was performed on 38 Chinese patients (76 eyes) in our department. After follow-up of 6–15 months, 35 patients (92%) showed satisfactory aesthetic results with approximately 20–40% fat absorption rate. No cases required a second procedure. Periumbilical scars remained hidden within the umbilicus area.Conclusions Periumbilical fat grafting in the ROOF of the sunken upper eyelid can both fill the depression and help correct over-wide double eyelid.EBM Level IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Article
Purpose: To compare the thickness of the retro- and sub-orbicularis oculi fat (ROOF and SOOF) between patients with thyroid eye disease (TED) and controls via MRI and to determine factors influencing fat thickness. Methods: This retrospective, comparative, case-control study included 136 patients (272 sides) with TED and 50 control patients (50 sides). The thickness of the ROOF and SOOF was measured on the quasi-sagittal plane through the optic nerve (the central plane) and 6 mm lateral and medial to the central plane at the level through the superior orbital rim and at the level just below the orbital septum in the lower eyelid, respectively. Results: The ROOF and SOOF were thickest on the lateral plane (p < 0.050; Tukey Kramer post hoc test) and were significantly thicker in patients with TED than controls on all planes (p < 0.050; Student t test). Multivariate stepwise analysis showed that age, sex, clinical activity score, Hertel exophthalmometric values, and number of enlarged extraocular muscles are significant predictors of the ROOF and SOOF thickness in patients with TED (p < 0.050). Conclusions: Patients with TED had thicker ROOF and SOOF on all planes than controls with various factors influencing the thickness. These results may be helpful in planning rehabilitative blepharoplasty with removal of the ROOF and SOOF for correction of eyelid fullness in TED.
Article
We read with great interest the article titled “Anatomical Study and Clinical Observation of Retro-orbicularis Oculi Fat (ROOF)” by Xian Wang and Haiping Wang. Our aim with this comment is to contribute to a more precise nomenclature of any correction of lateral hooding of the brow. We believe both a ROOF lift and reverse browpexy or transblepharoplasty browpexy are not just two different techniques for the same purpose, they are also techniques based on two different concepts. As treatments should be cause-based, each of these procedures could be performed independently, or in combination, depending on the specific anatomical requirements for an optimal result.
Article
Objective To study the anatomical location of retro-orbicularis oculi fat (ROOF) in the upper eyelid and to investigate how ROOF affects the appearance of the upper eyelid. Methods Twenty-eight Chinese hemifacial cadaver specimens were used (14 male cadavers; age range 52–82 years). In 28 hemifaces, the eyelids were dissected from the superficial to deep layers, and the appearance, location, extent, and surrounding tissue of ROOF were observed. Additionally, we observed the relationship between the upper eyelid morphology and ROOF of the upper eyelid in surgical patients who were treated in the plastic surgery department of Tongji Hospital affiliated with Huazhong University of Science and Technology in 2018. Results ROOF is a type of fascia adipose tissue that is located in a fat compartment between the muscles (the orbicularis oculi and frontalis muscles) and the orbital septum/frontalis fascia. In patients with hypertrophic ROOF, the upper eyelid appears as a heavy eyelid and as a drooping eyelid. And in patients with atrophic ROOF, the upper eyelid appears as a sunken eyelid. Conclusion ROOF is located in the fat compartment between the orbicularis muscle and the orbital septum/frontalis fascia. ROOF covers the entire upper eyelid and appears thinner medially and thicker laterally. It is continuous with the fat under the frontalis muscle and affects the appearance of the upper eyelid. It represents an important factor in upper eyelid surgery. No Level Assigned This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Article
Background: The midface is an area of high demand for minimally invasive cosmetic procedures, that is, soft-tissue filler injections. Objective: To investigate the functional anatomy behind the facial overfilled syndrome observed after soft-tissue filler injections. Materials and methods: The clinical part of the study enrolled 25 volunteers (12 men and 13 women, Caucasians); the anatomical part included 72 fresh frozen cephalic specimens obtained from 32 male and 40 female body donors. 3D surface scanning procedures were applied to calculate the maximal anterior projection of the midface. Results: Upon smiling, the point of maximal anterior projection shifted cranially in men by 12.43 ± 8.8 mm (difference between resting and smiling; p < .001) and by 8.75 ± 4.1 mm in women (p < .001). Cadaveric dissections identified a septum originated from the underside of the zygomaticus major muscle forming a transversely running boundary between the buccal space and the deep midfacial fat compartments. Conclusion: Facial overfilled syndrome can potentially be explained by the presence of the transverse facial septum. Dynamic filling-injecting small amounts of filler and asking the patient to smile repeatedly during the procedure-seems to be a viable way to avoid this adverse event during soft-tissue filler injection.
Article
Purpose: To investigate periorbital tissue enlargement in thyroid eye disease (TED) by 3-dimensional CT volumetric analysis. Methods: Twenty-four adult subjects, 16 with TED and 8 controls, were studied. Three-dimensional volumetric calculations were performed on CT imaging of the orbit and face, focusing on the retroorbicularis oculi fat, suborbicularis oculi fat, facial muscles in periorbital region, orbital fat, extraocular muscles, and orbital volume. Analysis was performed using JMP version 12 software. Each measure was compared between the TED and control groups using Wilcoxon rank sum test. Correlations were investigated between periorbital and orbital tissue using the Spearman's correlation coefficient method. Results: A statistically significant increase in volume was measured in TED patients in the superior and inferior periorbital fat tissue (p = 0.0044, p = 0.047), including the retroorbicularis oculi fat (p = 0.0011), suborbicularis oculi fat (p = 0.0093), and a decrease in facial muscle of superior periorbital region (p = 0.035). Strong positive correlation was noted between the muscles of superior and inferior periorbital region (rs = 0.65; p = 0.0006), and between the suborbicularis oculi fat and retroorbicularis oculi fat (rs = 0.50; p = 0.013). No correlation was observed between orbital and periorbital tissue, except between the orbital fat and the inferior periorbital fat tissue (p = 0.047). Conclusions: Facial fat in the periorbital region is enlarged in TED, with the superior component correlating with orbital fat tissue expansion. These findings may assist in the clinical evaluation and management of disfigurement in TED patients.
Chapter
Alloplastic augmentation of the midface and periorbital region remains the most suitable form of correction of skeletal defects. The solid, pliable, biocompatible nature of modern alloplastic synthetic implants offers a superior tool in the correction of facial deformities originating from skeletal bony insufficiency. Within the realm of the midface and periorbit, facial deformities are typically encountered stemming from maxillary hypoplasia. Malar augmentation, tear trough correction, and submalar and temporal fossa augmentation are all potential applications of alloplastic implants in facial contouring. In this chapter, we review the pertinent facial anatomy, modern implant material types, and the applications of alloplastic implants in the treatment of common midfacial deformities.
Article
Purpose: To quantify the complete dimensions of the retro-orbicularis oculi fat (ROOF) pad and to determine its relationship to other fat compartments of the forehead. Methods: The entire forehead of 14 hemifaces of seven fresh frozen human cadavers (four female, three male) was dissected in the subcutaneous and submuscular planes. For each plane, a ruler was placed at the facial midline, and images of the dissection plane were taken at 90° and 45°. Images were analyzed for vertical height, horizontal length, the distance to midline from the point of maximal height, and area for each hemiface of the ROOF and for the entire fat compartment contiguous with the ROOF. A two-tailed t test was conducted between ROOF and ROOF plus the extended fat plane across all measurements. A Wilcoxon nonparametric signed rank test was performed to determine equivalent fat distribution of the extended fat plane over each cadaver's respective eye. Results: The deep fat originating from the ROOF consistently extended laterally and superiorly in each specimen, distinctly separated via septae from the deep central, deep lateral, and the deep temporal fat compartments. The color, composition, and distribution of this contiguous deep fat did not differ phenotypically from the traditional ROOF. The extended deep fat plane possessed an average vertical height of 3.09 ± 0.68 cm, average distance to midline from point of maximal height of 3.56 ± 0.53 cm, an average horizontal length of 5.37 ± 0.82 cm, and an average area of 13.40 ± 2.69 cm. The extended deep fat demonstrated a statistically significant increase in maximal height, length, and total area compared with the ROOF. A Wilcoxon nonparametric signed rank test was nonsignificant (α = 0.01) across all measurements, demonstrating that the extended fat plane was similarly distributed over each eye. Conclusions: A layer of deep fat originating from the traditionally defined ROOF extends superiorly and laterally beneath the frontalis muscle, separate from the deep lateral, deep central, and deep temporal fat pads. This is the first study to clearly demonstrate a contiguous superficial musculoaponeurotic system layer of fat extending under both the orbicularis oculi and frontalis muscles. This plane of fat is more appropriately described as the retro-orbicularis oculi and frontalis fat.
Article
The goal of lower eyelid blepharoplasty is to rejuvenate the lower lid while maintaining a natural, unoperated appearance. Successful lower eyelid blepharoplasty depends on knowledge of the anatomy and surgical techniques, accurate preoperative analysis, and attention to detail. Common issues of the lower eyelid such as malar descent, tear trough deformity, pseudoherniated fat, lid laxity, and skin texture changes as well as dermatochalasis and festoons must be recognized. Specific techniques to address these include transcutaneous and transconjunctival approaches, fat excision, fat transposition, orbicularis suspension, lateral canthal tightening, malar suspension, and skin excision/resurfacing.
Chapter
The forehead could be considered as the hairless frontal elongation of the scalp. Being an anatomical continuity of the scalp, it consists of the same five distinct layers: the skin, connective subcutaneous tissue, galea aponeurotica, loose areolar connective tissue, and periosteum. The forehead arterial system consists of a latticework of anastomoses supplied from the supraorbital and the supratrochlear arteries and the frontal branches of the superficial temporal vessels. Additionally, the dorsal nasal artery contributes to the blood supply of the mid-forehead area. The forehead constitutes a wide donor site of flap material that can be harvested in great quantity. Flaps derived from the forehead can be used in closing its own defects, but the forehead is also the ideal donor site of regional flaps in order to reconstruct medium and large nasal defects.
Chapter
The cheek constitutes the face’s largest anatomic and aesthetic unit. The soft tissues and the fasciae of the cheek are arranged concentrically over its bony skeleton. From an anatomic and surgical point of view, these structures are layered as follows: skin, subcutaneous tissue, musculoaponeurotic layer (SMAS-mimic muscles), parotidomasseteric fascia, buccal space and contents, deep muscular layer, and retaining ligaments. Surgically important nerves and vessels travel through these layers often changing planes. All types of local flaps can be derived from the cheeks providing a wide range of restoration options. Random pattern advancement, transposition, and rotation flaps work well in this region and are used to reconstruct primarily the cheek itself, but also the nearby nose, lips, and lower lid.
Article
Purpose: To examine with histology the anatomical location of hyaluronic acid gel injected to the eyebrow of cadaver specimens. Methods: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the eyebrow. Following tissue fixation, full-thickness soft-tissue sections were obtained followed by histologic examination. Results: Histologic examination revealed the location of hyaluronic acid gel at the intended preperiosteal plane in all 5 specimens. Very dense retro-orbicularis oculi fat septa appeared to limit the anterior displacement of filler in each specimen. Conclusions: This study provides a greater understanding of the anatomical barriers and boundaries that help to determine, in part, the anatomical position of hyaluronic acid gel when injected to the preperiosteal eyebrow. The high degree of histologically confirmed consistency of product location of eyebrow injections noted in this study stands in contrast to the variability of position of gel injected in the infraorbital hollows.
Article
The transeyelid approach to midface lift is an elegant approach for mild descent of malar soft tissue. The subciliary approach is the most commonly used and technically less challenging for surgeons experienced in facelift techniques. This technique in midface rejuvenation also has the advantage of ease of combining with other periocular and mid and upper face rejuvenation, such as blepharoplasty and forehead lift. Complication is rare with lid malposition, scaring, and temporary nerve function impairment being the most common. This article describes midface surgical elevation techniques. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
Understanding the anatomy and distribution of facial fat and the alterations that occur during the aging process is essential to effectively and precisely achieve facial rejuvenation. Over the past several years, through cadaveric dissections and computed tomographic studies, much has been discovered concerning the adipose tissue of the face and how it influences the dynamic process of aging. Site-specific augmentation with fillers can now be used to refine facial shape and topography in a more predictable and precise fashion. The purpose of this article is to provide an introduction to facial fat compartmentalization along with clinical examples to illustrate how the knowledge of underlying anatomy influences site-specific augmentation.
Article
The tear trough and palpebromalar groove are of increasing interest to plastic surgeons, but their mechanisms of formation remain unclear. This study evaluated the anatomical foundation for tear trough and palpebromalar groove. Sagittal dissection and layered dissection were performed on 20 elderly cadaveric hemifaces with obvious tear troughs and palpebromalar grooves and on 16 young cadaveric hemifaces without obvious tear troughs and palpebromalar grooves. Cross-sectional specimens and tissue sections were compared between the two groups to identify the differences. The malar fat pad becomes atrophic and descends with aging. The orbicularis retaining ligament arose from the inferior orbital rim and ended at the junction of palpebral and orbital portions of the orbicularis oculi muscle. The ligament limited the descent of the orbicularis oculi muscle. The orbicularis retaining ligament continued with the origin of the orbicularis oculi muscle and the dense muscular attachment arose from the maxilla. Histologic evaluation confirmed the ligamentous features of the orbicularis retaining ligament. The orbicularis retaining ligament plays an important role in formation of the tear trough, and atrophy and descent of the malar fat pad make the tear trough and palpebromalar groove more obvious with aging. These findings may be of value in blepharoplasty and midfacial rejuvenation.
Article
: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens. : The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains. : Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel. : In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.
Article
Objectives: To report photographic evidence of eyebrow tissue expansion in patients with thyroid-associated orbitopathy (TAO) and to demonstrate consistency in grading through the use of standardized photographs. Methods: A retrospective cohort study of patients referred for evaluation of TAO in an orbitofacial tertiary care center between January 1, 2000, and December 31, 2010. A grading key was produced with representative views of each of 4 grades (0 [no expansion] to 3 [severe expansion]), corresponding to increasing severity of eyebrow tissue expansion. Photographs of each study patient, including both premorbid and morbid photographs, were retrieved from an electronic medical record system and graded by 6 independent, masked observers using this 4-point system. Results: Seventy-five patients with TAO were identified for inclusion. The average grade was 0.3 for premorbid eyes and 1.1 for morbid eyes. Intraclass correlation coefficients for the premorbid photographs were 0.705 and 0.632 for the right and left eyes, respectively. Intraclass correlation coefficients for the morbid photographs were 0.921 and 0.916 for the right and left eyes, respectively. Conclusions: Eyebrow tissue expansion is a common manifestation in TAO. Comparison of premorbid and morbid photographs is a useful means to identify and characterize the extent of brow involvement. The use of a grading key improves the consistency of identifying and grading eyebrow tissue expansion. Recognition of the eyebrow tissue as distinct anatomically in TAO may be crucial to rehabilitation of these patients, which may entail multiple surgical procedures.
Article
Despite the importance of anatomic variations in the muscular bands around the orbicularis oculi muscle (OOc), little is known about them. The morphology and variations therein of the medial muscular band of the OOc were thus examined in the current study. Sixty-one hemifaces of Korean cadavers were dissected to enable examination of the anatomic organization of the muscles around the OOc. A medial muscular band of the OOc was observed in 40 cases (65.6%). Three patterns of attachment were found. In type A (14 cases, 23%), it attached to the frontal belly without being attached to the medial canthal tendon; in type B (14 cases, 23%), it originated from the medial canthal tendon at the lower portion of the OOc and inserted into the cheek skin, and in type C (12 cases, 19.7%), it was also observed to insert into the cheek skin and attach to the frontal belly without being attached to the medial canthal tendon. The distance between the inferior edge of the OOc and the subnasale was 16.3 (SD, 4.3) mm and 14.5 (SD, 4.4) mm in cases with and without a medial muscular band, respectively. A space was observed on the inferolateral side of the OOc in about 67.2% of cases. These findings regarding the medial muscular band of the OOc increase further the anatomic variations associated with this region. In addition, it appears that this medial muscular band of the OOc can help to prevent drooping of the OOc.
Article
The aim of this study was to examine in detail the anatomic variations in the orbicularis oculi muscle (OOc) and relationship of the zygomaticus minor muscle (ZMi) with the OOc, thereby providing an anatomic basis for explaining facial animation and attachment to the periorbital muscle. Sixty-one hemifaces from embalmed Korean adult cadavers (34 males, 27 females; age range, 45-85 years; mean age, 62.6 years) were used in this study. The prevalence of cases in which the ZMi did not run straight from the upper lip, rather running straight to the corner of the levator labii superioris, was 36.1% (22/61), because the origin of ZMi covered the inferior border of the OOc. The prevalence of mixing of the belly of the orbital part of the outer edge of the OOc with the ZMi was 88.5%, and that of blending of the ZMi band into the lower inner corner of the OOc was 55.7%. The area of blending of the OOc and ZMi was located 17.8 mm down from the Frankfort plane and 8.9 mm lateral to the vertical line between the lateral canthus and the Frankfort plane in the lateral part of the OOc. At this position, the mixed belly extends medially for a distance of 16 mm. This research has identified the exact location where the ZMi and OOc blend and determined the relationship between the ZMi and the suborbicularis oculi fat. This result will be given as basic data for understanding facial expressions and for performing composite rhytidectomy.
Article
The restoration of a natural volume distribution is a major goal in facial rejuvenation. The aims of this study were to establish a radiographic method enabling effective measurements of the midfacial fat compartments and to compare the anatomy between human cadavers of younger versus older age. Data from computed tomographic scans of 12 nonfixed cadaver heads, divided into two age groups (group 1, 54 to 75 years, n = 6; and group 2, 75 to 104 years, n = 6), were analyzed. For evaluation of the volume distribution within a specific compartment, the sagittal diameter of the upper, middle, and lower thirds of each compartment was determined. For evaluation of a "sagging" of the compartments, the distance between the cephalad border and the infraorbital rim was determined. Computed tomography enables a reproducible depiction of the facial fat compartments and reveals aging changes. The distance between the fat compartments and the infraorbital rim was higher in group 2 compared with group 1. The sagittal diameter of the lower third of the compartments was higher, and the sagittal diameter of the upper third was smaller in group 2 compared with group 1. The buccal extension of the buccal fat pad was shown to be an independent, separate compartment. This study demonstrates an inferior migration of the midfacial fat compartments and an inferior volume shift within the compartments during aging. Additional distinct compartment-specific changes (e.g., volume loss of the deep medial cheek fat and buccal extension of the buccal fat pad) contribute to the appearance of the aged face.
Article
"Sunken eyelid" is a term used to describe a deeply sunken area between the upper eyelid and upper edge of the orbital bone. The condition frequently is accompanied by blepharoptosis. Correction of a "sunken eyelid" generally is performed with a fat graft. However, surgical limitations such as a movement dysfunction of the upper eyelid or irregular skin surface often are encountered using the grafting method previously reported. An open technique is believed to be more precise than a closed procedure, and satisfactory results may be achieved by repositioning the upper eyelid fat and applying a fat graft to the retro-orbicularis orbital fat (ROOF). Fat was harvested from the medial thigh area using a 10-ml syringe with minimal pressure. During the upper eyelid surgery, the orbital fat was relocated between the conjoined tendon of the levator aponeurosis and the lower orbicularis oculi muscle and skin flap. The ROOF was verified, and fat grafting then was performed from the upper medial side to the lower lateral side and from the medial aspect to the lateral direction using an 18-gauge Coleman needle. The sunken eyelids were classified into grades 1 to 4 according to the sunken depth (i.e., the distance between the most inferior orbital rim and the site of the most sunken area). The amount of fat graft and the technique of incorporating the fat were different according to sunken depth. From January 2006 to June 2008, 50 Korean and Chinese patients (48 women and 2 men) underwent fat repositioning and ROOF fat grafting using an open technique. The patients ranged in age from 24 to 67 years. The mean observation period was 4.7 months. The amount of fat graft for each palpebra was 0.3 to 3.3 ml, and the mean graft amount was 1.4 ml. Satisfactory results were obtained for most of the patients, but four patients required additional surgery. The reasons for the secondary surgery were a translocation of the fat graft to a lower position forming a lump (2 patients) and undercorrection (2 patients). The rate of fat absorption was relatively low and the complications very few compared with surgical cases involving a noninvasive method. More precise treatment is possible by dividing the depressed area of the upper eyelid according to the stage. Satisfactory results were achieved by relocating the orbital fat using an open method and adjusting the ROOF fat graft according to the stage.
Article
Periorbital rejuvenation has increasingly relied on augmentation with fillers. Numerous techniques have been described, including augmentation of the sub-orbicularis oculi fat. Cadaver studies initiated 2 years ago yielded presumptive evidence that sub-orbicularis oculi fat consists of two distinct regions. Knowledge of this anatomy is important for precision in facial rejuvenation. A pilot study was performed with radiopaque dye injection into the sub-orbicularis oculi fat and computed tomographic evaluation with three-dimensional reconstruction. Eight hemifacial fresh cadaver dissections were then performed with a modified dye injection technique to isolate regions of sub-orbicularis oculi fat and periorbital fat. The relationship of suborbicularis fat to deep cheek fat was observed. This study confirms the presence of two distinct regions of sub-orbicularis oculi fat. A medial component extends along the orbital rim from the medial limbus to the lateral canthus. A lateral component extends from the lateral canthus to the temporal fat pad. The lateral component terminated superiorly at the lateral orbital thickening. Deep cheek fat abutted the medial sub-orbicularis oculi fat, thus creating a deep fat system in continuity across the face of the maxilla and along the orbital rim. This anatomy helps to define midface adipose tissue as a system of superficial and deep fat, of which medial and lateral sub-orbicularis oculi fat are a part. A working hypothesis of facial aging continues with the concept that loss and/or ptosis of deep fat compartments leads to changes in shape and contour. Folds, in contrast, occur at transition points between thick and thinner superficial fat compartments. These anatomical observations further the goal of site-specific augmentation and facial rejuvenation.
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Sixty-three nonconsecutive patients have undergone resection of the retro-orbicularis oculus fat (ROOF) in conjunction with aesthetic blepharoplasty. In these patients, a consistent and useful ability to soften and flatten heaviness and bulkiness in the lateral upper orbital region was seen. Two patients developed postoperative hematoma, and two different patients had transient dry-eye symptoms following blepharoplasty. Twenty percent of patients had a transient degree of numbness in the lateral supraorbital nerve region, and all patients noted some transient numbness over the lateral upper brow region. No patient demonstrated significant paralysis of the orbicularis oculus or corrugator muscle. From this experience, retro-orbicularis oculus fat resection would appear to be a useful adjunct to standard blepharoplasty techniques in selected patients.
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Improvements have been made throughout the history of medicine, causing physicians to abandon a technique or medications clearly shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. Conventional lower eyelid procedures continue to include removal of orbital fat in most cases, and facelift procedures remain primarily a lateral vector pull. The unfortunate results of these traditional procedures are becoming easy to recognize. Optimal rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat, but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there still is wide disagreement among authors as to the best approach and surgical technique. This report describes a surgical technique for lower lid midfacial rejuvenation that is a composite of several previously published approaches with some modifications, particularly in the way the Sub-Superficial Musculo Aponeurotic System (SMAS) fat pad is plicated and the midfacial tissues suspended. The technique is simple and safe, resulting in a pleasing natural midface contour.
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After the concept of retro-orbicularis oculi fat had been developed, the authors focused in particular on the anatomic entity named suborbicularis oculi fat, consisting of the supraperiosteal submuscular fat excess situated over the zygoma. Its correction is demonstrated as well as its anatomic description and the fact that it contributes to the aesthetic deformity of the lower lids, just as the retro-orbicularis oculi fat contributes to the aesthetic deformity of the upper lids. The purpose of this paper is to study the upper and lower orbital areas, where a new approach is advocated for their correction in solo or in combination with a blepharoplasty.