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REVIEW ARTICLE

Lower Eyelid Anatomy


An Update
Hirohiko Kakizaki, MD, PhD,*†‡ Raman Malhotra, FRCOphth,† Simon N. Madge, MRCP, FRCOphth,‡
and Dinesh Selva, FRANZCO‡

associated with them (Figs. 1, 2).5 The CPH originates from the
Abstract: The gross anatomy of the lower eyelid is analogous to that of the
inferior rectus muscle fascia, wraps around the inferior oblique
upper eyelid, however, the lower eyelid has a more simplified structure with
muscle, and reaches Lockwood ligament. At this point, it becomes
less dynamic movement. Common malpositions of the lower eyelid include
known as the CPF, coursing forward to reach the lower margin of
entropion and ectropion, rehabilitative surgery of which requires a thorough
the tarsus and the subcutaneous tissue. In the region of the inferior
understanding of lower eyelid anatomy. Furthermore, precise anatomic
conjunctival fornix, some slips of smooth muscle fibers accompany
knowledge is a prerequisite for both reconstructive and cosmetic lower eyelid
surgery in order for it to be performed appropriately. In this review, we
the CPF anteriorly towards their insertion. Occasionally, the CPF
present the clinical anatomy of the structures of the lower eyelid, as well as
and the smooth muscle fibers together are known as the “inferior
highlighting relevant surgical implications. Featured here are the structure of tarsal muscle.”5 However, since the lower eyelid retractors have
the different eyelid lamellae, the lower eyelid retractors and their relations, until recently been considered a complex single layer,5 anatomic
the orbital septum, fat pad compartments, and Lockwood ligament. characterization of the inferior tarsal muscle was thus obscure.
The above model had until lately been believed to represent
Key Words: anatomy, lower eyelid, relevant tips, surgery the true anatomy of the lower eyelid retractors, however, recent
(Ann Plast Surg 2009;63: 344 –351) anatomic studies have shed new light on the true structure of the
lower eyelid retractors.6 In reality, the lower eyelid retractors com-
prise 2 layers (Figs. 1, 3). The posterior layer is the thicker of the 2,
includes the smooth muscle fibers described above and reaches
T he gross anatomy of the lower eyelid is analogous to that of the
upper eyelid,1 however, the lower eyelid has a more simplified
structure with less dynamic movement. Common malpositions of the
forward to the anterior, inferior, and posterior surface of the lower
tarsal plate. The main role of this posterior layer is to pull the lower
eyelid inferoposteriorly. The smooth muscle fibers here are not
lower eyelid include entropion and ectropion, rehabilitative surgery structures specific to the lower eyelid, but represent a portion of the
of which requires a thorough understanding of lower eyelid anat- smooth muscle fibers distributed around the globe.7 The anterior
omy. Furthermore, precise anatomic knowledge is a prerequisite for layer mainly comprises the anterior thin part of the CPF from
both reconstructive and cosmetic lower eyelid surgery in order for it Lockwood ligament. In addition, distal to the junction between the
to be performed appropriately. In this review, we present the clinical orbital septum and the CPF, extensional tissues from the orbital
anatomy of the structures of the lower eyelid, as well as highlighting septum and submuscular fascial tissue join the anterior layer. The
relevant tips for lower eyelid surgery. anterior layer does not attach to the inferior margin of the tarsus, but
reaches the subcutaneous tissue.8 These 2 layers are distinct layers
EYELID LAMELLAE and can thus be detached easily, using either blunt or sharp dissec-
The eyelid is divided into 3 lamellae: anterior, middle, and tions. Furthermore, the lower eyelid retractors have medial and
posterior (Fig. 1). The anterior lamella includes the skin and orbic- lateral horns, similar to those of the levator aponeurosis (observa-
ularis oculi muscle.2 The middle lamella is defined as the combina- tional finding). Although the lamina propria mucosae of the con-
tion of the orbital septum, orbital fat, and suborbicularis fibroadipose junctiva is conspicuous in the upper eyelid,9 it is difficult to discern
tissue.3,4 The posterior lamella includes the retractors, tarsal plate, such a lamina from the CPF in the lower eyelid.8
and conjunctiva.2 The movement of the lower eyelid margin and the movement
of the margin of the inferior oblique are similar.10 In other words,
LOWER EYELID RETRACTORS AND ITS RELATED the length of the CPF remains constant in downgaze, with the source
STRUCTURES of the stretch in the lower eyelid retractors lying in the CPH.10
The lower eyelid retractors, a component of the posterior The lower eyelid constitutes the free margin and its position
lamella of the lower eyelid,2 comprise the capsulopalpebral head is supported 3-dimensionally by the supporting tissues such as lower
(CPH), capsulopalpebral fascia (CPF), and the smooth muscle fibers eyelid retractors, medial and lateral canthal support mecha-
nisms.6,11,12 However, if involutional or other mechanical changes
occur to the supporting tissues, lower eyelid entropion or ectropion
Received July 19, 2008, and accepted for publication, after revision, August 30,
2008. can occur. As causative factors of such entities, upward or down-
From the *Department of Ophthalmology, Aichi Medical University, Nagakute, ward force vectors need to be considered. In involutional lower
Aichi,Japan; †Corneoplastic Unit and Eye Bank, Queen Victoria Hospital eyelid entropion, upward and forward force vectors rotate the lower
NHS Trust, East Grinstead, West Sussex RH19 3DZ, United Kingdom; and tarsal plate.13,14 This is a similar mechanism to the “postenucleation
‡South Australia Institute of Optholmology and Discipline of Optholmology
and Visual Sciences, University of Adelaide, South Australia, Australia. socket syndrome.”15 This mechanism tends to appear in Asian
Reprints: Hirohiko Kakizaki, MD, PhD, Department of Ophthalmology, Aichi populations because of its particular anatomy of the anterior projec-
Medical University, Nagakute, Aichi 480-1195, Japan. E-mail: cosme@ tion of the adipose tissue.13,14 On the other hand, in lower eyelid
d1.dion.ne.jp. ectropion, a downward force vector everts the lower eyelid margin.
Copyright © 2009 by Lippincott Williams & Wilkins
ISSN: 0148-7043/09/6303-0344 This mechanism tends to typically appear in Whites13,14 and is
DOI: 10.1097/SAP.0b013e31818c4b22 occasionally observed after lower eyelid blepharoplasty.16

344 | www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 63, Number 3, September 2009
Annals of Plastic Surgery • Volume 63, Number 3, September 2009 Anatomy of Lower Eyelid

FIGURE 1. Schema of the lower eyelid. The lower eyelid re-


tractors comprise double layers. The anterior layer is a coarse
FIGURE 3. Sagittal microscopic section of the lower eyelid.
connective tissue continuing from Lockwood ligament (LL),
See the legend of the Fig. 1. MR indicates muscle of Riolan;
and consists of the superficial part of the capsulopalpebral
SMFAT, submuscular fibroadipose tissue; OOM, orbicularis
fascia, the submuscular fibroadipose tissue and orbital sep-
oculi muscle; PL, posterior layer of the lower eyelid retrac-
tum. This layer extends to the anterior lamella of the lower
tors; AL, anterior layer of the lower eyelid retractors; LL,
eyelid. The posterior layer consists of dense fibers of the cap-
Lockwood ligament; IR, inferior rectus muscle; OR, the part
sulopalpebral fascia, including smooth muscle fibers. This
corresponding to the orbital rim; IO, inferior oblique muscle.
layer extends to the tarsus. MR indicates muscle of Riolan;
Bar ⫽ 2 mm.
OOM, orbicularis oculi muscle; SMFAT, submuscular fibroa-
dipose tissue; OS, orbital septum; LERA, lower eyelid retrac-
tor, anterior layer; LERP, lower eyelid retractor, posterior
layer; CPF, capsulopalpebral fascia; SMF, smooth muscle targeted in some forms of eyelid malposition surgery, the posterior
fiber; IOM, inferior oblique muscle; CPH, capsulopalpebral layer should always be sought. The lower eyelid retractors have
head; IRM, inferior rectus muscle. sometimes been considered difficult to identify and handle surgic-
ally.17 However, given that they are always to be found anterior to
the lower palpebral conjunctiva with a thickness similar to that of
the lower tarsal plate,8 identification and surgical handling of the
lower eyelid retractors is relatively facile.
In lower eyelid entropion surgery, or occasionally in ectro-
pion surgery in the absence of retraction, appropriate advancement
of the posterior layer provides an effective outcome.18 Although the
Jones’ et al entropion procedure19 targets the lower eyelid retractors,
it is a tucking procedure and thus may not always pick up the
posterior layer, leading to a slightly higher recurrence rate.18,20 In
addition, in a lower eyelid entropion surgery in Asian, removal of
the anteriorly projected adipose tissue may serve to mitigate the
upward and forward force vectors derived from this tissue.13,14
Although the degree of advancement required is not so great for
the correction of entropia and ectropia, much more significant advance-
ment is required in surgery for reverse ptosis.21 Reverse ptosis is a state
such that the lower eyelid is elevated upward as a result of, for example,
Horner syndrome, facial nerve palsy or enophthalmos,21,22 a condition
corresponding to upper eyelid ptosis.22
In lower eyelid retraction, or cicatricial lower eyelid entro-
pion, recession of the posterior layer of the retractors (as well as
FIGURE 2. Appearance of the lower eyelid retractors behind severing their horns) is a very effective manoeuvre to help address
the orbital septum. Reprinted with permission from Okajimas such entities.23 Simple retractor lysis without placement of a spacer,
Folia Anat Jpn. 2004;81:97–100. OS indicates orbital septum; however, is not efficacious in these conditions24 and spacers are
RE, recess of Eisler; Jun, junction between the orbital septum generally required to treat these malpositions. On the other hand,
and lower eyelid retractors; CPF, capsulopalpebral fascia; LL, retractor lysis may be an efficacious procedure when used as
Lockwood ligament; CPH, capsulopalpebral head; AE, arcuate prophylaxis against lower eyelid malposition following inferior
expansion; IL, inferior ligament; IO, inferior oblique muscle. rectus muscle recession4,25 or blepharoplasty.26 A transconjunctival
approach to the lower eyelid retractors is a good option because this
approach will always pick up the posterior retractor layer appropri-
Relevant Tips for Surgery ately without any particular technique.27–29
The main tractional component of the lower eyelid retractors In relation to the lower eyelid retractors, lower eyelid laxity
lies in the posterior layer.6 Thus, when the lower eyelid retactors are also needs to be considered. Lower eyelid laxity is comprised of

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Kakizaki et al Annals of Plastic Surgery • Volume 63, Number 3, September 2009

medial and lateral canthal laxities and the atrophic changes of the Some authors have stated that the orbital septum is a thin,
tarsal plate,30 and all these factors can also contribute to laxity of the weak, and stretchable structure that cannot be responsible for the
lower eyelid retractors. containment of orbital fat or the maintenance of the normal position
In repair for medial canthal laxity including the punctal of the globe in the bony orbit,56 however, although the orbital
eversion, the Lazy T31 and the support suture procedure32 are septum is a weak structure, the orbital septum is supported by the
applied to tighten the lower eyelid, in which the sutures must be suborbicularis fascia anteriorly6,45,46,55 and the ligaments posterio-
fixed to the posterior lacrimal crest33,34 to appropriately fit the tarsal rly,57 thus increasing its strength.
plate to the ocular surface. For lateral canthal laxity, lateral can- Under the inferolateral part of the orbital septum on the facial
thopexy35 and lateral canthoplasty36 including the lateral tarsal strip aspect of the zygoma lies a potential space, known as the “recess of
procedure37 are used. Horizontal eyelid shortening by simple wedge Eisler.”48 As a result of this anatomic feature, together with the
resection as in the Kuhnt-Szymanowski Smith procedure38 is ap- diminished ligamentous support described above, the periorbital fat
plied to the atrophic change of the tarsal plate to tighten the lower tends to sit beyond the orbital rim so concealing the inferolateral
eyelid, but this procedure may be also applied to both medial and orbital rim.45 In contrast, the medial fat bulges are located high,
lateral canthal laxity. Although the above procedures tighten the several millimeters above the inferomedial orbital rim, held up by
posterior layers, dermal-orbicularis pennant canthoplasty39 may be the unyielding lower septum and the arcus marginalis in this loca-
used for anterior lamellar tightening. If the lower eyelid laxity is tion.45 Due to this, as well as the deeper location of the septum,
severe, vertical support procedures such as usage of spacers,40 medial fat initially bulges forward, not inferomedially, thus tending
slings, or midface/cheek suspension41– 43 are additionally needed. to exaggerate the depth of the nasojugal furrow.45

Relevant Tips for Surgery


ORBITAL SEPTUM OF THE LOWER EYELID After a lower eyelid blepharoplasty, lateral canthal dystopia
The orbital septum constitutes one of the middle lamellar or lower eyelid retraction is occasionally seen.42,43 Although the
components of the eyelid,3 along with the orbital fat and submus- main cause is thought to be excess skin excision, the postoperative
cular fibroadipose tissue.44 It functions like a diaphragm to retain the cicatrix of the orbital septum contributes as well.42,43 Thus, to fully
contents within the orbit, requiring strength to do so.45 Structurally, address such complications, supplementation of skin by graft, flap,
it is fibrous and inelastic,46 yet it has a certain laxity consistent with or a midface lift technique should also be accompanied by release of
the mobility of the eyelid. Rather than being 1 single thick mem- the cicatrix.42,43 Orbital septal surgery is, of course, often intimately
brane, the orbital septum consists of several thin membranes47 and related to surgery for the treatment of the so-called baggy eyelid
is not of uniform thickness.45 The lateral part is much thicker than deformity; further surgical pearls relating to the anatomy of the
the medial part48 and both its thickness and strength differ from orbital septum are thus described in the next section.
patient to patient.49
The orbital septum of the lower eyelid originates from the
arcus marginalis (Figs. 1, 3).1 This prominent rim is seen as a white ADIPOSE TISSUE IN THE LOWER EYELID
line at surgery, which represents the distinct white, fibrous thicken- The fat pad compartments of the lower eyelid had been
ing of the peripheral 1 to 3 mm of the orbital septum as it fuses with originally thought to be divided into 3 parts: medial, central, and
the periorbita and periosteum.45,50 As it extends laterally, it becomes lateral (Figs. 4, 5).58,59 The medial and central fat pads are divided
less defined and its position changes.45 Inferomedially, the relatively by the inferior oblique muscle58,59; the boundaries of the middle and
thick attachment is on the inner part of the orbital rim, however, lateral fat pads are defined by the arcuate expansion of Lockwood
inferolaterally the insertion is thinner and is actually about 2 mm ligament.58,59 Although distinct fat compartments are not distin-
outside and inferior to the rim, which is rounded and poorly guishable in the deep orbit,58,60,61 which contains large particles and
defined45,50; it is here that the orbitomalar ligament51 (or orbicularis less connective tissue septa,62,63 they are in total continuity to the fat
retaining ligament)52 supports the orbital contents. compartments of the anterior orbit, which contains minute particles
The orbital septum joins the lower eyelid retractors 5 to 6 mm of fat and which is rich in connective tissue septa. As a result, the
below the lower margin of the tarsal plate in Whites5,53 and 3 mm in so-called fat compartments of the lower eyelid are not distinct
Asians.8 The orbital septum is anatomically divided into 2 parts: an anatomic entities, but rather clinically useful divisions53,64; only the
upper reinforced portion, supported by the CPF and a lower unrein- demarcational structures, the inferior oblique muscle and the arcuate
forced portion, which is not supported by the CPF.50 As a result of the expansion of Lockwood ligament, definite each compartment ante-
anatomic differences described above, the length of the unreinforced riorly. The lateral compartment is particularly difficult to define
portion is thus largely different between races. Usually, the length of the without the aid of the arcuate expansion of Lockwood ligament.53
central part is 9.3 mm in Whites,53 but 12.3 mm in Asian. In spite of the above classic description of the lower eyelid fat
One reason why the Asian lower eyelid appears to be thicker compartments, there exists a significant variety among individual
may be due to the large area of unreinforced orbital septum. As a orbits; in general, 4 anatomic variations of the infraorbital fat
result, anterosuperior protrusion of orbital fat8,54 and piling-up of compartments exist.64 The most common type (60%) is compart-
the orbicularis oculi muscle around the lower margin of the tarsal mentalized, as described above, into 3 parts; other types include a
plate are observed.8 2-compartment type (26.7%), another type in which either the
A looser and weaker fibrous connective tissue, the suborbicu- medial or lateral compartments, or both, are found under the central
laris oculi fascia (SOOF), covers the anterior surface of the orbital compartment (11.7%), and a noncompartmentalized single fat pad
septum as well as that part of the CPF just below the tarsal type (1.7%). There may be no symmetry between the 2 orbits in
plate.6,45,46,55 The orbicularis oculi muscle can be separated easily terms of the types of fat pad compartmentalization46 and moreover,
from this layer by blunt dissection.45,46,55 Although the correspond- in contradistinction to the upper eyelid,59 the colors of each fat pad
ing layer in the upper eyelid may contain rich adipose tissue, known compartment are the same, although 1 report stated that the medial
as “submuscular fibroadipose tissue,”44 that of the lower eyelid is fat pad was paler.65
less developed, even in Asians.8 Present in only small quantities, the A pretarsal fat compartment is also recognized in the lower
preseptal adipose tissue here almost entirely disappears when the eyelid.66 This is encapsulated and located on the lateral half of the
orbital septum is projected forward as a result of the aging process.47 tarsal plate above the lateral fat compartment; orbital septal fibers

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Annals of Plastic Surgery • Volume 63, Number 3, September 2009 Anatomy of Lower Eyelid

orbicularis oculi muscle and the infraorbital region (SOOF67),53


which is observed in both young and aged specimens.47 A variable
amount of cheek fat is always located superficial to the orbicularis
oculi muscle, with fibrous attachments to both overlying skin and the
underlying muscle.53 This fat pad extends laterally to the limit of the
lower eyelid and at times extends superiorly to overlie the lateral
portion of the orbital fat.53 SOOF is the supraperiosteal submuscular
fat excess situated over the zygoma,67– 69 otherwise known as the
“malar fat pad,”67,69 the analogous structure of the retro-orbicularis
oculi fat70 of the upper eyelid.67 The bulk of the SOOF is located
below the lateral half of the infraorbital rim.67 Malar bags arise as a
result of ptosis of SOOF.65
In conjunction with the connective tissue septa, the orbital
adipose tissue supports the intraorbital structures,62,63 with consid-
erable freedom of movement being achieved by sliding among the
low-friction fat lobules.60 Orbital fat contains more unsaturated fat
than elsewhere in the body, which has decreased viscosity, so
promoting frictionless movement60 and facilitating globe motility
FIGURE 4. (Top: superior, Right: nasal) Schema of the fat within the orbit. Elastin surrounding the globe also facilitates
compartments in the upper and lower eyelids. The fat pad smooth movement.60
compartments in the lower eyelid are generally divided into Intraorbital fat does not hypertrophy or increase in volume
3 parts: medial, central and lateral. The medial and the cen- except when associated with diseases such as endocrine exoph-
tral fat pads are bordered by the inferior oblique muscle. thalmos.17,55 Rather, it tends to involute with ageing.11,35,36 Its
The boundary of the middle and lateral fat pads are done by volume is not influenced by general obesity45 or diet, and remains
the arcuate expansion of Lockwood ligament. LG indicates obvious in cachectic patients, in victims of concentration camps,
lacrimal gland; LCT, lateral canthal tendon; LL, Lockwood or in undernourished people; in addition, herniated fat pads do
ligament; LFPL, lateral fat pad lower; AE, arcuate expansion not resorb.56
of Lockwood ligament; CFPL, central fat pad lower; IO, infe- Bulging orbital fat pads, due to lower eyelid fat herniation,
rior oblique muscle; PAFP, preaponeurotic fat pad; WL, Whit- represent a major component in most cases of lower eyelid ageing
nall ligament; SO, superior oblique muscle; Tr, Trochlea; deformities.45,49 Attenuation and descent of the cheek fat pads and
MFPU, medial fat pad upper; MCT, medial canthal tendon; SOOF result in an increased distance from the lower eyelid margin
MFPL, medial fat pad lower. to the inferior aspect of the orbicularis oculi muscle, producing an
orbit that appears deeper with a wider diameter.54,71 Accordingly,
the underlying bony landmarks of the skeleton in the orbital area
become progressively more obvious, producing the so-called tear
trough, or nasojugal groove, deformity.72–74 The structural changes
responsible for the bulging, however, remain unclear,45,75 although
many theories have been published regarding its etiology. In the
past, protrusion of intraorbital fat manifesting as lower eyelid bags
has been attributed to a congenital excess of fat or more commonly
to a weakness of the orbital septum;13,55 other explanations include
attenuation of the orbicularis oculi muscle13 and skin laxity or
excess,13 which allows the intraorbital fat to protrude.71 A further
possibility is that fat protrusion occurs as a result of weakening of
the support system of the globe, allowing it to descend and causing
enophthalmos and lower eyelid pseudoherniation.75 Weakening and
descent of Lockwood ligament, as opposed to a weakened orbital
septum, may cause the globe to descend, so reducing the space
between it and the floor of the orbit.56,59 None of these theories
alone can sufficiently explain the phenomenon as the fatty appear-
ance can occur both in the face of an intact septum and also in young
people, who have no laxity of the anatomic structures.49
FIGURE 5. The fat compartments in the lower eyelids. See Relevant Tips for Surgery
the legend of the Fig. 4. The color of each fat pad compart- Lower eyelid fat pad surgery is generally concerned with the
ment is not discerned. LFP indicates lateral fat pad; AE, arcu- reduction of the lower palpebral bulge, or the treatment of tear
ate expansion of Lockwood ligament; CFP, central fat pad; trough deformity. Surgical excision has been the mainstay of the
MFP, medial fat pad. management of protruding fat pads in cosmetic blepharoplasty.59,76,77
Although this procedure is efficacious in young72 and aged over-
weight patients,78 this approach is well-known to cause complica-
separate the pretarsal fat pad from the lateral fat pad. This pretarsal tions, which include chemosis, ecchymosis, ectropion, eyelid retrac-
fat compartment contributes to the visible bulk of the eyelid just tion, eyelid contour irregularities, and retrobulbar hematoma50,75,79;
below the eyelashes. furthermore, removal of the orbital fat pads has been linked to
Other layers of fat that contribute to the lower eyelid include blindness associated with cosmetic blepharoplasty.80 Orbital fat
the fat of the cheek and a variable amount of fat located between the removal from the lower eyelid simply converts the double convexity

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Kakizaki et al Annals of Plastic Surgery • Volume 63, Number 3, September 2009

deformity of the fat bulge to a concavity, which also causes a rather procedures are often needed to establish a desired effect because it
aged appearance.72,81 Although this technique may produce an is difficult to anticipate the absorption rate of the injected fat.78
attractive early result, in the long-term it usually contributes to the As the pretarsal fat compartment sits on the lateral half of the
senile enophthalmos and pseudoptosis seen in the elderly associated tarsal plate above the lateral orbital fat pad compartment, removing
with involutional changes.55 only this fat pad does not remove the bulge just below the eyelas-
Since the orbital fat continues deep into the orbit, removal of hes.68 To alleviate the bulge or knoll of the skin just below the lower
orbital fat from the lower eyelid occasionally causes the upper eyelid eyelashes, the pretarsal fat compartment should also be removed
sulcus to deepen82,83; to date, however, there have been no reports during lower eyelid blepharoplasty.68
of this complication following a fat repositioning procedure (see To access infraorbital fat via a transconjunctival approach, an
below). The precise etiology of this complication is yet to be incision must be placed in the lower third of the conjunctiva, close
determined, but the main cause is thought to be an anterior shift of to the inferior conjunctival fornix.53 A lower third incision with
the lower orbital fibrous connective tissue (Rouleau phenomenon).56 dissection toward the orbital rim is suggested to minimize surgical
Fat preservation procedures have been popularized because of complications and injury to both the inferior oblique and inferior
the disadvantages of the fat pad excision described above. Loeb84 rectus muscles.53,97,98 An incision in the middle third of the con-
was the first surgeon to report a fat preservation procedure, advo- junctiva allows access to the structures of the lower eyelid and
cating transferring the fat pad to fill the depressed area adjacent to orbital floor without entering the orbital fat pad compartment.53
The management of lower eyelid adipose tissue is also an
the nasojugal groove,84 however, in his procedure the central and
important consideration in strabismus surgery, particularly inferior
lateral fat pads were still excised. Hamra54 subsequently developed
rectus surgery, in which an adhesion syndrome occasionally occurs
this procedure, repositioning all the fat pad compartments to the
around the inferior oblique muscle.99 Since an adhesion syndrome
orbital rim. He stated that the medial and central fat pads could be has also been reported in relation to lower eyelid blepharoplasty,100
appropriately removed if needed, but the lateral fat pad should be one should keep in mind the possibility of this complication.
used for malar augmentation.54 Although this is a suitable concept in Removal of fat from the orbit in Graves’ ophthalmopathy has
Whites, it should not be universally applied in Asians because their been described as a decompression technique.101,102 Although the
malar eminence is typically large.77 Contrary to Hamra’s recom- fat is usually removed from the front, it is easier to remove the fat
mendation, Goldberg stated that the lateral fat pad and occasionally more posteriorly via the incised periorbita after completion of
the central fat pad could be removed conservatively.85 Differing periorbital dissection. This is because the anterior orbit includes
locations where the repositioned fat can be inserted include the well-developed connective tissue septa, but the posterior orbit con-
subperiosteal plane,85 the supraperiosteal plane86 and the intra- tains mainly large particles of fat with a loose and scant connective
SOOF level.87 To further camouflage orbital rim skeletonization, a tissue network.60
SOOF- or midface-lift may also be used.69,73,88 Restricted ocular
movements have been reported as a result of fat repositioning
procedures;68,72 an intraoperative forced duction test may help to LOCKWOOD LIGAMENT
prevent this complication.89 Although there are 4 independent ligaments in the upper
In an attempt to address one of the possible causes of lower eyelid, only Lockwood ligament and its branches constitute the
eyelid bulge formation, attenuation of the orbital septum, a variety lower eyelid ligament system (Figs. 2, 4).103 Lockwood ligament
of methods of reinforcing the orbital septum have been described. comprises 3 components: the inferior ligament, supporting the me-
De la Plaza and Arroyo,75 Mendelson,45 and Camirand et al56 stated dial margin of the lower eyelid retractors, the main Lockwood
that the herniated fat pads could be relocated intraorbitally by ligament and the arcuate expansion, all of which originate medially
suturing the CPF to the arcus marginalis. Sachs and Bosniak90 from the posterior lacrimal crest.103
corrected the herniated fat pads by suturing the CPF to the orbital The main Lockwood ligament, which corresponds to Whitnall
septum. Sensoz et al55 reported that fat pad protrusion could be ligament in the upper eyelid, inserts into Whitnall tubercle on the
effectively ameliorated by suturing the septum to the orbital perios- lateral orbital wall, 2 to 4 mm posterior to the lateral orbital
teum. Hamra refined his original fat repositioning procedure72 by rim.103,104 Although Lockwood ligament is thought to represent a
thickening of the CPF,56 it also supports the medial and lateral horns
additionally suturing the septum to the orbital periosteum.91 Other
of the lower eyelid retractors from inferiorly (observational finding).
techniques have been reported as alternative procedures to
Its average length is 43 mm, width is 3 to 5 mm, and thickness is 1
strengthen the orbital septum, in an attempt to repair lower eyelid
mm.56 Around its lateral attachment, Lockwood ligament partici-
bulging,7 although they do not provide assistance in camouflaging
pates in the formation of the lateral retinaculum,56 which includes,
the progressive visibility of the lower bony orbital rim seen with from superiorly, Whitnall ligament, the intermuscular transverse
advancing age.54 These techniques include orbital septum plica- ligament, the lateral check ligament, the lateral horn of the levator
tion,17,75 advancement of Lockwood ligament,49 cautery of the aponeurosis, the lateral canthal tendon, the orbital septum, and
orbital septum,92–94 and suturing the lower edge of the reinforced Lockwood ligament per se.105–107 Although, Lockwood ligament is
portion of the orbital septum to the orbital rim. In these various a strong anatomic structure supporting the globe from underneath56;
septum-tensing procedures, with the exception of Lockwood liga- other than by Lockwood ligament, the globe is supported by the
ment advancement, surgeons must attempt to mitigate against the medial and lateral check ligaments, orbital connective tissue septa
risk of ectropion, and scleral show.49,50,55 and the orbital adipose tissue.59,62,103
Possibly the most radical procedure for the reduction of the The arcuate expansion of Lockwood ligament, partly corre-
lower palpebral bulge is to remove all of the lower orbital septum, sponding to the lower positioned transverse ligament108 –111 of the
producing a hanging “curtain of fat,” although most such cases also upper eyelid, inserts on the inferolateral orbital rim after supporting
require horizontal lower eyelid tightening to prevent an ectropion.95 the lateral part of the orbital septum.1,103 As discussed above, it
Another method to improve the lower eyelid bulge is fat injec- usually divides the central and lateral fat pads53 and in its absence it
tion74,96 to the area of the saddle-back deformity71 (double convex- is difficult to define the central and lateral fat pad compartments.53
ity deformity81). In this procedure, the deformity is improved, The inferior ligamentous component of Lockwood ligament
preventing the sliding of the bulging fat.74,96 However, repeated corresponds to the medial horn supporting ligament112 in the upper

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Annals of Plastic Surgery • Volume 63, Number 3, September 2009 Anatomy of Lower Eyelid

eyelid. Although the ligament corresponding to the intermuscular 11. Kakizaki H, Zako M, Nakano T, et al. Direct insertion of the medial rectus
transverse ligament93,113–115 in the upper eyelid does not exist in the capsulopalpebral fascia to the tarsus. Ophthal Plast Reconstr Surg. 2008;
24:126 –130.
lower eyelid, there is instead an independent pulley system around
12. Kakizaki H, Zako M, Nakano T, et al. Microscopic findings of lateral tarsal
the inferior rectus muscle.116,117 fixation in Asians. Ophthal Plast Reconstr Surg. 2008;24:131–135.
The course of the lower eyelid ligamentous system deter- 13. Carter SR, Seiff SR, Grant PE, et al. The Asian lower eyelid: a comparative
mines the potential shape of the lower conjunctival fornix.118 Al- anatomic study using high-resolution magnetic resonance imaging. Ophthal
though in general the lower conjunctival fornix is thought to take the Plast Reconstr Surg. 1998;14:227–234.
shape of a circular cul-de-sac,105,119 the conjunctival fornix may 14. Carter SR, Chang J, Aguilar GL, et al. Involutional entropion and ectropion
extend more laterally becoming a larger trapezoid shape.118 of the Asian lower eyelid. Ophthal Plast Reconstr Surg. 2000;16:45– 49.
15. Smit TJ, Koornneef L, Zonneveld FW, et al. Computed tomography in the
Relevant Tips for Surgery assessment of the postenucleation socket syndrome. Ophthalmology. 1990;
Although Lockwood ligament has an important role in the 97:1347–1351.
prevention of globe ptosis,59,62,63,103 laxity of Lockwood ligament49 16. Kim EM, Bucky LP. Power of the pinch: pinch lower lid blepharoplasty.
Ann Plast Surg. 2008;60:532–537.
may be one of the causes of lower eyelid bulge formation. As a
result, some canthopexy procedures have been described in an 17. Mühlbauer W, Holm C. Orbital septorhaphy for the correction of baggy
upper and lower eyelids. Aesthetic Plast Surg. 2000;24:418 – 423.
attempt to tense Lockwood ligament56; in so doing, the other
18. Kakizaki H, Zako M, Kinoshita S, et al. Posterior layer advancement of the
supporting structures of the globe are simultaneously raised and lower eyelid retractor in involutional entropion repair. Ophthal Plast Re-
pushed backwards, which further augments the improvement in the constr Surg. 2007;23:292–295.
lower eyelid bulge. 19. Jones LT, Reeh MJ, Wobig JL. Senile entropion: a new concept for
Inferior traction of Lockwood ligament cannot cause traction correction. Am J Ophthalmol. 1972;74:327–329.
of the lower eyelid.49 Since Lockwood ligament is a strong fibrous 20. Altieri M, Iester M, Harman F, et al. Comparison of three techniques for
tissue, it can be used as a supporting element to a skin muscle flap repair of involutional lower lid entropion: a three-year follow-up study.
Ophthalmologica. 2003;217:265–272.
while retaining the orbital fat in lower eyelid blepharoplasty.49
21. Kakizaki H, Zako M, Iwaki M. Reverse ptosis repair targeting the posterior
layer of the lower eyelid retractor. Ophthal Plast Reconstr Surg. 2007;23:
CONCLUSION 288 –291.
An update of the surgical anatomy of the lower eyelid has been 22. Bartley GB, Frueh BR, Holds JB, et al. Lower eyelid reverse ptosis repair.
presented, along with the relevance to more recent lower eyelid proce- Ophthal Plast Reconstr Surg. 2002;18:79 – 83.
dures. Safe and confident surgery on the lower eyelid can only be 23. Kakizaki H, Zako M, Iwaki M. Lower eyelid lengthening surgery targeting
performed with a thorough understanding of the anatomy involved. All the posterior layer of the lower eyelid retractors via a transcutaneous
approach. Clin Ophthalmol. 2007;1:141–147.
cadavers were Japanese, and they were registered with Aichi Medical
24. Olver JM, Rose GE, Khaw PT, et al. Correction of lower eyelid retraction in
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and complied with the tenets of the Declaration of Helsinki. 180.
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ACKNOWLEDGMENTS mus. 2002;39:198 –202.
The authors thank Takashi Nakano and Ken Asamoto at 26. Rosenberg DB, Lattman J, Shah AR. Prevention of lower eyelid malposition
Department of Anatomy, Aichi Mediacal University for giving us the after blepharoplasty: anatomic and technical considerations of the inside-out
opportunity to use the cadavers, and authors also thank the late lepharoplasty. Arch Facial Plast Surg. 2007;9:434 – 438.
Osamu Miyaishi for staining the microscopic specimens. 27. Henderson JW. Relief of eyelid retraction: a surgical procedure. Arch
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