DOI: 10.1097/PRS.0b013e31819f25ec
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Issn Print: 0032-1052
Publication Date: 2009/04/01
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Excerpt
The anatomy is complex such that it is useful to address some of the article's main points in a numerical fashion. The similarities between the tear trough and lid/cheek creases are stated as follows:
There are major differences between the tear trough and lid/cheek creases, as follows:
These points are anatomically and clinically relevant. A previous theory suggested that the tear trough occurred from a gap between the lip/nose levator muscles and orbicularis. The present study shows that the tear trough is superior to this gap. Augmentation of filler between these two muscles does not improve the tear trough groove. Another point is that these creases do not occur from fixation of orbital septum to orbital rim as has been previously suggested, so methods other than release of orbital septum are necessary to improve these creases. Before discussing the clinical implications, these anatomical points hold a wealth of information on their own.
Without making the statement as such, the authors have defined the meaning of any fold that occurs on the face. This may be one of this article's more intriguing points, one that will benefit future studies and clinical discussions. The authors state that “in the subcutaneous plane, the tear trough and lid/cheek junction overlie the junction of the palpebral [preseptal] and orbital portions of the orbicularis oculi muscle and the cephalic border of the malar fat pad.” At (above) the tear trough “there is virtually no fat between the skin and muscular junction, accounting for its visibility as a cutaneous landmark.”
These statements define the meaning of “fold.” A fold occurs at a transition point between two areas of varying thickness of subcutaneous fat.
This occurs elsewhere. At the nasolabial crease, there is more subcutaneous fat in the nasolabial compartment than in the lip compartment. If one looks at a cross-section of tissue from cheek to lip, the orbicularis oris muscle is more superficial on the lip, just as the orbicularis oculi is more superficial on the lid above the tear trough. If one examines a cross-section of tissue from eyelid to cheek in the anatomy laboratory, the orbicularis appears to change course abruptly and course more deeply. This is attributable to the change in thickness of fat between two adjacent subcutaneous fat compartments.
An offshoot of this anatomical point is that it defines the anatomical location of the malar mound as occurring caudal to the lid/cheek crease at the boundary of preseptal and preorbital orbicularis oculi muscle. The morphology of the malar mound as a separate fat compartment is thus explained. Other creases and folds, including jowls, submental crease, labiomental crease, and preauricular fold, all occur at similar transition zones between compartments of varying fat thickness.
Another observation the authors make is that the tear trough and lid/cheek junctions occur inferior to the orbital rim and arcus marginalis. As cited in the authors' references, the arcus marginalis is not an anatomical structure: it is simply a fusion zone of periosteum arising from several facial bones. The arcus marginalis, as a fusion point, can be seen at the anterior superior orbital rim. The orbicularis retaining ligament, as the authors point out, has an origin several millimeters below this. This is in agreement with the reference cited by Ghavami et al.
