Comments on “Outer Fascia of Orbicularis Oculi Muscle as an Anchoring Target Tissue in Double Eyelid Surgery”

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To the Editor: The following comments refer to the article by Choi et al1 which I read with interest.
Choi et al performed 28 patients of primary double eyelid surgery and 3 cadaveric dissections, and recommended direct suture fixation of the levator aponeurosis to the outer fascia of the orbicularis oculi muscle (OFOOM), instead of to the dermis, to make a double fold. Thus, Choi et al proposed a new method of anchoring the target tissue in double eyelid surgery.
In the introduction, the author gave a new name, the “outer fascia of orbicularis oculi muscle (OFOOM),” to an area that has been described as a “subcutaneous tissue layer,” “subcutaneous fibrous layer,” or “fibroadipose layer” in the upper eyelid.
However, some textbooks have described the anatomy and nature of the structure under the dermis superficial to the orbicularis oculi muscle.
Whitnall wrote that upper eyelid skin is highly elastic, and loosely attached by “fine connective-tissue strands” to the underlying muscle, and that this tissue corresponds to the “superficial fascia” of other parts of the body, but differs in being devoid of fat (although Adachi found it to be normally present in the eyelids of the Japanese). He emphasized that its laxity readily allows the skin to be pinched up or raised by effusions, but it is absent at the commissures where the skin is more adherent, so that effusions in the one lid do not pass readily into the other.2
Duke-Elder described the dermis of the upper eyelid as being separated from the underlying muscular layer by a “subcutaneous areolar layer” that contains no fat, but is loosely adhered to the underlying muscle by connective tissue strands, an arrangement that permits the ready accumulation of edematous fluid underneath it and causes it to wrinkle up in old age. He wrote that it also permits free movement of the skin over the muscle, except at the palpebral sulci where the skin is adherent to the muscle.3
According to Whitnall and Duke-Elder, the upper eyelid skin is loosely attached to the underlying orbicularis oculi muscle by “fine connective-tissue strands” or “subcutaneous areolar layer.”2,3 Thereafter, the so-called OFOOM cannot provide an effective anchor for target tissue in the fixation of the levator aponeurosis in double eyelid surgery.
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