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The Tear Trough and Lid/Cheek Junction: Anatomy and Implications for Surgical Correction

Haddock, Nicholas T. M.D.; Saadeh, Pierre B. M.D.; Boutros, Sean M.D.; Thorne, Charles H. M.D.

Plastic & Reconstructive Surgery: April 2009 - Volume 123 - Issue 4 - pp 1332-1340
doi: 10.1097/PRS.0b013e31819f2b36
Cosmetic: Original Articles

Background: The tear trough and the lid/cheek junction become more visible with age. These landmarks are adjacent, forming in some patients a continuous indentation or groove below the infraorbital rim. Numerous, often conflicting procedures have been described to improve the appearance of the region. The purpose of this study was to evaluate the anatomy underlying the tear trough and the lid/cheek junction and to evaluate the procedures designed to correct them.

Methods: Twelve fresh cadaver lower lid and midface dissections were performed (six heads). The orbital regions were dissected in layers, and medical photography was performed.

Results: In the subcutaneous plane, the tear trough and lid/cheek junction overlie the junction of the palpebral and orbital portions of the orbicularis oculi muscle and the cephalic border of the malar fat pad. In the submuscular plane, these landmarks differ. Along the tear trough, the orbicularis muscle is attached directly to the bone. Along the lid/cheek junction, the attachment is ligamentous by means of the orbicularis retaining ligament.

Conclusions: The tear trough and lid/cheek junction are primarily explained by superficial (subcutaneous) anatomical features. Atrophy of skin and fat is the most likely explanation for age-related visibility of these landmarks. “Descent” of this region with age is unlikely (the structures are fixed to bone). Bulging orbital fat accentuates these landmarks. Interventions must extend significantly below the infraorbital rim. Fat or synthetic filler may be best placed in the intraorbicularis plane (tear trough) and in the suborbicularis plane (lid/cheek junction).

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

From the Institute of Reconstructive Plastic Surgery, New York University School of Medicine, and Houston Plastic and Craniofacial Surgery.

Received for publication April 4, 2008; accepted September 16, 2008.

Presented at the 40th Anniversary Meeting of the American Society for Aesthetic Plastic Surgery, in New York, New York, April 19 through 24, 2007.

Disclosure: None of the authors has a conflict of interest.

Charles H. Thorne, M.D., Institute of Reconstructive Plastic Surgery, New York University Medical Center, TH 169, 550 First Avenue, New York, N.Y. 10016

©2009American Society of Plastic Surgeons