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The Tear Trough Ligament: Anatomical Basis for the Tear Trough Deformity

Wong, Chin-Ho M.R.C.S.(Ed.), F.A.M.S.(Plast. Surg.); Hsieh, Michael K. H. B.Sc.; Mendelson, Bryan F.R.C.S.(Ed.), F.R.A.C.S., F.A.C.S.

Plastic and Reconstructive Surgery: June 2012 - Volume 129 - Issue 6 - p 1392–1402
doi: 10.1097/PRS.0b013e31824ecd77
Cosmetic: Original Articles

Background: The exact anatomical cause of the tear trough remains undefined. This study was performed to identify the anatomical basis for the tear trough deformity.

Methods: Forty-eight cadaveric hemifaces were dissected. With the skin over the midcheek intact, the tear trough area was approached through the preseptal space above and prezygomatic space below. The origins of the palpebral and orbital parts of the orbicularis oculi (which sandwich the ligament) were released meticulously from the maxilla, and the tear trough ligament was isolated intact and in continuity with the orbicularis retaining ligament. The ligaments were submitted for histologic analysis.

Results: A true osteocutaneous ligament called the tear trough ligament was consistently found on the maxilla, between the palpebral and orbital parts of the orbicularis oculi, cephalad and caudal to the ligament, respectively. It commences medially, at the level of the insertion of the medial canthal tendon, just inferior to the anterior lacrimal crest, to approximately the medial-pupil line, where it continues laterally as the bilayered orbicularis retaining ligament. Histologic evaluation confirmed the ligamentous nature of the tear trough ligament, with features identical to those of the zygomatic ligament.

Conclusions: This study clearly demonstrated that the prominence of the tear trough has its anatomical origin in the tear trough ligament. This ligament has not been isolated previously using standard dissection, but using the approach described, the tear trough ligament is clearly seen. The description of this ligament sheds new light on considerations when designing procedures to address the tear trough and the midcheek.


Singapore; and Toorak, Victoria, Australia

From W Aesthetic Plastic Surgery, Mount Elizabeth Novena Hospital, and the Center for Facial Plastic Surgery.

Received for publication October 11, 2011; accepted December 20, 2011.

Presented at the Third Annual Melbourne Advanced Facial Anatomy Course, in Melbourne, Victoria, Australia, October 21 through 22, 2011.

Disclosure: The authors declare no conflicts of interest in the present work.

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Chin-Ho Wong, M.R.C.S.(Ed.), F.A.M.S.(Plast. Surg.); W Aesthetic Plastic Surgery, 38 Irrawaddy Road, #08–42, Mount Elizabeth Novena Hospital, 329563, Singapore,

©2012American Society of Plastic Surgeons