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Letters

Deep and Superficial Eyelid Fascia

Putterman, Allen M. M.D.

Author Information
Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 721e-723e
doi: 10.1097/PRS.0b013e318245e7a2
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Sir:

Figure
Figure

I suggest that we change the names of the orbital septum to “deep eyelid fascia” and the suborbicularis fascia to “superficial eyelid fascia.” In recent publications, there has been confusion regarding the orbital septum and suborbicularis fascia. In “Lower Blepharoplasty with Orbital Septum Reconstruction Using Upper Blepharoplasty Excision Material” (Plast Reconstr Surg. 2011;127:137e–139e), Dr. Balik described covering herniated orbital fat in the lower eyelid with orbicularis muscle from the upper eyelid, similar to repair of inguinal hernias with mesh. However, Dr. Balik refers to the cause of the baggy eyelid as a weakness of the orbital septum, which I believe is incorrect.

Before my 1973 publication with Urist of the article, “Baggy Eyelids: A True Hernia,”1 it was assumed that baggy eyelids occurred because there was too much orbital fat2; the orbital septum was missing3; or the orbital septum was weak, thinned, and degenerated.4 We demonstrated through cadaver evaluation and surgical procedures that the orbital septum in baggy eyelids remained strong and normal but was detached from the levator aponeurosis in the upper eyelid and from the capsulopalpebral fascia in the lower eyelid. This detachment allowed orbital fat to flow into the eyelids as a true hernia (Fig. 1). We also demonstrated that the thin, friable connective tissue over the orbital fat was the suborbicularis fascia, which was being mistakenly confused with the true orbital septum. In that research, we attempted to correct the baggy eyelids by reattaching the septum to the levator aponeurosis; this worked temporarily, but 6 months later, the palpebral bags recurred. We did not continue this experiment by reattaching the septum to the capsulopalpebral fascia or levator aponeurosis in other cases, but since then, Dr. Balik and others have.510

Fig. 1
Fig. 1:
Cross-section of eyelids with detachment of the deep eyelid fascia (previously called orbital septum) from the levator aponeurosis and capsulopalpebral fascia allowing orbital fat to flow into the eyelids as a true hernia. The superficial eyelid fascia (previously called suborbicularis fascia) covers the prolapsed fat and can be mistaken for deep eyelid fascia (orbital septum). (Copyright © 2011, University of Illinois Board of Trustees. Used with permission.)

The anatomy of the orbital septum and its surgical applications are at times questionable. I believe this is because the superficial fascia of the eyelid, which is part of the superficial fascia of the body, is often confused with the orbital septum, which is part of the deep body fascia.

In 1974, Urist and I described the anatomy of the orbital septum.11 We demonstrated through fresh cadaver analysis that the orbital septum in the upper eyelid was a strong, inelastic tissue that originated from periosteum several millimeters posterior to the superior orbital rim. We also showed that the orbital septum inserted onto the levator aponeurosis approximately 10 mm above the superior tarsal border (in non-Asian patients) and that it contained orbital fat in the orbit (Fig. 2). In the lower eyelid, the orbital septum originated several millimeters posterior to the inferior orbital rim, inserted onto the capsulopalpebral fascia (the analogue of the levator aponeurosis) approximately 5 mm beneath the inferior tarsal border, and also contained orbital fat in the orbit. Anterior to the orbital septum, levator aponeurosis, capsulopalpebral fascia, and tarsus, and posterior to the orbicularis oculi muscle, was a loose connective tissue that we referred to as suborbicularis fascia. It is now clear that the orbital septum is actually the deep eyelid fascia and that the suborbicularis fascia is the superficial eyelid fascia.

Fig. 2
Fig. 2:
Cross-section of eyelids demonstrating normal relationships of deep eyelid fascia (previously called orbital septum), levator aponeurosis, capsulopalpebral fascia, and superficial eyelid fascia (previously called suborbicularis fascia). (Copyright © 2011, University of Illinois Board of Trustees. Used with permission.)

In 2008, Parsa et al. reported successfully treating baggy lower eyelids by reattaching capsulopalpebral fascia to the arcus marginalis.5 I believe that it probably was the deep eyelid fascia (i.e., orbital septum) that the authors attached to the capsulopalpebral fascia, to repair the separation of those tissues that had led to the fat flowing into the eyelid.

Body fascia is gaining a great deal of attention regarding its importance in the function of the musculoskeletal system.1216 Injury to this tissue is believed to cause pain and abnormal movements of the body. The alternative medicine fields such as chiropractic medicine, osteopathy, and massage therapy have had a boom in treating people with this torn and separated tissue. In facial plastic surgery, the importance of the deep fascia (superficial musculoaponeurotic system) and deep temporalis fascia is well known. However, the superficial fascia that we brush away in our dissections is probably also important, yet it is still in its infancy of study.

To avoid further confusion about the orbital septum, I believe that we should refer to this structure as the deep eyelid fascia. I suggest that we rename the loose connective tissue that is anterior to the deep eyelid fascia as the capsulopalpebral fascia, levator aponeurosis, and tarsus, and that we rename the tissue beneath the orbicularis oculi muscle as the superficial eyelid fascia (Figs. 1 and 2).

Allen M. Putterman, M.D.

111 North Wabash, Suite 1722, Chicago, Ill. 60602

ACKNOWLEDGMENT

The author is supported by an unrestricted grant from Research to Prevent Blindness (New York, N.Y.).

REFERENCES

1. Putterman AM, Urist MJ. Baggy eyelids: A true hernia. Ann Ophthalmol. 1973;5:1029–1032.
2. Callahan A. Reconstructive Surgery of the Eyelids and Ocular Adnexa. Birmingham: Aesculapius Publishing, 1966:230.
3. Rogers B. Personal communication.
4. Smith B, Converse JM, eds. Proceedings of the Second International Symposium on Plastic and Reconstructive Surgery of the Eye and Adnexa. St. Louis: Mosby; 1967:362.
5. Parsa AA, Lye KD, Radcliffe N, Parsa FD. Lower blepharoplasty with capsulopalpebral fascia hernia repair for palpebral bags: A long-term prospective study. Plast Reconstr Surg. 2008;121:1387–1397.
6. de la Plaza R, Arroyo JM. A new technique for treatment of palpebral bags. Plast Reconstr Surg. 1988;81:677–687.
7. Parsa FD, Myashiro MJ, Elahi E, Mirzai TM. Lower eyelid hernia repair for palpebral bags: A comparative study. Plast Reconstr Surg. 1998;102:2459–2465.
8. de la Plaza R. Septo-orbitoperiosteoplasty for the treatment of palpebral bags: A 10-year experience (Discussion). Plast Reconstr Surg. 1998;101:1664–1665.
9. Camirand A. Preserving the orbital fat in lower eyelidplasty. Plast Reconstr Surg. 1999;103:737–739.
10. Sensöz O, Unlü RE, Perçin A, Baran CN, Celebioglu S, Ortak T. Septo-orbitoperiostoplasty for the treatment of palpebral bags: A 10-year experience. Plast Reconstr Surg. 1998;101:1657–1663.
11. Putterman AM, Urist MJ. Surgical anatomy of the orbital septum. Ann Ophthalmol. 1974;6:290–294.
12. Chino K, Oda T, Kurihara T, et al.. In vivo fascicle behavior of synergistic muscles on concentric and eccentric plantar flexion in humans. J Electromyogr Kinesiol. 2008;18:79–88.
13. Huijing PA, Langevin H. Communicating about fascia: History, pitfalls and recommendations. In: Huijing PA, Hollander P, Findley TW, Schleip R, eds. Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Munich, Germany: Elsevier; 2009.
14. Schleip R. Fascial plasticity: A new neurobiological explanation. Part 2. J Bodywork Movement Ther. 2003;7:104–116.
15. Van der Wal J. The architecture of the connective tissue in the musculoskeletal system: An often overlooked functional parameter as to proprioception in the locomotor apparatus. In: Huijing PA, Hollander P, Findley TW, Schleip R, eds. Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Munich, Germany: Elsevier; 2009.
16. Myers T. Fascial fitness: Training in the neuromyofascial web. IDEA Fitness J. , 2011. Available at: http://www.ideafit.com/fitness-library/fascial-fitness. Accessed July 12, 2011.

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