Discussion: The tear trough ligament: anatomical basis for the tear trough deformity.

I their cadaveric study of 36 hemifaces, the authors describe a ligamentous structure that arises from medial orbital rim periosteum and inserts into dermis. The authors suggest that this is an osteocutaneous ligament that defines the anatomical area referred to as the tear trough or medial nasojugal crease. The conclusion of the article is that the tear trough ligament is the primary etiologic factor in the development of the tear trough deformity; effective treatment requires submuscular preperiosteal release to effect a marked correction. This study defines a tear trough ligament that originates from the maxilla near the medial canthal tendon inferior to the lacrimal crest. It travels to the medial pupillary line, where it becomes continuous with the bilaminar orbicularis retaining ligament. The dissections are meticulous; the anatomy is precise; and the work is clinically relevant in that it explains why release of the orbicularis origin helps to diminish the tear trough deformity. This classic article advances some of the authors’ previous work and ideas concerning lower eyelid and cheek anatomy. The present work addresses one of the most difficult areas and concepts in facial anatomy: the submuscular fascial network of the face. Work in this field began in the late 1800s with Juvara’s early work on spaces and fascial  Other studies, including articles by Collier and Yglsias2 and Grodinsky and Holyoke3 from the 1930s defined fusion zones as part of this network. More recently, the concept of facial ligaments has been investigated by a number of authors over the past 30 years. This article defines the ligamentous structure of the tear trough region. An anatomical discussion focuses on the presence, possible function, and exact extent of the facial ligaments. The authors’ work adds validity to the concept of submuscular ligamentous attachments of the face. The pertinent literature has been cited. Points of fixation have been described in the forehead, lower eyelid, and cheek. These may represent points of suspension, as suggested by the authors. Release of these ligaments is then required if the surgical goal is to reposition or elevate soft tissue. There exists another possible function for these soft-tissue ligaments. Fixation of the facial muscles to periosteum, a valid definition of the term “ligament,” has been noted in association with the orbicularis oculi muscle. This occurs when the orbicularis oculi muscle changes in position from deep to superficial, at the lid-cheek junction, as it courses toward the orbital rim. We have observed that this also occurs with the platysma muscle, and probably with the orbicularis oris muscle as well. It is noteworthy that ligaments are associated with all of these muscles as they course over a bony margin. In the case of the platysma muscle, there is a ligament that travels from the muscle to the mandibular border. With the orbicularis oris muscle, a ligament travels from the undersurface of the muscle to the maxilla and mandible. In each case, fascial attachments originate from the undersurface of these facial muscles and insert into bone when the muscle travels over a free bony margin. This adds a point of fixation for the action of the muscle, in effect providing an insertion point as a fulcrum for motion. These muscles—the orbicularis oculi and oris, and platysma—do not otherwise have strong origin at bone, unlike other facial muscles such as the levator labii or anguli muscles. Conceptually, the orbicularis retaining ligament, and the platysma ligament (the mandibular ligament), are bilaminar because fascia from the undersurface of the muscle above and below the bony margin contributes to the structure. This concept suggests this