Anatomy for Blepharoplasty and Brow-lift

James M. Ridgway, M.D.,1 and Wayne F. Larrabee, M.D.1

ABSTRACT

The eyelids and eyebrows provide communicative, emotional, and protective

functions through a complex interplay of muscles, tendons, and other local soft tissues. A
surgical intervention involving these regions are renowned for their deceptive simplicity
and notable complications. With these challenges in mind, this article provides the reader
with a detailed and systematic review of the eyelid and brow anatomy.

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KEYWORDS: Blepharoplasty, brow-lift, anatomy, eyelid

C entral to the surgical treatment of the eye and The highest point of the upper lid margin is medial to a
brow is the requisite understanding of surgical anatomy. vertical line placed through the central point of the
Whether reconstructive or rejuvenating, direct or endo- pupil.1 The lower lid’s most inferior marginal point is
scopic, tissue ablative or sparing, the restoration of form lateral to the aforementioned pupillary line. The lateral
and function rests upon this simple but essential tenet. canthus is 2 to 4 mm superior in relation to that of the
medial canthus. Additionally, the lateral canthus posi-
tions the eyelids in direct relation to the globe, whereas
BLEPHAROPLASTY ANATOMY the medial canthus is anteriorly located and intimately
associated with the lacrimal sac.
The Eyelid Multiple structures line the margin of the eyelid
The eyelids are soft tissue envelopes that prevent expo- including lashes, meibomian glands, and the gray line.
sure and desiccation of the cornea, distribute tears over The meibomian glands are present along the posterior
the eye, and are involved in voluntary as well as reflex- lid margin and mark the transition of exterior skin to
mediated closure for protection. They are secured by orbital conjunctiva. Between the lash line and the
their canthal attachments along the medial and lateral meibomian glands is the gray line. This line along the
aspects of the orbit. When open, the globe, iris, and lid margin represents the muscle of Riolan, the most
cornea are visualized through an aperture known as the superficial extent of the orbicularis oculi.
palpebral fissure. This opening measures 27 to 30 mm
in length and 8 to 11 mm in height in the average adult
subject. The eyelid skin is relatively devoid of subcuta- Lamellae
neous fat and at its medial portion represents the For better anatomic understanding and surgical ap-
thinnest skin of the body. proach, each eyelid is divided into anterior and posterior
When evaluating the eyelids, there are notable divisions, or lamella. The anterior lamella is composed of
differences between upper and lower, as well as medial the anterior skin and the underlying orbicularis oculi.
and lateral, components. The upper lid commonly rests The posterior lamella encompasses the tarsus, lid retrac-
1 to 2 mm below the superior limbus of the iris, whereas tors, conjunctiva, and orbital septum (Fig. 1). Of note,
the lower lid typically rests along the inferior limbus. some authors classify the orbital septum as the middle

1
Department of Otolaryngology–Head and Neck Surgery, University M.D., F.A.C.S.
of Washington, Seattle, Washington. Facial Plast Surg 2010;26:177–185. Copyright # 2010 by Thieme
Address for correspondence and reprint requests: James M. Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
Ridgway, M.D., Department of Otolaryngology–Head and Neck USA. Tel: +1(212) 584-4662.
Surgery, University of Washington, Box 356515, Seattle, WA 98195 DOI: http://dx.doi.org/10.1055/s-0030-1254327.
(e-mail: jridgwaymd@gmail.com; jridgway@u.washington.edu). ISSN 0736-6825.
Blepharoplasty and Brow Lifting; Guest Editor, Gregory S. Keller,
177
178 FACIAL PLASTIC SURGERY/VOLUME 26, NUMBER 3 2010

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Figure 1 Cross-sectional anatomy of the eye. (Copyright # 2010 J.M. Ridgway, M.D. Used with permission.)

lamella, rather than a component of the posterior are involved in voluntary and involuntary closure. The
lamella, due to its surgical and anatomic importance as pretarsal and preseptal divisions are commonly refer-
a boundary between the preseptal soft tissues and post- enced together as the pars palpebrarum, which, in
septal contents of the orbit. essence, represents the mobile eyelid. Taken together
Fibers of the levator aponeurosis in the upper lid, the palpebral portion is observed in blinking and volun-
as well as fibers from the orbitomalar ligament in the tary winking, and the orbital portion is recruited in
lower lid, traverse these lamellar divisions. With varying forced eyelid closure.
degrees of levator aponeurosis fibers passing through the The upper and lower pretarsal segments overlay
orbicularis oculi and inserting into the overlying soft the tarsal plates and originate from the confluence of
tissues, the upper lid crease is produced. superficial and deep heads at the medial canthal tendon.
The preseptal muscular segments of the upper and lower
lids overlay the orbital septum and arise from the borders
Orbicularis Oculi of the medial canthal tendon. The pars palpebrarum
The orbicularis oculi is a contiguous muscle composed then extends laterally, in a horizontal fashion, to form
of pretarsal, preseptal, and orbital segments, which the lateral canthal tendon. Of interest, these muscles do
 ANATOMY FOR BLEPHAROPLASTY AND BROW-LIFT/RIDGWAY, LARRABEE 179

not directly insert upon the lateral orbital rim, but are from the common tendon and extends posteriorly
stabilized by their ligamentous attachment to the lateral along the lacrimal sac. Insertion occurs along the
canthus. posterior lacrimal crest, anterior to Horner’s muscle,
The orbital segment (pars orbitalis) of the orbi- and onto the lacrimal sac itself. Disruption of this
cularis oculi is an extensive series of concentric striated canthal segment will result in anterior displacement of
muscular loops that originate from the maxillary and the MCT. The superior arm has fibrous origins from
orbital processes of the frontal bone as well as the medial both the anterior and posterior arms, providing a soft
canthal tendon. These muscular loops course along the tissue ceiling for the lacrimal sac fossa.2 Within this
orbital rim with extensions superiorly onto the forehead, complex array of fibrous bands rests the lacrimal sac,
3 to 4 cm beyond the lateral canthus, and inferiorly to the isolated soft-tissue pump of the lacrimal drainage
variable distance across the cheek. Unlike the pars system.
palpebrarum, there is no interruption at the lateral The lateral canthal tendon (LCT) is formed by
commissure. The orbital segment overlies the frontalis the lateral fibrous crural extensions arising from the
and corrugator supercilii muscles with interdigitation upper and lower tarsal plates. The crura unite to form
along its superior border. Zygomatic and temporal a common tendon that traverses the orbital septum to
branches of the facial nerve provide innervation of the insert onto the lateral orbital tubercle, 1.5 mm posterior
muscle along its undersurface. to the lateral bony orbital rim. The LCT is 10.6 mm in
Posterior to the orbicularis oculi, and anterior to length and 6.6 mm in width along the lateral orbital rim.
the orbital septum, is the postorbicular fascial plane. Superiorly, the tendon is contiguous with the lateral

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This avascular plane extends to the eyelid margin and horn of the levator aponeurosis, whereas the posterior
allows for bloodless dissection and identification of the aspect is contiguous with the lateral check ligament of
orbital septum. the lateral rectus muscle.3 This posterior relationship is
responsible for the posterolateral displacement of the
canthus during lateral gaze.
Tarsal Plates
Each crescent-shaped tarsal plate measures 29 mm in
length and 1 mm in thickness. The superior tarsus has a Orbital Septum
height ranging from 8 to 12 mm, whereas the smaller The orbital septum is a firm, inelastic sheet of connective
lower lid tarsus ranges from 4 to 7 mm. The tarsal tissue that is commonly noted to begin at the arcus
plates, together with the medial and lateral tendons, marginalis along the bony orbital rim but actually rep-
form the tarsoligamentous sling, which provides sup- resents a continuation of the inner orbital fascial system.
port for the eyelids. Additionally, they provide the The septum serves as a structural and functional barrier
lattice for the insertion of the orbital septum and the against pathogenic invasion and anterior displacement of
muscles of eyelid retraction. the orbital fat pads. In the Occidental upper lid, the
The pretarsal skin is firmly attached to the under- orbital septum directly inserts into the levator aponeu-
lying tarsal plate, which is composed of dense connective rosis at or just above the lid crease. This commonly
tissue. Contrarily, the highly elastic preseptal skin is represents a distance of 2 to 3 mm above the tarsal plate
loose in its local soft tissue attachments thereby allowing but has been observed to extend 10 to 15 mm in distance
for the edematous response observed in inflammatory as well.4 Similarly, in the lower lid, the orbital septum
conditions and the postsurgical state. inserts into the capsulopalpebral fascia, the analogue of
the levator aponeurosis for the lower lid, 5 mm from
the inferior tarsal border.
Medial and Lateral Canthi In the lower lid there is a line of fusion at the
The medial canthal tendon (MCT) arises from the bony union of the capsulopalpebral fascia and the orbital
orbit at three separate points, or arms, that then fuse to septum. This develops along an oblique direction from
form a common tendon laterally. This tendon then superomedial to inferolateral and is often visualized
divides laterally into the superior and inferior crura, or during operative dissection. The inferolateral exten-
legs, of the MCT. Subsequently, these fibrous bands fuse sion attaches to the orbital rim by a triangular fascia
along the medial ends of the tarsal plates effectively known as the arcuate expansion. This anatomic rela-
stabilizing the medial aspects of the upper and lower lids tionship is of merit as the lower orbital septum can be
to the medial bony orbit. partitioned into an upper region supported by the
As mentioned, the MCT is stabilized along capsulopalpebral fascia and a weaker, lower orbital
three separate points: anterior, posterior, and superior. septum that is not so supported.5 Attenuation of the
The anterior arm inserts onto the maxillary crest, lower orbital septum with pseudoherniation of the
anterior to the lacrimal crest, and provides the majority orbital fat results in the classic appearance of the aging
of the MCT’s strength. The posterior arm originates lower lid.
180 FACIAL PLASTIC SURGERY/VOLUME 26, NUMBER 3 2010

Eyelid and Preaponeurotic Fat from the trochlea to the lateral orbital rim, under the
The orbital septum is the defining boundary between the lacrimal gland. At Whitnall’s ligament, the levator
eyelid and orbital fat compartments. Adipose located muscle is redirected from a horizontal to a vertical
anterior to the orbital septum (preseptal) represents the direction. It is also in this region that the levator muscle
eyelid fat, whereas a posterior location to the septum transitions from its proximal muscular component to the
(postseptal) represents the orbital fat. Anterior to the distal aponeurosis.9
orbital septum, but posterior to the orbicularis oculi, is The levator aponeurosis ranges from 14 to 20 mm
the retro-orbicularis oculi fat (ROOF) and the suborbi- in length from Whitnall’s ligament and forms lateral
cularis oculi fat (SOOF). The crescent-shaped ROOF is and medial horns along its respective borders. The
located in the upper eyelid, lateral to the supraorbital lateral horn is a strong and complex fascial system that
nerve, inferior to the interdigitation of the frontalis and essentially isolates the lacrimal gland from the remain-
orbicularis oculi muscles, and mostly above the supra- ing orbit, delineates palpebral and orbital components of
orbital rim. The ROOF is implicated in lateral upper lid the lacrimal gland, and attaches to the lateral orbital
bulkiness of the aging eye.6 In comparison, the SOOF is tubercle. The medial horn is less well developed and
attached at the level of the arcus marginalis along the inserts along the medial canthal tendon. In recent studies
inferior orbital rim. Its descent has been related to the of the Asian eyelid, the levator aponeurosis has been
development of the tear trough deformity and to hol- noted to be composed of two separate layers. The
lowing along the orbital rim. anterior layer ends at the junctional region of the orbital
The orbital fat is arranged into separate compart- septum and submuscular fibroadipose tissue, whereas the

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ments, or pockets, in the upper and lower eyelids. The posterior layer extends to the anteroinferior third of
medial fat pockets contain a whiter and more fibrous the upper lid tarsus.10 Taken together, the anterior and
adipose tissue in comparison with the bright-yellow fat posterior layers retract the preaponeurotic fat pad and
observed in the central and lateral pockets. In the upper the anterior lamella.
eyelid there are only the medial and central fat pockets, The upper lid crease is formed by the subcuta-
also referred to as the nasal and preaponeurotic fat, neous insertion of the levator aponeurosis into the
respectively. Each compartment is located posterior to overlying lamella. At its central point, the horizontal
the orbital septum and anterior to the levator aponeu- lid crease is located 8 to 11 mm above the eyelid margin.
rosis. This relationship is of critical importance in ptosis In the Asian eyelid, the upper lid crease is deficient or
surgery as well as maneuvers in a previously traumatized even absent due to a distal insertion of the orbital
or operated field. The medial and central fat pockets are septum onto the levator aponeurosis. This configura-
partitioned by the trochlea and fibrous strands from tion allows for the descent of the preaponeurotic fat
Whitnall’s ligament.7 Laterally, in the upper lid, the into the eyelid and the partitioning of the levator
lacrimal gland is located along the undersurface of the aponeurosis from the orbicularis septa.11
orbital rim and is readily discerned from the adjacent Underlying the levator aponeurosis is the sym-
central fat. pathetically innervated tarsal muscle of Müller. This
Within the lower eyelid there are three pockets: smooth muscle originates from the undersurface of
medial, central, and lateral. The medial and central fat the levator muscle, just distal to Whitnall’s ligament,
pockets are partitioned by the inferior oblique muscle, and inserts along the superior tarsal border.12 The
and the arcuate expansion represents the division of the contraction of this muscle contributes to a few milli-
central and lateral compartments. meters of upper eyelid elevation and is notably af-
The lateral fat pad of the lower lid has been noted fected in sympathetic disruption as seen in Horner’s
to have more than one subsection, accounting for the syndrome.
continued appearance of pseudoherniated fat despite The primary retractor of the lower lid is the fascial
operative blepharoplasty. extension of the inferior rectus muscle, the capsulopal-
pebral fascia. Analogous to the levator aponeurosis of the
upper lid, the fascia develops along the undersurface of
Retractors of the Upper and Lower Eyelids the inferior rectus from the capsulopalpebral head.
The primary retractor of the upper lid is the levator During its extension inferiorly the fascia divides around
palpebrae superioris. This muscle originates along the the inferior oblique muscle, reunites distally, and then
lesser wing of the sphenoid bone, superior to the annulus contributes to the inferior suspensory ligament (Lock-
of Zinn, and extends anteriorly toward the orbital rim. It wood’s ligament). At this point, the majority of fascia
is 36 mm in length and innervated by the oculomotor invests into the inferior border of the lower lid tarsal
nerve (III).8 Within the upper lid, just posterior to the plate. Projections from the capsulopalpebral fascia also
superior orbital rim, the levator muscle is surrounded by fuse with the orbital septum as well as the anterior
the fascial sheath of the superior suspensory ligament of lamella to ultimately define the transverse crease of the
Whitnall. This horizontal fascial band extends medially lower lid.
 ANATOMY FOR BLEPHAROPLASTY AND BROW-LIFT/RIDGWAY, LARRABEE 181

The inferior tarsal muscle, also known as Müller’s Blood Supply, Lymphatics, and Innervation
muscle, lies under the fascia as observed in the upper lid.
The fibers are sympathetically innervated and composed VASCULAR SUPPLY
of smooth muscle. The muscle arises near the capsulo- The vascular supply to the eyelids and brow is complex
palpebral head and inserts a few millimeters below the with contributions from both the internal and external
inferior tarsal border. carotid systems. The ophthalmic artery is the first branch
of the internal carotid artery and supplies the optic nerve,
globe, orbital soft tissues, and overlying eyelids. The
Conjunctiva artery traverses the orbital space in an anteromedial
The conjunctiva is a translucent mucous membrane direction with extensive vascular arborization. Near the
that lines the posterior regions of the eyelids (palpebral orbital apex, the ophthalmic artery gives rise to the
conjunctiva) and the anterior globe (bulbar conjunctiva) lacrimal and supraorbital arteries. The supraorbital artery
but spares the corneal surface. The palpebral conjunctiva passes forward joining the supraorbital nerve and exits
is notably attached to the posterior tarsal plates and the the orbit along the supraorbital notch or foramen, if
undersurface of Müller’s muscle. The palpebral and present, to supply the brow and forehead.
bulbar conjunctiva unite along the arch-like folds, or The distal extension of the ophthalmic artery, the
fornices, located at the apical interface of the eyelids and nasofrontal artery, divides into the supratrochlear and
globe. dorsonasal arteries, posterior to the trochlea. The supra-
trochlear artery continues along an anterosuperior course

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to supply the soft tissues of the forehead and scalp. The
Lacrimal System dorsonasal artery continues in a more medial direction,
The lacrimal system is responsible for the corneal pro- between the MCT and trochlea, and gives rise to the
tective effects of tear formation, distribution, and elimi- medial palpebral artery before supplying the soft tissues
nation. In normal circumstances, there is a constant of the upper nose and medial forehead. The medial
production of a trilayered tear film beginning in the palpebral artery subsequently divides into the superior
superolateral conjunctiva. The inner mucoprotein layer and inferior portions. These vessels pass horizontally to
is the product of goblet cells located in the conjunctiva, join with the lateral palpebral arteries of the lacrimal
glands of Manz, and crypts of Henle. The intermediate artery and compose the marginal arcade for the upper
aqueous layer is secreted by the main lacrimal gland in and lower lids.
addition to the accessory lacrimal glands of Kraus and The marginal arcade system of the eyelids exists 2
Wolfring. This layer provides oxygen to the cornea, to 4 mm from the lid margins (lash lines). Within the
removes debris, and provides host antibodies and com- upper lid, a second arcade system, the peripheral arcade,
plement factors. The outer lipid layer is produced by the exists within Müller’s muscle, just superior to the tarsal
meibomian (tarsal), Zeis, and Moll glands to prevent border. Additionally, two other arterial arcades exist
evaporation of the underlying layers.13 The tear film is along the superior orbital rim. These arcades, known
further distributed and eliminated by the lacrimal drain- as the superficial and deep orbital arcades, are observed
age system during the blinking process. along the superficial and deep surfaces of the orbicularis
The puncta represent the starting point of the oculi with their primary arterial contributions from the
lacrimal drainage system and are located 5 to 7 mm supratrochlear artery.14
lateral to the medial canthal angle. The puncta are Vascular contributions from the external carotid
directed toward the globe, with the inferior puncta artery include the infraorbital artery, the superficial
located slightly more lateral than its superior counter- temporal artery, and the terminal branch of the facial
part. Tears pass from the medial canthal area, through artery, the angular artery. The lacrimal artery, as men-
the puncta, and into the upper and lower canaliculi. A tioned, arises from the ophthalmic artery near the orbital
canaliculus has a short 2-mm vertical segment and an apex but has also been noted to arise from the external
8-mm horizontal component joined together by a dilated carotid system in 20% of patients.15
region known as the ampulla. The canaliculi often join to
form a common canaliculus but have been known to LYMPHATIC DRAINAGE
insert into the lacrimal sac independently as well. The The lymphatics of the eyelids are rich and complex with
lacrimal sac rests in the bony lacrimal fossa and is distribution to both the superficial parotid and sub-
separated into a fundus and body. The fundus extends mandibular lymph nodes. Drainage of the medial eye-
5 mm above the MCT, and the body extends 10 mm lids follows the course of the facial vein and leads to the
inferiorly to give rise to the nasolacrimal duct. The duct submandibular nodes, and lateral lymphatics lead to the
is divided into an intraosseous portion that traverses the preauricular lymph nodes of the parotid gland. How-
nasolacrimal canal and a distal membranous portion that ever, recent primate model research characterizes a
opens into the inferior meatus of the nasal cavity. more complicated pattern of lymphatic drainage in
182 FACIAL PLASTIC SURGERY/VOLUME 26, NUMBER 3 2010

which there is dual drainage of the central upper eye- subunits: the central forehead, lateral temporal units,
lid.16,17 Additional divisions of the eyelid lymphatic and the eyebrows. The bony landmarks of the zygomatic
drainage include a superficial (subcutaneous) pretarsal arches, orbital rims, and nasal root represent the lower
system and a deep posttarsal system. These distribution anatomic boundaries, and a natural hairline represents
patterns have been classically described, but debate the upper limits. The temporal line divides the lateral
continues about the various relationships of the eyelid forehead from the temporal regions, and the orbital rim
lymphatic systems and the postoperative complication serves as a consistent marker in the evaluation of brow
of chemosis. ptosis.
An understanding of subunit interrelation is es-
INNERVATION sential for conceptual planning as well as surgical out-
The capacity for touch, temperature, pain, and proprio- come. The central forehead is a direct extension of the
ception of the orbital soft tissues and eyelids is provided scalp and is layered, from superficial to deep, with skin,
by the ophthalmic (CN V1) and maxillary (CN V2) connective tissue, galea aponeurotica, loose areolar tis-
divisions of the trigeminal nerve (CN V). The ophthal- sue, and periosteum. The first three layers of the central
mic division divides into the frontal, lacrimal, and naso- forehead are tightly held together in contrast with the
ciliary nerves at its distal branches. The largest branch of loosely attached skin and fascia of the temporal region.
the ophthalmic nerve, the frontal nerve, divides anteriorly Within the soft tissues overlying the superciliary ridges is
to become the supraorbital and supratrochlear nerves. a confluence of muscular insertions that include the
These nerves are the primary means for sensation of the paired frontalis, orbicularis oculi, corrugator supercilii,

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upper eyelid and forehead. The supraorbital nerve exits procerus, and depressor supercilii muscles. The interplay
the orbit along the supraorbital notch, or foramen, and of these muscles is responsible for the wide array of brow
the supratrochlear nerve exits the bony orbit along the expressions as well as the associated changes observed
undersurface of the corrugator supercilii muscle. with aging.
Sensation of the medial canthus is provided by the
terminal branch of the nasociliary nerve, the infratro-
chlear nerve. The infraorbital nerve provides the remain- Soft Tissue Divisions
ing sensation of the lower lid. The galea aponeurotica separates along the superior
origin of the frontalis muscle to form the superficial
and deep galeal planes. These planes envelop the muscles
BROW-LIFT ANATOMY along their anterior and posterior surfaces and extend to
The eyebrows create an aesthetic relief along the upper the lower forehead. Along the brow region, numerous
orbital rim that provides communicative, emotional, and fibrous septa from the paired muscles penetrate the thin
protective functions as well as recognizable features that superficial galea and interdigitate into the orbicularis
are often integrated into an individual’s identity of self. oculi, procerus, and the overlying dermis. Contraction of
With a variety of potential shapes, the eyebrow reflects the frontalis muscles is the primary elevating mechanism
the interplay of the brow and forehead musculature of the eyebrow and the process by which transverse
along its medial head, central peak and lateral tail. forehead rhytides are produced. At the level of the
Once again, anatomic understanding is central to surgi- midforehead, the deep galea plane divides into anterior
cal approach. and posterior fascial planes, which then envelop the
The ideal female brow, as classically presented by fibrofatty brow fat pad.20 The eyebrow fat pad underlies
Westmore, included placement of the medial brow along the forehead musculature and facilitates the movement
the vertical plane of the alar-facial junction, ending of the eyebrow along the bony orbital margin.21 Ana-
laterally at an oblique line drawn from the lateral alar tomic characteristics include posterior relation to the
point through the lateral canthus, and positioning of the orbicularis oculi, anterior relation to the orbital septum
medial and lateral ends of the eyebrow near a horizontal and bony rim, lateral attachment to the superior orbital
level.18 Location of the ideal brow apex has ranged from rim, and an extension from the superior orbital nerve to a
above the lateral limbus to the lateral canthus with varying lateral distance along the lateral bony orbit.6,22
current concepts resting somewhere in-between.18,19 Although subdivisions of the brow fat pad have been
The male eyebrow is stationed lower and along the level described and include the ROOF and superficial tem-
of the supraorbital rim, less arched in dimension, and poral fat, it is also valuable to anatomically consider brow
complimented by a prominent lateral brow. fat as a whole as well.
Beneath the deep galeal plane, and above the
calvarial periosteum, is the subgaleal plane. Composed
Forehead of loose areolar tissue, this layer is bound by the
The soft tissues of the forehead represent the upper third temporal lines laterally and the fusion of the deep
of the face and are divided into the five aesthetic galeal plane with periosteum along the lower forehead.
 ANATOMY FOR BLEPHAROPLASTY AND BROW-LIFT/RIDGWAY, LARRABEE 183

The ease of visualized dissection in this region pro- Tissue Dynamics

duces an optical cavity in which the eyebrows and Surgical considerations in the treatment of brow ptosis
nasal dorsum may be endoscopically approached from are intimately linked with soft tissue forces of the fore-
above. head, brow, and temporal regions. To this end, evalua-
Continuing laterally toward the temporalis muscle, tion of the brow elevators and depressors is paramount.
the galea aponeurotica merges with the superficial tem- The frontalis muscle is the primary brow elevator with
poral fascia, also known as the temporoparietal fascia, strong medial and central brow activity but tapered
at the temporal fusion line. The superficial temporal fascia activity in the lateral brow. The eyebrow depressors
is continuous with the superficial musculoaponeurotic include the corrugator supercilii, procerus, orbicularis
system (SMAS) of the lower face and overlays the oculi, and depressor supercilii muscles. The corrugator
superficial temporal fat pad. Under the superficial supercilii traverses the brow fat pad laterally to insert, in
temporal fascia, and directly over the temporalis wide fashion, into the overlying dermis and create
muscle, is the deep temporal fascia (Fig. 2). This fascia characteristic vertical glabellar furrows. By contrast, the
divides into intermediate and deep temporal fascia procerus muscle produces horizontal rhytides as a result
layers at the level of the supraorbital ridge with the of a near-vertical muscular contraction from its bony
intermediate fat pad residing between these layers.23 nasal origin. The orbicularis oculi and depressor super-
The intermediate and deep temporal fascia attach to the cilii muscles augment the depressor influence against the
superior ridge of the zygomatic arch at their respective frontalis muscles, deficient lateral brow elevators, and
lateral and medial locations. Medial to the deep tem- gravitational descent of the temporal soft tissues. Taken

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poral fascia is the deep temporal fat pad. Caution is together, these forces dictate brow appearance and
taken to avoid injury of this structure as the develop- reasonably account for the earlier and greater ptosis of
ment of a temporal wasting may occur. the lateral eyebrow over time. When aiming to surgically
counteract these forces, one must attend to the conflu-
ence of connective tissue between the superficial tempo-
ral fascia and the underlying zygomaticofrontal suture
line.24 This tissue, known as the orbital ligament, tethers
the eyebrow, restricts superior mobility, and compro-
mises surgical efforts if left untransected.

Vascular Supply
The vascular supply to the forehead is a continuation of
the vascular supply to the orbit with contributions from
both the internal and external carotid systems as pre-
viously noted.

Facial and Sensory Nerves

The muscles of brow and forehead expression are in-
nervated by the various branches of the facial nerve
(CN VII). Innervation of the frontalis and corrugator
supercilii muscles is provided by the temporal branch of
CN VII, whereas the orbicularis oculi receives innerva-
tion from both zygomatic and temporal branches. Each
of these muscle groups receives their innervation along
their posterior surfaces. The procerus muscle receives
innervation exclusively from the buccal branch of the
facial nerve.
The temporal branch of the facial nerve exits the
substance of the parotid gland and enters the SMAS.
Figure 2 Soft tissue layers of the forehead and temporal
Branching of the facial nerve into three to five rami is
region as seen in gross anatomic dissection (Part 1), and the
correlated illustration with labels(Part 2). A, SMAS; B, inter- commonly observed in this region.25 The SMAS is
mediate temporal fascia; C, deep temporal fascia; D, tempor- continuous with the superficial temporal fascia during
alis muscle; E, temporal fusion line; F, calvarium; G, the temporal rami course over the zygomatic arch. The
periosteum. (Copyright # 2010 J.M. Ridgway, M.D. Used temporal rami cross the zygomatic arch 2.5 cm ante-
with permission.) rior to the external auditory canal (0.8 to 3.5 cm) but
184 FACIAL PLASTIC SURGERY/VOLUME 26, NUMBER 3 2010

CONCLUSION
The soft tissues of the eyelid, brow, and forehead are
complex in their anatomic, physiologic, and surgical
relationships. The cornerstone of any surgical under-
taking is a comprehensive understanding of surgical
goals and the means by which they are achieved. What
is required more than a physician’s ability to become the
master of surgical technique is to remain a student of
anatomy as well.

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