the zygomatic ligament of the face: a critical reviematic space, an important area of the midface....

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Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

F : Rossell-Perry P. The zygomatic ligament of the face: a critical review. OA Anatomy 2013 Feb 06;1(1):3.

The zygomatic ligament of the face: a critical review

P Rossell-Perry*

AbstractIntroductionThe soft tissue of the face covers the underlying bony structures and is supported by ligaments that run from deep within the dermis to the overlying layers of the skin, serving as anchoring units for the face. The zygomatic ligament of the face is an osteocutaneous ligament that originates from the periosteum of the zygoma and/or the ante-rior and lateral border of the zygo-matic arch (posterior to the origin of the zygomaticus minor muscle). It is found inserted into the super-ficial muscular aponeurotic system which is connected to the dermis of the cheek. This ligament restrains the facial skin against gravitational changes and delineates the anterior border of the cheeks. Attenuation of support from this ligament is respon-sible for many changes that occur during facial aging. The main appli-cation of this anatomical structure is in cosmetic surgery. The surgical correction of the retaining ligaments of the face, plication of the superficial muscular aponeurotic system and repositioning the soft tissues of the face, are all common techniques used in the rejuvenation of the face. An overview of the literature regarding the location of the zygomatic liga-ment, its important relations and clinical applications are reviewed in this article.ConclusionThe zygomatic ligament consists of the prezygotmatic space, zygomatic

branches of the facial nerve and the zygomaticofacial nerve. The main application of the zygomatic liga-ment is in cosmetic surgery. Further studies are necessary to establish relationships between the zygomatic ligament and variables such as age, sex, race and other such factors.

IntroductionThe zygomatic ligament was initially described by McGregor in 19591. He described this anatomical struc-ture in relation to his surgical tech-niques for facial rejuvenation during the Annual Meeting of the Cali-fornia Society of Plastic Surgeons in Yosemite, California1. However, Mrs. Rosebud Preddy, a medical artist at the Letterman General Hospital in San Francisco, California, denomi-nated the ligament as ‘McGregor’s patch’ when she prepared a slide presentation for Dr. Mar McGregor2.This denomination has persisted since. McGregor described the liga-ment as, ‘An area of fibrous attach-ment between the anterior edge of the parotid fascia and the dermis of the skin of the cheek’1. His facelift procedure did not recommend exten-sion of the undermining skin beyond this patch. Plastic surgeons have mainly contributed in the study of the zygomatic ligament. Most of their publications are descriptive studies (outcome studies).The first good description of the anatomy of face ligaments was provided by Furnas in 1989 2. The zygomatic ligament was described as, ‘a bundle of white firm fibres, 3 mm in width and 0.5 mm in thickness, located 4.5 cm in front of the tragus’. He also described that ‘the ligament is 6 to 8 mm in length, travelling directly from the zygomatic bone to the dermis’2. The article was limited in its analysis of the anatom-ical relations of the ligament and its

histological description. He consid-ered the face ligaments as a reminis-cent of the retaining ligaments of the finger. It was found that these liga-ments stabilise the skin of the fingers in order to allow better tactile func-tion3. Similar descriptions have been presented with regard to the tissues of the breast and feet4. The concepts described by Furnas were further elucidated by Stuzin et al. in 19925. Stuzin et al.5,6 described the zygo-matic and mandibular ligaments as being osteocutaneous (i.e. originating from the periosteum and inserting directly into the dermis). The other supporting ligaments are formed as a coalescence that occurs between the superficial and deep facial fascia in certain regions of the face, e.g. the masseteric ligament. Owsley7 and Kaye8 provided a brief description of the zygomatic ligament as, ‘a vertical septum between the masseteric fascia and SMAS’ and ‘an adherent area over the malar eminence’, during facelift procedures. The ligaments of the face have been classified by Moss et al.9 as true ligaments, septa and adhesions. The zygomatic and masseteric ligaments are considered as true ligaments. A true ligament is a discrete cylindrical arrangement of fibrous tissue that is surrounded by fatty tissue. Microscopic examination of these ligaments showed bands of dense connective tissue. These liga-ments are known to arise from the deep fascia or periosteum and cross the sub superficial muscular aponeu-rotic system (SMAS) plane and the SMAS, where they divide into several branches which distribute the attach-ment of the ligament to the dermis. Rossell-Perry et al.10 conducted a recent study to understand the liga-mentous attachments of the face and found both types of ligament struc-tures for the masseteric ligament

Clin

ical Anato

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* Corresponding authorE-mail: [email protected]

San Martin de Porres University, Schell St No 120 Apt., 1503 Miraflores, Lima, Peru



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(true ligament and septa). Ozdemir et al.11 and Rohrich et al.12 conducted histological studies of the facial liga-ments. The length of the ligament ranged from 7 mm to10 mm between the skin and the zygoma and had significant collagenised connective tissue formation as described by histological examination. Rohrich et al.12 also described subcutaneous fat compartments in the face, limited by ‘septa’ originating from the under-lying fascia and inserting into the dermis of the skin. Histological examination of the area between the nasolabial fold and the medial cheek showed a fibrous structure that inserts into the dermis of the skin. This structure is termed by these authors as the ‘middle cheek septum’. A good description of the location and relations of the zygomatic ligaments has been published by Mendelson et al.13-16. They described the prezygo-matic space, an important area of the midface. This space is a junction area between the orbicularis retaining

ligament (above), orbicularis oculi muscle and sub orbicularis oculi fa tpad (anterior), the zygomatic liga-ments (below),the zygoma and preperiosteal fat (posterior) and the lower temple (laterally). Recent studies about the zygomatic ligament have described its anatomy, functional characteristics and biomechanical properties17,18. Brandt et al.17 showed that the zygomatic ligament is the strongest and stiffest retaining structure in the face. In addition, they did not find any variations in the dimensions and biophysical properties of the ligament in relation with hemiface, age or sex. This critical review discusses the anatomy and the reconstructive applications of the zygomatic ligament.

Discussion

There are four main ligaments in the face: zygomatic, masseteric (or parotidomasseteric), mandibular and platysmaauricular2,5 (Figure 1). Other minor structures in the face are the preauricular parotid, SMAS malar and the anterior platysma cutaneous ligaments11. The soft tissue of the face is supported over the under-lying bony structures by these liga-ments that run from deep within the dermis to the overlying layers of the skin through the retinacula cutis, fixing facial structures and serving as anchoring units for the face. The retinacula cutis is a connective tissue composed of numerous small fibrous

Figure 1: Location of the main re-taining ligaments of the face.1: Orbital rim; 2: Zygomatic ligaments; 3: Masseteric ligaments; 4: Mandibu-lar ligament; 5: Gonion; 6: Menton; 7: Tragus; 8: Malar fat pad; 9: Mas-seter muscle; 10: Zygomatic arch; 11: Superficial muscular aponeurotic system (SMAS).Black arrow: entrance to the prezy-gomatic space.

Figure 2: The zygomatic ligament of the face and its relations.1: Zygomatic ligaments; 2: Orbicularis retaining ligament; 3: Sub orbicularis oculi fat pad; 4: Orbicularis oculi muscle; 5: Zygomatic major muscle; 6: Facial artery; 7: Facial vein; 8: Buccal branch to the orbicularis oculi muscle from the facial nerve; 9: Eyelid.Black arrow: entrance to the prezy-gomatic space.

Figure 3: The zygomatic ligament of the face and the prezygomatic space.1: Zygomatic ligaments; 2: Zygo-matic major muscle; 3: Orbicularis retaining ligament; 4: Orbital rim; 5: Zygoma; 6: Orbicularis oculi mus-cle and sub orbicularis oculi fat pad; 7: Cutaneous flap; 8: Bichat´s fat pad; 9: Malar fat pad.Black arrow: entrance to the prezy-gomatic space.

Descriptive anatomy

conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies.

The author has referenced some of its own studies in this review. These referenced studies have been

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form an interconnecting framework that limits shearing forces on the fa-ce. This framework provides a ‘re-taining system’ for the human face12.

Superficial AnatomyFurnas described the location of the zygomatic ligaments as being 4.5 cm in front of the tragus2. In a recent publication, Rossell-Perry et al.10 found the location of the zygomatic ligament to be 4.3 cm to 5.5 cm in front of the tragus (average: 5.0 +/− 0.336). Ozdemir et al.11 found the location of the zygomatic ligament to be 4.2 cm to 4.8 cm in front of the tragus in men and 3.9 cm to 4.5 cm in women. This is less evident in younger people and more obvious in the elderly. The proximal inser-tion is usually not related to the age, as described by Furnas, and remains unchanged during the process of aging21. Raksin et al.22 observed that the location of the zygomatic ligaments was mildly affected by age. The localisation of the zygo-matic ligaments may vary depending on age (distal insertion only), sex, race and populations. There are no studies describing the anatomic vari-ations of the zygomatic ligament for these variables.

RelationsThe most important relations of the zygomatic ligaments are: 1) above, the prezygomatic space and the zygo-maticofacial nerve, a branch of the maxillary division of the trigeminal nerve (Figures 3 and 4); 2) medi-ally, buccal branch of the facial nerve to the orbicularis oculi muscle, the infraorbitary nerve and the malar fat pad (Figure 2); 3) below, the upper zygomatic branch of the facial nerve, zygomatic muscles, transverse facial artery, parotid duct, Bichat´s fat pad and masseteric ligaments (Figures 5, 6 and 7) and 4) laterally, the lower temple.

FunctionThe importance of the zygomatic ligament lies in its ability to suspend malar soft tissue over the zygomatic eminence. The ligament efficiency depends on the width of its attach-ments to the skin and if small, the

Figure 4: Structures above the zygo-matic ligament.1: Zygomatic ligaments; 2: Cutane-ous flap; 3: Orbicularis oculi muscle; 4: Lateral canthal tendon; 5: Lateral orbital rim; 6: Zygomatic arch; 7: Zy-gomatic orbital artery; 8: Frontal branches of the facial nerve; 9: Su-perficial temporal fascia (divided); 10: Deep temporal fascia (divided); 11: Temporal muscle; 12: Superficial muscle aponeurotic system (SMAS); 13: Orbicularis retaining ligament; 14: Malar fat pad.Black arrow: entrance to the prezy-gomatic space.

Figure 5: Relations between the zygomatic ligament and branches of the facial nerve.1: Zygomatic ligament; 2: Zygomatic minor muscle; 3: Zygomatic major muscle; 4: Orbicularis oculi muscle and sub orbicularis oculi fat pad; 5: Zygomatic branches of the facial nerve; 6: Bichat´s fat pad; 7: Zygoma; 8: Malar fat pad; 9: Buccal branch of the facial nerve;10: Orbicularis retaining ligament; 11: Facial vein.Black arrow: entrance to the prezy-gomatic space.

Figure 6: Structures below the zygo-matic ligaments.1: Location of the zygomatic liga-ment; 2: Zygomatic major muscle; 3: Auricular temporal nerve; 4: Tem-poral division of the facial nerve; 5: Parotid duct; 6: Cervical division of the facial nerve; 7: Masseter muscle; 8: Risorius; 9: Marginal branch of the facial nerve; 10: Facial vein; 11: Facial artery; 12: Depressor angularis oris muscle; 13: Malar fat pad; 14: Modi-olus; 15: Bichat´s fat pad; 16: Zygo-matic branch of the facial nerve; 17: Cervical branch of the facial nerve; 18: Parotid gland (retracted).

strands that extend through the superficial fascia, attaching the deep surface of the dermis to the under-lying deep fascia, determining the mobility of the skin over the deep structures4,19. The zygomatic liga-ment, as described by Stuzin et al., is not a single structure5,6. The original description of the ‘McGregor patch’ refers to the main component of these series of fibrous tissues that begin laterally where the zygomatic arch joins the body of the zygoma. This main structure extends through the malar fat pad and inserts into the overlying malar skin2,20. An isolated structure originates along the most medial portion of the zygoma near the zygomaticomaxilla-ry suture5 (Figure 2). These septa



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ligament can stretch in time. The downward movement of the malar fat pad mainly results from lack of ligament support, which is one of the main reasons for an aging face. The malar fat pad protects the thin anterior wall of the maxilla and the maxillary sinus against traumas23. Rohrich et al.12 suggested that these septa and ligaments stabilise the blood supply to the skin. The septal membranes are located in the vascular zones that occur between the anatomical compartments. This is particularly evident in the medial face, where perforators from the transverse facial artery and angular artery are found. In addition, the zygomatic ligaments may aid in the prevention of the lower eyelid ectro-pion24,25. Defects of the midface with absence of the zygomatic ligament and repaired with flaps may develop lower eyelid ectropion26.

InnervationBranches from the zygomaticofacial nerve and infraorbital nerve provide sensation to the zygomatic ligaments.

Blood supplyBranches from the transverse facial artery, angular artery and infraor-bital artery provide blood supply to the zygomatic ligaments. Venous

drainage is carried out through the venous plexus formed mainly by transverse facial vein and facial (angular) vein.

Clinical applicationsThe main application of these anatomical structures is in cosmetic surgery. The surgical correction of the retaining ligaments of the face, plication of the SMAS and reposi-tioning the soft tissues of the face that have descended with gravita-tion, are common techniques used in rejuvenation of the face. Management of facial aging of the nasolabial folds should be carried out by restoration of the malar soft tissue, by repo-sitioning the tissue to its previous position. Improvements in the aging of the face, based on ligamen-tary suspension of the soft tissues, has been described by Aufricht27, Stuzin6, Muzzafar et al.24, Mendelson et al.15,28, Ozdemir et al.11 and other plastic surgeons. These authors have described the importance of the surgical anatomy of the retaining liga-ments of the face and its importance in facelift surgery. Aston29 described a technique for midface elevation and suspension based on fingertip dissec-tion of the malar fat pad through the prezygomatic space. Recently, Rossell-Perry et al. published a tech-nique describing SMAS plication to facial ligaments which is used to improve aging of the nasolabial folds and neck10.

ConclusionThe zygomatic ligament is not a single structure. The original descrip-tion of the ‘McGregor patch’ refers to the main component of these series of fibrous tissues that begin later-ally where the zygomatic arch joins the body of the zygoma. The most important relations of this structure are the prezygomatic space, the zygo-matic branches of the facial nerve and the zygomaticofacial nerve. The main application of these anatomical structures is in cosmetic surgeries (facelift). Further studies are recom-

mended to improve our under-standing of the relationship between the zygomatic ligament and variables such as age, sex, race or other such factors.

Abbreviations listSMAS, superficial muscular aponeu-rotic system.

References1. McGregor M. Face Lift Techniques. Presented to the Annual Meeting of the California Society of Plastic Surgeons. Yosemite, California, 1959.2. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989 Jan;83(1):11–16.3. Grayson J. The cutaneous ligaments of the digits. J Anat. 1941 Jan;75(Pt 2):164–5.4. Nash LG, Phillips MN, Nicholson H, Barnett R, Zhang M. Skin ligaments: regional distribution and variation in morphology. Clin Anat. 2004 May;17(4):287–93.5. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992 Mar;89(3):441–9.6. Stuzin JM. Face lifting. Plast Reconstr Surg. 2008 Jan;121(1 Suppl):1–19.7. Owsley JQ Jr. Platysma-fascial rhyt-idectomy: a preliminary report. Plast Reconstr Surg. 1977 Dec; 60(6):843–50.8. Kaye BL. The extended face-lift with ancillary procedures. Ann Plast Surg. 1981 May;6(5):335–46.9. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and perior-bital regions. Plast Reconstr Surg. 2000 Apr;105(4):1475–90.10. Rossell-Perry P, Paredes-Leandro P. Anatomic study of the retaining liga-ments of the face and applications for facial rejuvenation. Aesthetic Plast Surg. 2012 Oct.11. Ozdemir R, Kilinç H, Unlü RE, Uysal AC, Sensöz O, Baran CN. Anatomicohisto-logic study of the retaining ligaments of the face and use in facelift: retaining liga-ment correction and SMAS plication. Plast Reconstr Surg. 2002 Sep;110(4):1134–47.12. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcuta-neous fat compartments. Plast Reconstr Surg. 2008 May;121(5):1804–9.

Figure 7: Relations of the masseteric ligament.1: Location of the zygomatic ligaments; 2: Masseteric ligament; 3: Cutaneous flap; 4: Buccal branch of the facial nerve; 5: Masseter muscle; 6: Facial vein; 7: Bichat´s fat pad; 8: Zygomatic major muscle; 9: Facial artery.

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13. Mendelson BC. SMAS fixation to the facial skeleton: rationale and results. Plast Reconstr Surg. 1997 Dec;100(7):1834–42.14. Mendelson BC, Muzzafar AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002 Sep;110(3):885–96.15. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments. Clin Plast Surg. 2008 Jul;35(3):395–404.16. Mendelson BC. Facelift anatomy, SMAS, retaining ligaments and facial spaces. In: Aston SJ, Steinbrech DS, Walden JL, editors. Aesthetic Plastic Surgery. London: Elsevier; 2009.p53–72.17. Brandt MG, Hassa A, Roth K, Wehrli B, Moore CC. Biomechanical properties of the facial retaining ligaments. Arch Facial Plast Surg.2012 Jul–Aug;14(4):289–94.18. Hwang K, Kim DH, Kim DJ, Kim YS. Anatomy and tensile strength of the zygo-matic ligament. J Craniofac Surg. 2011 Sep;22(5):1831–3.

19. Stedman TL, editor. Stedman´S Medical Dictionary For The Health Professions and Nursing. 5th ed. Lippin-cott Williams and Wilkins; 2005.20. Bosse JP, Papillon J. Surgical anatomy of the SMAS and the malar region. In: Trans-actions of the 9th International Congress of Plastic and Reconstructive Surgery. New York: McGraw-Hill; 1987.p348.21. Ozdemir R, Kilinç H, Unlü RE, Uysal AC, Sensöz O, Baran CN. Anatomicohis-tologic study of the retaining ligaments of the face and use in facelift: retaining ligament correction and SMAS plication. Plast Reconstr Surg. 2002 Sep;110(4):1134–47.22. Raskin E, Latrenta GS. Why do we age in our cheeks? Aesthet Surg J. 2007 Jan–Feb;27(1):19–28.23. Owsley JQ. Lifting the malar fat pad for correction of prominent nasola-bial folds. Plast Reconstr Surg. 1993 Mar;91(3):463–74.24. Muzzafar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the

ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002 Sep;110(3):873–84.25. Hwang K, Nam YS, Kim DJ, Han SH. Surgical anatomy of retaining ligaments in the periorbital area. J Craniofac Surg. 2008 May;19(3):800–4.26. Zoumalan RA, Murakami CS. Facial flap complications. Facial Plast Surg. 2012 Jun;28(3):347–53.27. Aufricht G. Surgery for excess skin of face and neck. In: Wallace A, editor. Trans-actions II Congress International Society of Plastic Surgeons. London: E & S Living-stone; 1959.p495–502.28. Mendelson BC. Surgery of the superfi-cial musculoaponeurotic system: princi-ples of release, vectors, and fixation. Plast Reconstr Surg. 2001 May;107(6):1545–52.29. Aston SJ. The FAME facelift: finger assisted malar elevation. Presented at The Cutting Edge Aesthetic Surgery Symposium, New York, November 1998.

the zygomatic ligament of the face: a critical reviematic space, an important area of the midface....

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