Upper and Lower Eyelids

These are composed of an anterior lamella and posterior lamella separated by the orbital septum. The anterior lamella is formed by the skin and underlying orbicularis oculi muscle. The orbital septum, originating from a band of thickened periosteum at the orbital rim (the arcus marginalis), separates both lamellae and is often referred to as the middle lamella.

The posterior lamella is composed of the tarsal plate, eyelid retractors, and conjunctiva. Fibers from the capsulopalpebral fascia attach to the anterior lamella a few millimeters below the tarsus to form the lower eyelid crease. The forces imposed by the lower eyelid retractors and the canthal ligaments determine the position of the lower eyelid margin.

Orbit

The eyes are suspended in the orbital socket by the ocular muscles, the optic nerve and blood vessels, and periorbital fat, which often visibly bulge in the aging face. In the upper eyelid, there are two medial fat pads communicating directly with retro-ocular fat and one long lateral fat pad situated immediately anterior to the levator palpebrae superioris in the supraorbital sulcus. In the lower eyelid, there are three compartments, with the medial and intermediate pads separated by the inferior oblique muscle and the lateral pad held within its own fascial compartment.

Infraorbital Region

This is divided into medial and lateral parts by the course of the facial vein, typically coursing in a line 4 to 6 mm medial to the midpupillary line. The medial part is formed of two layers, the skin and the orbicularis oculi muscle, which is firmly attached to the underlying bone.

In the lateral part of the infraorbital region, seven different layers can be identified—the skin, subcutaneous fat layer, orbicularis oculi muscle, SOOF, deep fascia (continuation of the superficial lamina of the deep temporal fascia), prezygomatic fat layer, and periosteum.

The orbicularis oculi muscle is attached to the orbital rim by the orbicularis-retaining ligament. The zygomatic ligament is a true osseocutaneous ligament that originates from the periosteum of the zygoma and/or the zygomatic arch and attaches to the overlying skin.

The malar fat pad is located in the superficial fat layer of the midface, below the zygoma. This layer also comprises the nasolabial fat and jowl fat pads. Reflection of this subcutaneous fat layer and the orbicularis oculi muscle will expose the SOOF superolaterally and deep cheek fat inferomedially.

The SOOF is a layer of periorbital fat that lies deep to the superficial malar fat pad and the orbicularis muscle of the lower eyelid, extending superiorly to the lateral canthus. The tear trough forms the inferior boundary of the SOOF, and the lateral orbital thickening forms the superior boundary. SOOF has a horizontal medial component and a larger vertical lateral component. Symmetric SOOF elevation is important when considering a midface lift using a subciliary approach (Hamra).

The ROOF is analogous to the SOOF except that it is located in the upper eyelid deep to the orbicularis oculi and above the orbital fat pads in a separate layer. ROOF ptosis contributes to eyebrow ptosis in the aging face. Brow elevation lifts the ROOF; it is not a good idea to remove the ROOF ( Figs. 9.2, 9.3 and 9.4 ).

Preoperative frontal view of asymmetric eyebrow positioning in a 49 year old ex-boxer. There has been previous trauma to the right lateral eyebrow and a clinician’s attempt to rebuild the brow using filler. This has resulted in a residual lump. The brow ptosis and more significant eyelid hooding is over the untethered left ROOF hence the asymmetry.

A perioperative view of the same patient, clearly demonstrating the exposed right ROOF. The brow tissues are being easily manipulated upwards and are sliding over the ROOF. The ROOF is a frictionless fat pad that allows free movement and expression of overlying adjacent tissues, providing there is adjacent motor activity of course.

A postoperative view of the same patient following a standard upper eyelid blepharoplasty with ROOF preservation. The filler “lump” is still apparent. Any attempt to remove it surgically would create a significant contour defect.