Anatomy of Lower Eyelid and Eyelid

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ANNPLA-1370; No. of Pages 10
Annales de chirurgie plastique esthétique (2017) xxx, xxx—xxx
Available online at
ScienceDirect
www.sciencedirect.com
Anatomy of lower eyelid and eyelid—cheek

junction
Anatomie de la paupière inférieure et de la jonction
palpébrojugale
A. Mojallal a,*, S. Cotofana b
a
Department of Plastic, Reconstructive and Aesthetic Surgery, Croix-Rousse Hospital, hospices civils de Lyon
(HCL), University of Lyon Claude-Bernard 1, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
b
Department of Medical Education, Albany Medical College, 47 New Scotland avenue MC-135, 12208 Albany,
NY, USA
KEYWORDS Summary
Lower eyelid; Background. — Understanding the anatomy of the lower eyelid and the lid—cheek junction is
Facial fat compartments; important for surgical and non-surgical approaches. It is important to understand the correla-
Aging; tion between the clinical presentation and the individual anatomy to direct an adequate
Subcutaneous fat; treatment.
Soft tissue fillers; Methods. — A review of the literature based on the authors experience combined with
Eyelid anatomy anatomical dissections was conducted to reveal the current concepts of the surgical and
non-surgical anatomy. The various anatomical structures important for the understanding of
the symptoms and the proposed treatment are described in this article.
Results. — The anatomy of the lower eyelid and the lid—cheek junction has to be understood
as a unit. Structures are continuous from the eyelid to the cheek influencing each other during
aging. The concept of superficial, i.e. superficial to the orbicularis oculi muscle and deep facial
fat compartments, i.e. deep to the orbicularis oculi muscle has to be applied in order to
understand the relevant anatomy regarding the ligaments, fat compartments, muscular and
tarsal structures and the vascularization.
Conclusion. — The understanding of the layered arrangement of the lower eyelid and eyelid-
cheek junction anatomy enables practitioners to perform safe and effective surgical and non-
surgical procedures.
# 2017 Elsevier Masson SAS. All rights reserved.
* Corresponding author.
E-mail address: [email protected] (A. Mojallal).
http://dx.doi.org/10.1016/j.anplas.2017.09.007
0294-1260/# 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Mojallal A, Cotofana S. Anatomy of lower eyelid and eyelid—cheek junction. Ann Chir Plast Esthet (2017),
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2 A. Mojallal, S. Cotofana
Résumé
MOTS CLÉS Introduction. — La compréhension de l’anatomie de la paupière inférieure et de la jonction
Paupière inférieure ; palpébrojugale est importante pour les approches chirurgicales et non chirurgicales. Il est
Compartiments de important de faire la corrélation entre la sémiologie, très variable selon l’individu et la structure
graisse faciale ; anatomique pour proposer un traitement adéquat. Nous présentons ici les structures anatomi-
Vieillissement ; ques présentées dans la littérature ainsi que des travaux originaux de dissection.
Graisse sous-cutanée ; Matériel et méthodes. — Une revue de la littérature centrée sur les travaux de dissections
Remplisseurs de anatomiques a été menée afin de révéler les concepts actuels de l’anatomie chirurgicale et non
tissu mou chirurgicale. Les différentes structures anatomiques importantes pour la compréhension des
symptômes et le traitement proposé sont décrites dans cet article.
Résultats. — L’anatomie de la paupière inférieure et de la jonction palpébrojugale doit être
comprise comme une unité. Les structures sont en continuité entre la joue et la paupière et sont
fortement influencées par le vieillissement. Le concept de compartiment superficiel, c’est-à-dire
superficiel au muscle orbiculaire-oculi et compartiments profonds, c’est-à-dire profondément au
muscle orbiculaire, sera décrit ainsi que l’anatomie pertinente concernant les ligaments, les
compartiments graisseux, les structures musculaire et tarsienne ainsi que la vascularisation.
Conclusion. — La connaissance et le respect de l’agencement de l’anatomie du visage en
structures anatomiques indépendantes permet aux praticiens d’effectuer des procédures chir-
urgicales et non chirurgicales sûres et efficaces.
# 2017 Elsevier Masson SAS. Tous droits réservés.
Introduction 0.82 0.21 mm [1]. In the lateral lower eyelid portion, a thin
layer of subcutaneous fat can be observed, which is absent in
Fighting the signs of facial aging using surgical or non-surgical the medial part of the lower eye lid, i.e. the tear trough. Here
approaches has become a popular and widely accepted the eyelid skin overlying the orbicularis oculi muscle is almost
method in today’s society. As the eyes are the central com- translucent and some authors attribute the resulting Tyndall-
ponent of the face and the first aspect when focusing some- effect as the cause for the blueish appearance of the tear
one’s face the appearance of the eyes and their surroundings trough, which can also be observed on the lateral nasal wall
are the key target of most interventions. medially to this area (Figs. 3a, b). The skin overlying the upper
The surrounding structures of the eye influence likewise cheek (malar fat pad) is thicker than the skin of the lower
the appearance, i.e. ‘‘the look’’ of the eye and have to thus eyelid and a substantial amount of subcutaneous fate can be
be treated with greatest care including the forehead, the identified here. The difference between these two types of
position of the eyebrows, the wrinkles of the glabellar area skin (eyelid versus upper cheek) accentuates the eyelid—cheek
and the upper and the lower eyelid. junction deformity. During aging, however, the subcutaneous
The lower eyelid however is of great importance as ther- fat is likewise absent in the lateral part of the lower eyelid
apeutic options influence the appearance of the upper cheek which can increase the palpaebromalar groove deformity and
and the eyelid cheek junction and should thus be considered as lead to the impression of a sunken eye and a skeletonized face.
a unit when treating this area. Different lower eyelid and tear When inspecting the lower eye-lid and the lid—cheek junc-
trough deformities can occur depending on the anatomical tion three creases can be observed (Fig. 1a—e). The most
disposition of underlying structures from lower eyelid hollow- superior is the inferior palpaebral crease which is in general
ness or dark circle to tear trough depression with or without fat covered by the lower lid lashes and is regarded as the location
herniation and skin excess (Fig. 1a—e). where the inferior margin of the tarsus meets with the
As the underlying anatomy cannot be separated between retractor muscles. The other two creases are medially the
the eyelid and the lid—cheek junction, it will be described in nasojugal crease (also termed fold, sulcus or groove) which is
the following as a unit to provide a comprehensive under- located at the inferior end of the tear through and represents
standing of this delicate anatomical region. the location of the angular vein. Laterally, a sulcus is visible,
representing the end of the orbit and the lower eye lid and the
beginning of the zygomatic bone (also termed here malar
Anatomy of the lower eyelid bone) (Figs. 1a—e). Another term for this visible depression
is orbitomalar groove (or hollow), palpaebromalar sulcus (or
The lower eyelid can be separated into an anterior lamella groove or depression) or simply eyelid—cheek junction. How-
containing the skin and the preseptal and pretarsal parts of ever, the correct anatomical term according to the nomina
the orbicularis oculi muscle and into a posterior lamella anatomica [2] is Sulcus infrapalpaebralis which was interest-
containing the tarsus, the orbital septum, the inferior tarsal ingly not adopted by the last facial nomenclature consensus
muscle and the capsulo-palpaebral fascia (Fig. 2). paper published in 1993 by George et al. [3].
Skin Orbicularis oculi muscle
The skin of the lower eyelid can be regarded as one of The orbicularis oculi is a thin muscle consisting of concen-
the thinnest in the human body measuring in mean trically arranged muscles fibres encircling the orbit and can
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Lower eye-lid anatomy 3
Figure 1 Presentation of different clinical cases: a: lower eyelid hollowness and ‘‘dark circle’’; b: prominent tear trough deformity
(note: the deformity starts at the medial canthus and affects the medial 1/3 of the lower eyelid and eyelid-cheek junction); c: tear trough
deformity, lower eyelid hollowness, intraorbital fat herniation and ‘‘dark circle’’ combined; d: tear trough deformity, intraorbital fat
herniation and skin excess combined; e: total tear trough deformity, intraorbital fat herniation and skin excess combined.
be subdivided into 3 parts: orbital, preseptal and pretarsal the muscle which is the part inferior/superior/medial/lat-
(Fig. 2). The muscle is supplied by nerve fibers originating eral to the orbital rim leads to forcible and voluntary eyelid
from the frontal, zygomatic and buccal branches of the facial closure, i.e. squeezing and winking, whereas contraction of
nerve enabling the muscle to contract leading thus to various the preseptal part, which spans from the orbital rim to the
movements and functions. The muscle is attached to the tarsal plate and medially to the posterior lacrimal crest (this
anterior portion of the orbital aperture and some muscle part is called Jones muscle) leads to regular and voluntary
fibers contain connective tissue fibers which intermingle eyelid closure, i.e. winking and blinking.
with the periosteum of this area and form the orbicularis The preseptal part of the muscle overlies the tarsal plate
retaining ligament (Fig. 3b). In the tear trough area, the and its contractions result in a horizontal movement of the
muscle is firmly attached to the bone where it forms the tear eyelid and in the stabilization of the eyelid against the globe.
trough ligament (Fig. 4). Contraction of the orbital part of This part of the muscle is attached with fibers to the anterior
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Figure 2 Schematic drawing of the right lower eyelid at the level of the mid-pupillary line (view from right side). Note that the
projection of the superior aspect of the inferior orbital margin is located cranial to the skin representation of the tear trough. The
latter can be accentuated by herniation of the intraorbital fat pads.
Figure 3 Anatomic dissection of a male cephalic specimen: a: undissected view revealing differences in skin quality, thickness and
texture between eyelid and cheek skin; b: removal of skin reveals the absence of subcutaneous fat superficial to the pre-septal part of
the orbicularis oculi muscle. In the orbital part of the muscle (red line) a substantial amount of subcutaneous fat can be identified.
Here medial subcutaneous cheek fat (= malar fat pad).
and to the posterior lacrimal crest forming the lacrimal sack Orbicularis retaining ligament
diaphragm together with the lacrimal sack fascia and the
deep crus of the medial palpaebral/canthal ligament/ten- The orbicularis retaining ligament can be regarded as the
don, with the posterior fibers being called tensor tarsi muscle pan-orbital connection between the orbicularis oculi muscle
of Horner. According to the Jones and Wobig theory, closure and the anterior aspect of the bony orbit both in the supra-
of the eyelid creates a negative pressure in the lacrimal sack and infraorbital area (Fig. 5). In the lateral part at the level
due to the contractions of the Jones and the Horner muscles of the mid-pupillary line a broad and firm connection
(absorbtion into the lacrimal sack) and creates additionally a between muscle and bone is detectable which is termed
medial ‘‘peristaltic’’ movement in the lacrimal canaliculi the lateral orbital thickening (Fig. 6) [4]. In the lateral aspect
system which is directed medially towards the lacrimal sack of the infraorbital portion, the orbicularis retaining ligament
due to contraction of the pretarsal part of the orbicularis can be separated into two lamellae which fuse in the area of
oculi muscle. the tear trough into one single layered ligament [5]. There
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Figure 4 The orbicularis oculi muscle is fixed to the bone by the orbicularis retaining ligament. In the medial part, the muscle is
firmly attached to the bone. This is the area of convergence of both orbicularis retaining ligament and zygomatico-cutaneous
ligament. The angular vein lies inferior to the tear trough ligament at the level of the nasojugal groove. Between the nasojugal groove
and the location of the tear trough ligament the tear trough deformity and the ‘‘dark circles’’ can be identified clinically.
Figure 5 Section of a cephalic specimen at the level of the lateral margin of the eye globe. Lower eyelid and eyelid-cheek junction
are shown.
the orbicularis-retaining ligament changes its name towards and hematomas. The septum is thicker in the lateral part, i.e.
tear trough ligament before it inserts next to the medial lateral to the mid-pupillary line and thinner in the medial part.
canthal tendon (Fig. 7). Before it attaches to the inferior margin of the tarsal plate, the
orbital septum fuses with the inferior tarsal muscle and
Orbital septum the capsulo-palpaebral fascia (Figs. 2, 5, 7). Medially the
septum travels with the overlying preseptal part of the orbi-
Whilst the orbicularis retaining ligament can be understood cularis oculi muscle and inserts majorly into the posterior
to be attached to the anterior aspect of the orbit, the orbital lacrimal crest whereas laterally it inserts into the lateral
septum lies in a perpendicular, i.e. cranio-caudal orientation orbital tubercle.
emerging from upper aspect of the orbital rim forming a 90
degrees angle with it in young individuals (Figs. 2, 5, 7). The tarsal apparatus
During aging, which also includes processes of bone resorp-
tion, this 90 degrees angle can change between the points of The tarsal plate together with the medial and the lateral
origin of these two ligamentous structures facilitating the canthal ligaments are crucial for maintaining the position
pseudo-prolapse of the intra-orbital fat pads. and the function of the lower eyelid and can be thus termed
The orbital septum is a thin sheet of fibrous connective as the tarsal apparatus. The inferior tarsal plate of the lower
tissue separating the intra-orbital from the extra-orbital struc- eyelid measures 4 to 5 mm in the mid-pupillary line in cranio-
tures which has great importance in the spread of infections caudal orientation and has a convex curve following the
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Figure 6 Anatomic dissection of the right lower eyelid and eyelid-cheek junction. The lateral orbital thickening and the lateral
(posterior) part of the orbicularis retaining ligament is the firm connection between the orbicularis oculi muscle and the lateral orbital
rim. This adherence is located several millimeters lower than the orbital rim and gives a bony appearance of the lateral part of the eyelid.
Figure 7 Anatomic dissection of the left peri-orbital region

with removal of the orbicularis oculi muscle and the orbital
Figure 8 Anatomic dissection of the right lower eyelid and the
septum. The tear trough ligament inserts in close proximity to
eyelid-cheek junction. The inferior tarsal plate is exposed after
the medial canthal ligament. Laterally the lateral orbital thick-
the orbicularis oculi muscle is removed.
ening and the lateral/inferior part of the orbicularis retaining
ligament (dotted lines) is indicated.
canaliculi and is attached to the posterior lacrimal crest; the
curvature of the eyeball (Fig. 8). Inferiorly the attachment of superficial portion lies superficial to the lacrimal sack and
the orbital septum and the lower eyelid retractors can be the canaliculi and attaches to the frontal process of the
found, whereas in the superior margin oil-secreting meibo- maxilla anterior and superior to the anterior lacrimal crest;
mian glands can be identified in a vertical alignment. Their the superior supporting portion arises anterior to the other
orifices are visible at the eyelid margin just posterior to the portions and attaches to the orbital process of the frontal
gray line and anterior to the mucocutaneous junction. The bone. Of those 3 portions provides the superficial portion the
tarsal plates are covered posteriorly by conjunctiva and are major support for the medial canthal angle.
anchored via the medial and the lateral canthal tendons to The lateral palpaebral/canthal tendon (LCT) is formed in
the medial and lateral bony aspects of the orbit. a similar fashion like the MCT by the crura of the upper and
The medial palpaebral/canthal ligament/tendon (MCT) is lower eyelid tarsal plate and insert into a bony aspect called
formed by the superior and the inferior crus of the upper and the lateral orbital tubercle also called Whitnall’s tubercle.
the lower eyelid tarsal plates and is located deep to the The upper and lower eyelid pretarsal parts of the orbicularis
orbicularis oculi muscle and superficial to the conjunctiva oculi muscle attach to the LCT and the lateral horn of the
(Fig. 7). The MCT inserts with 3 portions into the medial levator aponeurosis fuses with its fibers. Together with the
aspect of the orbit: the deep portion runs posterior to the LCT, the lateral check ligament, fibers of the connective
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Nerves of the lower eyelid
Sensory supply of the lower eyelid and the lid—cheek junc-

tion is provided medial to the lateral canthus by the infra-
orbital nerve a branch of the maxillary nerve (cranial nerve
5 [CN 5]), emerging from the infraorbital foramen located
between the levator labii superioris and the levator anguli
oris muscle. Lateral to the lateral canthus by the branches of
the zygomaticofacial nerve (maxillary division of CN 5) and
in smaller parts by the infraorbital nerve [9].
Motor supply to the orbicularis oculi muscle is provided by
buccal, zygomatic and frontal branches of the facial nerve
which is cranial nerve number 7 (CN 7). Motor supply to the
lower eyelid retractors is provided by branches of the ocu-
lomotor nerve which is cranial nerve number 3 (CN 3) and
enters the orbit via the superior orbital fissure after travel-
ling the medial wall of the cavernous sinus.
Vessels of the lower eyelid and lid—cheek

Figure 9 Image of the left bony orbit in view from superior and junction
lateral.
Arteries
The major arteries providing arterial blood supply to this

region are the facial, angular, infraorbital, zygomaticoorbi-
tal, transverse facial and the anterior branch of the superfi-
cial temporal artery (Fig. 11) [10]. All of these arteries are
terminal branches of the external carotid artery and are
subject to high variation. They run towards the lower eyelid
and form the arterial plexus which is majorly represented by
the inferior-medial palpebral and superior medial palpebral
arteries (Fig. 12).
The palpaebral arteries however, receive blood also from
branches of the internal carotid artery (Fig. 11). These ana-
stomoses are formed by the lacrimal, dorsal nasal, anterior
Figure 10 Anatomic dissection of the left infraorbital region

with exposure of the intraorbital structures: The three intraor-
bital fat pads: nasal,central and temporal. The nasal fat pad is
separated from the central fat pad by the inferior oblique muscle
whereas the central fat pad is separated from the temporal fat
pad by the arcuate expansion of the ligament of Lockwood.
tissue sheet of the rectus lateralis muscle and the both the
suspensory ligaments of Lockwood and Whitnall attach in
form of a broad insertion of about 10 mm to the lateral
orbital tubercle (Fig. 9).
Intra-orbital fat pads posterior to the lower

eyelid
Posterior to the orbital septum of the lower eyelid 3 intraor-

bital fat pads can be identified: nasal, central and temporal
(Fig. 10). The nasal is separated from the central by the
inferior oblique muscle, whereas the central is separated
from the temporal by the arcuate expansion of the ligament
of Lockwood, which forms the inferior suspension of the
globe (Fig. 10) [6,7]. The fat appears to be more orange and Figure 11 Contrast enhanced CT-angiography after applica-
more solid as compared to the extra-orbital fat and it has tion of contrast agent into the right facial artery. Note the
been shown that this fat can be classified as visceral white density of the arterial network of the face and peri-orbital
adipose tissue according to a recent summary [8]. region with connections to the internal carotid artery system.
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Figure 12 Anatomic dissection of the right peri-orbital regoin after injection of red dye into the common carotid artery. Note the
dense peri-orbital and the palpaebral arterial network.
groove and in distance of 4 mm to the inferior orbital rim

before it reaches the medial canthus (Figs. 5, 7, 13) [11].
Lymphatic system
The lymphatic system of the eyelids is divided into a superfi-

cial and a deep system. The superficial system drains the skin
and the orbicularis oculi muscle, whereas the deep system
drains the tarsal apparatus and the conjunctiva. Medial to
the midpupillary line lymphatic drainage follows the sub-
mandibular nodes whereas laterally drainage occurs into the
preauricular and deep parotid nodes.
Anatomy the lid—cheek junction
The appearance of the lid—cheek junction is less accentu-

ated in younger individuals before the process of fat re-
distribution takes place [12—14]. Here a smooth transition
from the structures of the lower eyelid to the cheek is given.
Albeit separated by the orbicularis retaining ligament, the
orbicularis oculi muscle extends into the cheek area and can
Figure 13 Contrast enhanced CT-angiography after applica-

tion of contrast agent into the left facial vein. Note the con-
nections to the temporal and intraorbital veins.
and posterior ethmoid arteries which are all together con-

nected via the ophthalmic artery. In cases of internal carotid
artery stenosis the blood flow is reversed and branches of the
external carotid artery warrant cerebral perfusion via these
anastomoses and ultimately by the ophthalmic artery.
Veins
Venous blood of the lower eyelid and lid—cheek junction is

drained via the angular and lateral nasal vein towards the
facial vein and via the superior and inferior ophthalmic vein
into the cavernous sinus or into the pterygoid venous plexus.
Other venous drainage pathways are central forehead, the
sentinel and the superficial temporal veins. In the inferior- Figure 14 Anatomic dissection of the left peri-orbital area
medial wall of the suborbicularis occuli fat (SOOF) the revealing the deep fat compartments, located deep to the
angular vein can be identified which runs superficial to the orbicularis oculi muscle. SOOF: suborbicularis oculi fat; ROOF:
levator labii superioris muscle at the level of the nasojugal retroorbicularis oculi fat; OOM: orbicularis oculi muscle.
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Figure 15 Lateral and medial SOOF. The prezygomatic space and the deep fat compartments are located below the SOOF.
be identified in the same plane as the superficial musculo- unit is crucial especially when fighting the signs of facial
aponeurotic system (SMAS) (Fig. 2) [15]. Superficial to the aging. Depending on the deformity identified in each pa-
orbicularis oculi muscle the superficial facial fat compart- tient it is important to direct the consecutive therapeutic
ments are identifiable, with the medial cheek fat compart- applications:
ment (also termed the malar fat pad) being close to the
lateral aspect of the lower eyelid and the superficial naso- type 1 deformity: non-surgical techniques, i.e. minimally
labial fat compartment being close to the medial aspect. The invasive applications (f.i. soft tissue fillers);
nasolabial fat compartment however, is separated from the type 2 deformity: non-surgical or surgical techniques;
medial aspect of lower eyelid by the tear trough and the type 3 deformity: surgical approach is necessary with
nasojugal groove represents the boundary between the tear great importance to preserve the function of the orbicu-
trough and the upper margin of the superficial nasolabial fat laris oculi muscle and to prevent eyelid retraction by a
compartment. The size of the triangular shaped space, i.e. preventive cathal support. Preoperative meticulous clini-
the space between the two superficial fat compartments cal assessment is the key of any surgical approach to type
(nasolabial vs. medial cheek) increases with age due to the 3 deformity.
volume loss of the subcutaneous medial cheek fat and the
inferior displacement of the nasolabial fat compartment
can be subject to the treatment with soft tissue fillers Disclosure of interest
when recontouring and/or restoring volume deficiencies in
this area.
The authors declare that they have no competing interest.
Deep to the orbicularis oculi muscle the sub-orbicularis
oculi fat (SOOF) can be identified being bounded superiorly
by the orbicularis retaining ligament and inferiorly by the Acknowledgments
zygomatico-cutaneous ligament (Fig. 14) [15]. Laterally this
deep fat compartment is connected via the temporal tunnel We would like to thank 3Arts-Pro for their support in the
to the inferior temporal compartment, which is bounded realization of Fig. 2 and the Department of anatomy at
superiorly by the lateral orbital thickening and the inferiorly Rockefeller Medical School (UCLB-1) for their support with
by the McGregors patch [16]. The SOOF extends medially the anatomical dissections carried out in Lyon, France.
until 2—4 mm medial to the mid-pupillary line and forms thus The imaging part of this study as well as the anatomic
the deep lateral boundary of the tear trough. (Note that the dissections carried out at Albany Medical College, Albany,
tear trough consists of 3 layers only: skin, muscle and NY, USA received funding from Q-Med AB, Sweden (Grant
periosteum). The SOOF has been shown to consist of 2 No.: 15092016) and by MERZ Pharmaceuticals GmbH (Grant
sub-compartments, i.e. medial and lateral SOOF [15] and No.: 13072015).
authors have indicated that the superficial lamina of the
deep temporal fascia separates the SOOF from the prezygo-
matic space [15], which contains deepest facial fat (Fig. 15) References
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ANNPLA-1370; No. of Pages 10

Annales de chirurgie plastique esthétique (2017) xxx, xxx—xxx

Anatomy of lower eyelid and eyelid—cheek

A. Mojallal a,*, S. Cotofana b

Skin Orbicularis oculi muscle

Lower eye-lid anatomy 3

Lower eye-lid anatomy 5

Figure 7 Anatomic dissection of the left peri-orbital region

Lower eye-lid anatomy 7

Nerves of the lower eyelid

Sensory supply of the lower eyelid and the lid—cheek junc-

Vessels of the lower eyelid and lid—cheek

The major arteries providing arterial blood supply to this

Figure 10 Anatomic dissection of the left infraorbital region

Intra-orbital fat pads posterior to the lower

Posterior to the orbital septum of the lower eyelid 3 intraor-

groove and in distance of 4 mm to the inferior orbital rim

The lymphatic system of the eyelids is divided into a superfi-

Anatomy the lid—cheek junction

The appearance of the lid—cheek junction is less accentu-

Figure 13 Contrast enhanced CT-angiography after applica-

and posterior ethmoid arteries which are all together con-

Venous blood of the lower eyelid and lid—cheek junction is

Lower eye-lid anatomy 9

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