FEATURE

Restoring youth to the upper midface by

blending the lid-cheek junction
BY ANNA MARIA FENECH MAGRIN

Rejuvenation of the eyes has a very high impact on the overall appearance of the face.
The shadow pattern of the inferior orbital rim is one of the most important shadows of
the ageing midface [1]. Although every patient has individual needs, blending of the
lid-cheek junction is of particular importance to achieve a youthful appearance.

Ageing process of the face tissue volume reduction caused by malar fat pad atrophy and
Facial ageing is a multifactorial process. Physiological and descent enhances the tear trough deformity.
morphological changes occur in bones, ligaments, muscles, fascia,
fat and skin [2,3]. The nomenclature
Facial soft tissues tend to descend with age. Repositioning the Different authors refer to the surface markings of this area with
soft tissues toward their original position is a common goal which different nomenclature. The author recommends the following as
one tries to achieve when performing certain procedures, ranging the most straightforward nomenclature to be used when making
from surgical facelifts to thread lifts and the use of soft tissue reference to the relevant anatomical regions of the face.
injection techniques [4]. The depression in the medial infraorbital area is called the tear
trough. The depression immediately inferior to the tear trough
is called the nasojugal groove. The nasojugal groove extends
The infraorbital region
inferolaterally from the medial canthus to a point inferior to the
The anatomy of the lower eyelid and the lid-cheek junction has
medial limbus. It becomes progressively more prominent with
to be understood as a unit. This is because the structures are
ageing.
continuous from the eyelid to the cheek, and they influence each
The nasojugal groove is continuous with the mid-cheek groove,
other during ageing. The lower eyelid and tear trough deformities
which can also be referred to as a mediojugal fold or malar groove
can occur depending on the underlying structures. These vary from
[2,6].
lower eyelid hollowness, dark circles, tear trough depression with or
The palpebromalar groove is the lateral depression between the
without fat herniation, and skin excess [5].
lower eyelid and the cheek eminence, and is also referred to as the
Patients usually present with dark circles in the medial infraorbital
lid-cheek groove or lid-cheek junction.
area, more commonly known as the tear troughs. However, this
The nasojugal groove (the tear trough) and the palpebromalar
is not the only problematic area. A great challenge is faced when
groove (lid-cheek groove) form a ‘V’ shaped deformity with
dealing with the lateral infraorbital area, particularly the lateral
increasing age. These two grooves connect to become a continuous
depressions between the lower eyelid and the cheek eminence,
groove that sharply demarcates the bulging orbital fat above,
which is called the lid-cheek junction. These are also known as the
from the retruded midcheek below. The resulting demarcation of
palpebromalar grooves [6].
these grooves is determined by the attachment of the underlying
ligaments.
Surface anatomy
The skin of the face has consistent attachment points to the The layers in the infraorbital region of the face
underlying structures through the facial retaining ligaments. As the The infraorbital region can be divided into lateral and medial parts.
volume of the face deflates, these attachment points will define The boundary between the lateral and medial parts lies about
most of the shadows that develop with age [7]. 4-6mm medial to the midpupillary line [2,5,9-11].
This was shown by Yang et al. [8], who reported that the In the lateral part, seven different layers can be identified, while in
orbicularis retaining ligament (ORL) and the malar fat pad play the medial part, only three layers can be identified.
important roles in the formation of the tear trough deformity and Layer one is the skin, layer two is the orbicularis oculi muscle, and
palpebromalar groove. The groove in the lateral portion of the lid- layer three, is the periosteum [2]. The skin in the infraorbital region
cheek junction is formed mainly due to the ORL, which arises from is described as being the thinnest in the human body. In the medial
the inferior orbital rim and ends at the junction of the palpebral part, the orbicularis oculi muscle can sometimes be seen through
and orbital portions of the orbicularis oculi muscle. The histology the thin skin, and gives a blueish appearance to the tear trough area.
and structure of the ORL changes in the mid-pupillary line when it In the lateral infraorbital area, there’s a layer of superficial
continues into the tear trough. Yang et al. also showed that the sub- fat above the muscle. This is part of the malar mound. This is
orbicularis oculi fat pad (SOOF) was located mainly at the inferior practically absent in the medial area. The skin over the malar fat pad
lateral orbit underneath the orbicularis oculi muscle, while there is thicker than over the lower eyelid and this further accentuates the
was no obvious oculi fat pad in sagittal sections of the tear trough. lid-cheek junction.
Therefore, the orbicularis retaining ligament limits the age-induced Layer three of the lateral part is the orbicularis oculi muscle. This
descent of the orbicularis oculi muscle, and the subcutaneous muscle is attached to the anterior portion of the orbital aperture by

The PMFA Journal | February/March 2023 | VOL 10 NO 3 | www.thepmfajournal.com

Beatriz Casante - beatrizcasante@hotmail.com - CPF: 459.205.698-16

 FEATURE

Tear trough
Tear trough ligament
Palpebromalar Orbicularis
groove retaining
ligament
Zygomatico
Tear trough / -cutaneous
nasojugal groove ligament

Mid cheek groove

/ malar groove /
mediojugal groove

Figure 1: Nomenclature of surface anatomy, folds and grooves shown on model with corresponding ligaments shown on a cadaveric dissection.

fascia on its undersurface, which intermingle with the periosteum Injection technique / algorithm
of this area. This is called the ORL. The ORL is very important to Patient examination is very important. The type of the lower eyelid
consider when treating this area. It loops around the anterior aspect and tear trough deformity needs to be established. The presence
of the orbit and it connects the muscle to the orbit. It inserts 2-3mm of palpebral fat pads or inferior eyelid oedema can be an absolute
below the orbital rim. The subdivision of the orbicularis oculi muscle or relative contraindication to the treatment. When there is the
into its palpebral and orbital parts corresponds to the course of the presence of relatively moderate oedema, it is recommended to
ORL. Laterally it forms the lateral orbital thickening [2,5,10-12]. inject half the indicated volume, or even less [4,6,9].
The ORL is the boundary between the extraorbital fat such The infraorbital area can be treated in different ways. The
as SOOF and the intraorbital fat. This means it forms the deep following is a description of an injection technique used by the
boundary which separates the cheek from the lower eyelid and author.
intraorbital fat. In the tear trough area, the ORL changes its name to First, the tear trough should only be treated if and when indicated.
become the tear trough ligament. A 25G, 50mm blunt-tipped cannula is used. The same entry point is
Layer four is the sub-orbicularis oculi fat, known as SOOF. This is used for both the tear trough deformity correction and for the rest
located underneath the orbicularis oculi muscle and is divided into of the infraorbital area, as the whole infraorbital area is treated as a
the medial and lateral portions. The SOOF is one of the deep fat unit. Therefore, the entry point is through an inferior approach, on an
compartments of the face. It is bound superiorly by the orbicularis imaginary vertical line dropped down from the lateral limbus, around
retaining ligament and inferiorly by the zygomatico-cutaneous 1.5 to 2cm below the lid-cheek crease. This is done so the cannula
ligament (ZCL). It corresponds to the malar mound above, which is slides lateral to the major vessels. The entry point is performed
the superficial infraorbital fat. This is the reason why it is important using a 23G needle.
The cannula is advanced cranially towards the medial infra-
to inject into the deep layer, as injection into the superficial layer
orbital tear trough region. One will encounter some resistance as
leads to prolonged oedema [3,9].
the orbicularis oculi is reached and some gentle tugging is usually
The point where the ZCL and ORL fuse medially can be seen as
needed to go deep to the muscle. The cannula has to glide easily,
a vertical landmark on the surface approximately 2-4mm medial
once the deep plane is reached. If one comes across obstacles, the
to the mid-pupillary line, which corresponds to the medial limbus
cannula should not be advanced further; it needs to be retracted
(Figure 1). When the zygomatico-cutaneous ligament connects with
for a few millimetres. The depth and the angle of entry has to be
the ORL, it encloses the space where the SOOF is located. Therefore,
slightly changed until the penetration is easier. When the cannula
the medial limbus is the most medial extent of the SOOF, and is
reaches the tear trough depression, this can be felt and controlled
the point where the tear trough begins. The orbicularis retaining
with the non-dominant hand. Generally, no more than 0.2-0.3ml of
ligament changes its name once it fuses with the zygomatico- hyaluronic acid (HA) are injected, in four to six passages on each
cutaneous ligament. This is now known as the tear trough ligament side, using a slow, retrograde, fanning technique [4,11]. It’s always
[2,10]. preferable to under correct, as we know this area, being devoid of
Layer five is the fascia, which is the continuation of the superficial fat is unforgiving, and overcorrection can lead to lumpiness and
lamina of the deep temporal fascia. Layer six is the fat in the pre- unsatisfactory results. From this same entry point, the middle and
zygomatic space. Many authors don’t make a distinction between lateral portion of the lid-cheek groove can also be treated.
the pre-zygomatic space and the SOOF. One of the aims is to readjust the alignment of the ORL. With
Layer seven is the periosteum. The inferior orbital rim changes ageing, this ligament changes orientation from 90 degrees between
in shape, position and also projection during the ageing process. the maxilla and the ORL, to 45 degrees. Therefore, by injecting a filler
It becomes lower, especially in the lateral portion. A decrease in below the ligament, it repositions it to its original angle, and also
the projection can also be observed in CT scan images, which repositions the mid-face, improving the appearance of the lid-cheek
were utilised in the studies carried out by Khan and Shaw [13]. This junction. Recontouring of the inferior orbital rim is also an integral
causes a loss of bony support to the already atrophic tissues. part of this treatment protocol.

The PMFA Journal | February/March 2023 | VOL 10 NO 3 | www.thepmfajournal.com

Beatriz Casante - beatrizcasante@hotmail.com - CPF: 459.205.698-16

 FEATURE

The needle is inserted perpendicular to the skin until it reaches

the bone. The entry points are marked 2-3mm below the lid-cheek
junction, which corresponds to the wider and deeper part of the
crease. The position of the superficial vessels should be noted to
try and avoid haematomas. The HA is deposited in bolus injections
of 0.1-0.15ml in contact with the periosteum, until reaching the
level of the medial limbus. Again, it is always important to inject in
a deep plane, underneath the orbicularis oculi muscle.

Conclusion
In summary, entering the layer which is deep to the orbicularis oculi
muscle is of key importance when depositing the filler agent in the
lid-cheek junction. Knowledge of the anatomy is very important
when treating the infraorbital area. It is always better to undertreat
then to overtreat as too much filler may lead to unfavourable
results.

References
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rejuvenation. Clinics in Plastic Surgery 2015;42(1):115-21.
2. Cotofana S, Fratila AA, Schenck TL, et al. The anatomy of the aging face: a
review. Facial Plastic Surgery 2016;32(03):253-60.
3. Cotofana S, Lachman N. Anatomy of the facial fat compartments and their
relevance in aesthetic surgery. JDDG: Journal der Deutschen Dermatologischen
Gesellschaft 2019;17(4):399-413.
4. Bernardini FP, Casabona G, Alfertshofer MG, et al. Soft tissue filler
augmentation of the orbicularis retaining ligament to improve the lid‐cheek
junction. Journal of Cosmetic Dermatology 2021;20(11):3446-53.
5. Mojallal A, Cotofana S. Anatomy of lower eyelid and eyelid–cheek junction.
Annales de Chirurgie Plastique Esthétique 2017;62(5):365-74.
6. Lee JH, Hong G. Definitions of groove and hollowness of the infraorbital
Figure 2: Inferior / medial entry point and cannula injection path (blue lines). Lateral entry
region and clinical treatment using soft-tissue filler. Archives of Plastic Surgery
point and cannula injection path (red lines).
2018;45(03):214-21.
7. Glasgold M. Introduction to volumetric facial rejuvenation. Facial Plastic
Surgery 2015;31(01):10-4.
As one glides superiorly with the cannula to treat the middle
8. Yang C, Zhang P, Xing X. Tear trough and palpebromalar groove in young
part of the infraorbital area, a resistance or a pop is felt, and this versus elderly adults: a sectional anatomy study. Plastic and reconstructive
would be the ZCL. One should stop before feeling the second pop surgery 2013;132(4):796-808.
or when further resistance is felt, as there’s a risk of going into 9. Sykes JM, Cotofana S, Trevidic P, et al. Upper face: clinical anatomy and
regional approaches with injectable fillers. Plastic and reconstructive surgery
the orbit. Therefore, with the finger of the non-dominant hand, the 2015;136(5):204S-18S.
inferior orbital rim should be secured, to prevent the cannula from 10. Pessa JE, Rohrich RJ. Facial Topography. Clinical Anatomy of the Face. St.
passing cranial to the ORL or into the retro-septal space. The same Louis, USA; Thieme Medical Publishers, Inc; 2012.
11. Ingallina FM. Facial Anatomy & Volumizing Injections. Superior & Middle Third.
is repeated in the lateral infraorbital regions, while about five to six
3Aface Academy.
passes are done from caudal to cranial. In the lateral region, the 12. Rohrich RJ, Avashia YJ, Savetsky IL. Prediction of facial aging using the facial
lateral SOOF is reached in layer four. fat compartments. Plastic and Reconstructive Surgery 2021;147(1S-2):38S-
Once the cannula is palpable at the inferior orbital rim, the 42S.
13. Kahn DM, Shaw RB. Aging of the Bony Orbit: A Three-Dimensional Computed
product is administered in small boluses and retrograde threading
Tomographic Study. Aesthetic Surgery Journal 2008;28(3):258-64.
technique, of 0.02-0.2ml at a time. One should always keep in
mind that the superior anatomical boundary for the cannula is the
ORL. Perforation of this and injection of the intraorbital fat leads to
worsening of the eyelid bags. AUTHOR
After volumisation of the deep fat compartment, the SOOF,
the second step is the contouring phase. Recontouring of the
inferior orbital rim is performed. Another dermal access can be
done for this. This would be located 1-1.5cm lateral and 1.5cm
caudal to the lateral canthal ligament (Figure 2). A 25G 50mm This article has
blunt-tipped cannula is used. The cannula is advanced from lateral been verified for
to medial, gliding deep to the orbicularis oculi muscle within the CPD. Scan the QR
code to answer
supraperiosteal plane. a few short
From here, the tear trough can also be reached. A resistance questions and
can be felt when the ZCL is reached. One must push gently Anna Maria Fenech Magrin, download a form
MD, MSc Public Health (Melit), MSc Aesthetic Medicine to be included in
through it to reach the tear trough area. The target layer for both your CPD folder.
(London); Clinical Senior Lecturer in Aesthetic Medicine;
injection steps should be the deep to the orbicularis oculi muscle Deputy Course Lead MSc Aesthetic Medicine; Centre
and inferior to the ORL. for Cell Biology & Cutaneous Research at the Blizard
Institute, within Barts & The London School of Medicine
Another technique that can be used is the bolus injection and Dentistry, Queen Mary University of London.
technique using a needle. The bolus injections can be performed
with the syringe supplied by the filler material manufacturer. Declaration of competing interests: None declared.

The PMFA Journal | February/March 2023 | VOL 10 NO 3 | www.thepmfajournal.com

Beatriz Casante - beatrizcasante@hotmail.com - CPF: 459.205.698-16