Volume 145, Number 4 • Letters
Finally, although not clearly mentioned or dis-
Fig. 1. Lateral oblique view of the lower periorbita with the orbi-
cularis oculi muscle reflected anteriorly. The inferior lamella of
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVJ2toCr/9wZZz1CogGMv/mqEuqUfl+xGrJcgplpVyLkd on 04/08/2020
the orbicularis retaining ligament is shown with the sub–orbi-
cularis oculi fat pad (SOOF) spanning both cranial and caudal
to the orbicularis retaining ligament. The inferior orbital rim is
indicated by the dotted line.
Fig. 2. Surgeon’s view of the lower eyelid preseptal space, with
the orbicularis oculi muscle held back at the top of the image
with hooks. The medial and lateral sub–orbicularis oculi fat pads
(SOOF) are shown abutting the lateral inferior orbital rim. The
superior lamella of the orbicularis retaining ligament (arrow-
head) is seen just caudal to the inferior orbital rim (RIM).
Injection of fat or fillers over the rim in the lateral half
of the infraorbital rim causes almost immediate correc-
tion of the palpebromalar line and seamless blending
of the eyelid-cheek junction. This is mainly due to the
fact that the orbicularis retaining ligament is naturally
surrounded by fat, contrary to the tear trough liga-
ment, which is an area of adhesion devoid of fat. This
clear distinction of the medial infraorbital area, where
the orbicularis oculi is adhered to bone, and the lateral
infraorbital area, where the orbicularis is lying over
a plush layer of fat, should be kept in mind, as it has
implications in periorbital rejuvenation.
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
cussed in the text, Cotofana et al.1 showed the lateral
and medial sub–orbicularis oculi fat compartments
to extend to the infraorbital rim in computed tomo-
graphic scans shown in their Figures 1 and 2, while
Wong et al. showed fat sandwiched between the two
orbicularis retaining ligament lamellae in their Fig-
ure 9.2,3 This further supports our aforementioned
conclusions.
DOI: 10.1097/PRS.0000000000006706
Mohammed S. Alghoul, M.D.
Elbert E. Vaca, M.D.
Lauren M. Mioton, M.D.
Division of Plastic and Reconstructive Surgery
Northwestern University Feinberg School of Medicine
Chicago, Ill.
James E. Zins, M.D.
Department of Plastic and Reconstructive Surgery
Cleveland Clinic
Cleveland, Ohio
Correspondence to Dr. Alghoul
Division of Plastic Surgery
Northwestern University Feinberg School of Medicine
675 North St. Clair Street, Suite 19-250
Chicago, Ill. 60611
mo.alghoul@gmail.com
Instagram: @Alghoulplasticsurgery
Facebook: Alghoulplasticsurgery
‍ ISCLOSURE
D
None of the authors has conflicts of interest to disclose.
REFERENCES
1. Cotofana S, Gotkin RH, Frank K, et al. The func-
tional anatomy of the deep facial fat compartments: A
detailed imaging-based investigation. Plast Reconstr Surg.
2019;143:53–63.
2. Wong CH, Mendelson B. Facial soft-tissue spaces and retain-
ing ligaments of the midcheek: Defining the premaxillary
space. Plast Reconstr Surg. 2013;132:49–56.
3. Wong CH, Hsieh MK, Mendelson B. The tear trough liga-
ment: Anatomical basis for the tear trough deformity. Plast
Reconstr Surg. 2012;129:1392–1402.
Reply: The Functional Anatomy of the Deep
Facial Fat Compartments: A Detailed Imaging-
Based Investigation
Sir:
We read with interest the observations of Alghoul et
al. in their correspondence regarding our recent publi-
cation on the functional anatomy of the deep facial fat
compartments.1 The authors shared their belief in an,
up to this point, undescribed relationship of the orbi-
cularis retaining ligament and the sub–orbicularis oculi
fat, where “the orbicularis retaining ligament is encased
within the sub–orbicularis oculi fat compartment.” They
871e

cite anecdotal evidence of anatomic dissections of fresh
injected cephalic specimens and intraoperative obser-
vations without providing information on sample size
evaluated, results, or descriptive statistical analysis. Two
figures accompany their correspondence that unfortu-
nately do not show the two laminae of the orbicularis
retaining ligament in the same image. This would have
strengthened their idea.
The orbicularis retaining ligament can be under-
stood as an enthesis of the orbicularis oculi muscle and is
observed to be macroscopically of variable shapes when
coursing from lateral to medial: at the lateral orbital
rim, the ligament is broad and termed the lateral orbital
thickening.2 In the lateral infraorbital region, it consists
of two laminae: the superior lamina and the inferior
lamina of the orbicularis retaining ligament.2 Interest-
ingly, the point of fusion of the two laminae coincides
with the fusion of the orbicularis retaining ligament with
the zygomaticocutaneous ligament and is located at the
vertical line passing through the medial corneal limbus.
In the medial infraorbital region, the orbicularis retain-
ing ligament is known as the tear trough ligament and
forms the cranial boundary of the tear trough. Medially,
no fat can be identified deep to the orbicularis oculi
muscle, whereas laterally, two deep facial fat compart-
ments have been described.3,4 Immediately deep to the
orbicularis oculi muscle, the sub–orbicularis oculi fat
can be appreciated, which is separated by the midfacial
extension of the superficial lamina of the deep tempo-
ral fascia from the fat within the prezygomatic space.5 In
contrast to the description of Alghoul et al., these two
entities should be clearly separated.
On a microscopic level, utilizing micro–computed
tomographic analyses, O et al.6 showed that in the lat-
eral infraorbital area, the orbicularis retaining ligament
had a multilayered (not just two) and honeycomb-like
appearance with parallel running fibrous tissue plate,
which resulted in vertical widening of the orbicularis
retaining ligament. These honeycombs were filled with
fat that can be termed intralaminar fat.
It can thus be presumed that Alghoul et al.’s findings
correspond to this intralaminar fat—that is, the fat con-
tained within the lateral infraorbital aspect of the orbi-
cularis retaining ligament. Whether this fat is of equal
composition as the sub–orbicularis oculi fat, whether the
honeycombs have distinct connections to the sub–orbi-
cularis oculi fat, or whether this fat can really be termed
sub–orbicularis oculi fat is unclear. Future investigations
should explore this topic to provide reliable evidence for
the expressed assumption by Alghoul et al.
What is undoubtable, however, is that this area
responds very well to autologous fat and soft-tissue
filler volumization and age-related changes can be
ameliorated. We hope the authors find our discussion
of the anatomy of the infra-orbital area to be of value,
and we would be grateful for the opportunity to col-
laborate on future research projects investigating this
aesthetically important region.
DOI: 10.1097/PRS.0000000000006707
872e
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • April 2020
Sebastian Cotofana, M.D., Ph.D.
Division of Anatomy
Department of Medical Education
Albany Medical College
Division of Plastic Surgery
Department of Surgery
Albany Medical Center
Albany, N.Y.
Robert H. Gotkin, M.D.
Private practice
New York, N.Y.
Correspondence to Dr. Cotofana
Department of Clinical Anatomy
Mayo Clinic College of Medicine and Science
Mayo Clinic
Stabile Building 9-38, 200 First Street Rochester, Minn. 55905
cotofana.sebastian@mayo.edu
DISCLOSURE
The authors have no commercial associations or financial
disclosures that might pose or create a conflict of interest with
the methods applied or the results presented in this communi-
cation. This work received no funding.
REFERENCES
1. Cotofana S, Gotkin RH, Frank K, et al. The functional anat-
omy of the deep facial fat compartments: A detailed imaging-
based investigation. Plast Reconstr Surg. 2019;143:53–63.
2. Wong CH, Hsieh MK, Mendelson B. The tear trough liga-
ment: Anatomical basis for the tear trough deformity. Plast
Reconstr Surg. 2012;129:1392–1402.
3. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy
of the ligamentous attachments of the lower lid and lateral
canthus. Plast Reconstr Surg. 2002;110:873–884; discussion
897.
4. Mojallal A, Cotofana S. Anatomy of lower eyelid and eyelid-
cheek junction. Ann Chir Plast Esthet. 2017;62:365–374.
5. Andretto Amodeo C, Casasco A, Icaro Cornaglia A, Kang R,
Keller GS. The suborbicularis oculi fat (SOOF) and the fas-
cial planes: Has everything already been explained? JAMA
Facial Plast Surg. 2014;16:36–41.
6. O J, Kwon HJ, Choi YJ, Cho TH, Yang HM. Three-dimen-
sional structure of the orbicularis retaining ligament: An
anatomical study using micro-computed tomography. Sci
Rep. 2018;8:17042.
Female Genital and Vaginal Plastic Surgery:
An Overview
Sir:
W e read with great interest the review by Placik and
Devgan about genital and vaginal plastic surgery.1
They list all of the most wanted cosmetic genital and vag-
inal surgeries in a critical manner, giving useful insights
on recent trends in the field. Nevertheless, we would like
to make some remarks that could complete the content
on some of the topics mentioned in the review.