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ANATOMICAL STUDY
Ligaments of the Face: Past, Present, and Future
Kun Hwang, MD, PhD and Jeongho Choi, MD, PhDy
Abstract: The aim of this study is to search for the origin of the term
‘‘ligament" in the face, present its status, and suggest a principle to
rectify the use of unclear terminology.
The structure that connects the zygoma to the skin was first
presented by McGregor (1959). Kaye (1981), in describing his
‘‘extended facelift,’’ wrote that the adherent area of the cheek over
the malar eminence (McGregor’s patch) usually requires sharp
dissection. Bosse (1987) reported that the zygomatic ligament is
quite solidly bound to the malar eminence and usually requires
sharp dissection to release it. The origin of the term was introduced
later by Furnas, who stated that when Preddy, a medical artist,
prepared drawings for McGregor’s slide presentations, she insisted
on naming it ‘‘McGregor’s patch.’’ With the idea that ‘‘perhaps’’ the
‘‘retaining ligaments’’ of the face share a teleologic kinship with
Cleland’s ligaments or Grayson’s ligaments of the hands, Furnas
(1989) observed the structure that anchors the skin of the cheek to
the inferior border of the zygoma just posterior to the origin of the
zygomaticus minor muscle, and named it ‘‘the zygomatic liga-
ments.’’ Subsequently, numerous articles have been published using
different terminologies that cause confusion.
To rectify the present confusing terminology of the ligament of
face, the histologically proven structures should be designated by
one term only following the Nomina Anatomica principles.
Key Words: eponyms, face, ligaments
(J Craniofac Surg 2018;00: 00–00)
E pluribus Unum (One From Many)
W e engage in many types of argument in academic activities, as
well in everyday life. An argument stems from differences in
opinion. One makes an argument to validate one’s claim; however,
there are many cases in which arguments arise from the misuse and
overuse of language. The use of ambiguous terminology leads to
such problems, which can be understandable and, to some degree,
inevitable given the nature of language.
In the field of plastic surgery, much of what we do requires an in-
depth knowledge of anatomy.1 Therefore, identifying anatomical
From the Department of Plastic Surgery, Inha University School of
Medicine, Incheon, Korea; and yChoi’s Aesthetic Plastic Surgical Clinic,
Seoul, Korea.
Received August 28, 2017.
Accepted for publication January 7, 2018.
Address correspondence and reprint requests to Kun Hwang, MD, PhD,
Department of Plastic Surgery, Inha University School of Medicine, 27
Inhang-ro, Jung-gu, Incheon 22332, Korea; E-mail: jokerhg@inha.ac.kr
This study was supported by a grant from Inha University Hospital.
The authors report no conflict of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004416
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
structures with their proper names is crucial for operations to be
successful, as well as for communicating with each other.
In facial rejuvenation surgery, the term ‘‘retaining ligament’’ has
been introduced,2 and many new names have appeared designating
the same structure.3,4
Some confusion in the terminology of the facial retaining
ligaments has emerged, not so much by ambiguous terminology
with multiple usages, as by vagueness, in which the scope of a term
is not properly calibrated even though it has a single referent.
The aim of this study is to search for the origin of the term
‘‘ligament" in the face, present its status, and suggest a principle to
rectify the use of unclear terminology.
Definition of ‘‘Ligament’’
Dorland’s dictionary defines ‘‘ligament’’ as: a band of fibrous
tissue connecting bones or cartilages, serving to support and
strengthen joints; a double layer of peritoneum extending from
one visceral organ to another; cord-like remnants of fetal tubular
structures that are nonfunctional after birth.
Ligaments in the Hand
Cleland (1878) first used the term ‘‘cutaneous ligament,’’
describing the structure that retains the skin at the sides of the
joints and thus prevents bagging during movement of the joint.5
Cleland’s ligaments originate at the edge of osseous flexor tendon
gutter at the proximal interphalangeal joint, run dorsal to neuro-
vascular bundle, and insert into the digital fascia.
Another structure was introduced by Grayson (1941).6 Gray-
son’s ligaments are thin and go from the tendon sheath to the skin,
and to some extent protect the neurovascular bundle, thereby
preventing bow-stringing of the neurovascular bundle during flex-
ion. They start at the volar aspect of the flexor tendon sheath, run
volar to the neurovascular bundle, and insert into the skin.
Although Grayson’s ligaments do not precisely correspond to
the dictionary definition (connecting bones or cartilages, serving to
support and strengthen joints), these 2 structures were defined as
ligaments in the hand, and the terms are still widely used.
Origin of the Term ‘‘Ligament" in the Face
The structure that connects the zygoma to the skin was first
presented by McGregor (1959).7
Kaye (1981), in describing his ‘‘extended facelift,’’ wrote that
the adherent area of the cheek over the malar eminence (McGre-
gor’s patch) usually requires sharp dissection.8 In this article, he
used the term ‘‘McGregor’s patch" without any citation.
Bosse (1987) reported that the zygomatic ligament is quite
solidly bound to the malar eminence and usually requires sharp
dissection to release it.9
The origin of the term was introduced later by Furnas, who
stated that when Mrs. Rosebud Preddy, a medical artist, prepared
drawings for McGregor’s slide presentations, she insisted on nam-
ing it ‘‘McGregor’s patch’’ (Furnas).
With the idea that ‘‘perhaps’’ the ‘‘retaining ligaments’’ of the
face share a teleologic kinship with Cleland’s ligaments or Gray-
son’s ligaments of the hands, Furnas (1989) observed the structure
that anchors the skin of the cheek to the inferior border of the
1
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Hwang and Choi The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018

zygoma just posterior to the origin of the zygomaticus minor

muscle, and named it ‘‘the zygomatic ligaments (McGregor’s
patch).’’2

Present Status of the Cutaneous Ligaments of

the Face
Since the concept of retaining ligaments was described in a
publication by Furnas, numerous articles have been published using
different terminologies that cause confusion.3

McGregor’s Patch
‘‘McGregor’s patch" have synonyms such as zygomatic cutane-
ous ligament or the zygomatic ligament (Fig. 1A).2,10– 13 Release of
the McGregor’s patch results in increased mobility of the
midfacial skin.

Platysma Auricular Ligament and Auricle-

platysma Ligament
Furnas2 wrote that ‘‘The posterior border of the platysma
recedes into an intricate fascial condensation that often attaches
intimately to the overlying skin. This structure provides firm
anchorage between the platysma and the dermis of the inferior
auricular region’’. Botti14 described a structure originating from the
dermis of the earlobe and the superficial parotid fascia that fans out
to insert into the superolateral border of the platysma (Fig. 1B).

Parotid Cutaneous Ligament, Platysma Auricular

Fascia, Preauricular Parotid Cutaneous Ligament
Stuzin’s ‘‘parotid cutaneous ligament" (1992)10 and Özdemir’s
‘‘preauricular parotid cutaneous ligament" (2002),15 seem to des-
ignate the structure which Furnas had conceptualized as a broader
range of fibrous connective tissue in the preauricular area in
describing the platysma auricular fascia (PAF) (Fig. 1C).

Platysma Auricular Fascia

Mendelson16 suggested that the PAF combines the part of the
SMAS layer between the ear cartilage and the posterior edge of the
platysma (Fig. 1D).

Anterior Platysma-cutaneous Ligament,

Masseteric Cutaneous Ligament and Parotid
Masseteric Cutaneous Ligament
Furnas2 observed aponeurotic connections sometimes seen
between the anterior platysma and the skin of the middle and
anterior cheek, and named it anterior platysma-cutaneous ligament
(Fig. 1E). Stuzin10 observed this structure originating along the
anterior border of the masseter and proposed the term ‘‘masseteric
cutaneous ligament"17 for this structure (Fig. 1F). Özdemir
observed this structure originating from the middle portion of
the masseter muscle and named it parotid masseteric cutaneous
ligament. He thought ligament exists where the anterior parotid
makes the transition onto the fascia of the masseter muscle
(Fig. 1G).

Platysma Cutaneous Ligament

Özdemir15 observed a septal form of adhesion at the anterior
platysma, and at the mandibular body and angle, and named it the
platysma cutaneous ligament (Fig. 1H).
As above a group of researchers even newly defined the ‘‘liga-
ments,’’ ‘‘septum,’’ and ‘‘adhesion,’’ which they argued to be quite
different from the structures described in the previous anatomical
and histological literature.18 Another researcher criticized their
favoritism and the surgical irrelevance of their arguments.19
FIGURE 1. Schematic illustration of the retaining ligaments of the cheek. (A)
McGregor’s patch. (B) Platysma auricular ligament and auricle-platysma
ligament. (C) Parotid cutaneous ligament, platysma auricular fascia,
preauricular parotid cutaneous ligament. (D) Platysma auricular fascia. (E)
Anterior platysma-cutaneous ligament. (F) Masseteric cutaneous ligament. (G)
Parotid masseteric cutaneous ligament. (H) Platysma cutaneous ligament.

2 # 2018 Mutaz B. Habal, MD

Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018
Revisions and Principles of International
Anatomical Nomenclature
Several revisions have been made to guidelines on international
anatomical terminology. The Basle Nomina Anatomica (BNA) was
proposed in 1887 and published in 1895. It was revised in the
Birmingham Revision (BR, 1933) and Jena Nomina Anatomica,
(JNA or INA, 1936). The BR and INA were revised to create the
Paris Nomina Anatomica (PNA or NA, 1955, 1966, 1977, 1989).20
The sixth revised edition of the NA is Terminologia Anatomica
(TA, 1998), which is widely used at present.21
In the development of the BNA, the committee felt that their first
duty must be to consider the principles on which international
anatomical nomenclature should be based, and after a free and frank
discussion extending over several sessions, the following principles
were unanimously adapted (FCAT):
1 ‘‘That, with a very limited number of exception, each structure
shall be designated by one term only.’’
2 ‘‘That every term in the official list shall be in Latin, each
country to be at liberty to translate the official Latin terms into
its own vernacular for teaching purposes.’’
3 ‘‘That each term shall be, so far as possible, short, and simple.’’
4 ‘‘That the terms shall be primarily memory signs, but shall
preferably have some informative or descriptive value.’’
5 ‘‘That structures closely related topographically shall, as far as
possible, have similar names’’—for example, the Arteria
femoralis, Vena femoralis, Nervus femoralis, etc.
6 ‘‘That differentiating adjectives shall be, in general, arranged as
opposites’’—for example, major and minor, superficialis and
profundus, etc.
7 ‘‘That eponyms shall not be used in the Official Nomenclature of
Gross or Microscopic Anatomy."
DISCUSSION
Although it may sound plausible to reduce the degree of ambiguity
in such simple notions as one meter (for length) or one second (for
time) by utilizing an improved definition, it is not easy to develop a
rigorous definition of a complex concept such as the facial retaining
ligament, whose fundamental meaning is not based in a nominal
definition with its original intention and is not within the scope of
regulation by a dictionary definition.
This difficulty lies in the fact that even if anatomists and
surgeons are required to remain faithful to the meaning of termi-
nology based on an improved definition, they are simultaneously
expected to transcend the established meaning to sharpen the
rigorousness of the term.
Plastic and reconstructive surgery is not a discipline that
describes a notion deductively with the help of mathematical
symbols. Therefore, precisely because some lacks or excesses
are bound to happen in describing anatomical structures and
surgical methods, it is necessary to make efforts to reduce the
degree of ambiguity in order to improve the rigorousness of the
terminology by being faithful to the nominal definition, as well as to
the dictionary definition, and by introducing improved definitions
of structures and surgical methods.
In this respect, it is of immense benefit to heed the insights of
philosophers, including Wittgenstein and various scientists22: to
arrive at the true meaning of a word, the focus should be to identify
its meaning in the context in which it is used, rather than searching
for ‘‘an original meaning’’ of the word based on the erroneous
assumption that there is a permanent meaning in a word that
corresponds to its referent on a one-to-one basis.
Then how should we rectify the confusing terminology?
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Ligaments of the Face
FIGURE 2. The parasagittal section of the ZL. It connects the dermis to the
periosteum (Mallory trichrome staining). ZL, zygomatic ligament; ZM,
zygomaticus major muscle. A part of this picture has been published in 25.
First, following the NA principles, each structure should be
designated by one term only, and each term should be short and
simple, and have some informative or descriptive value. Second, the
cutaneous ligaments should be proven histologically in their full
length, not a part only. Third, the ligament must have sufficient
strength (Fig. 2).23–25 Lastly, consensus conference will be needed.
In conclusion, to rectify the present confusing terminology of the
ligament of face, the histologically proven structures should be
designated by one term only following the NA principles.
ACKNOWLEDGEMENT
The authors are grateful to Kwan Hyun Yoon, PhD, for illustration.
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4 # 2018 Mutaz B. Habal, MD

Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.