Facial Surgery

Aesthetic Surgery Journal

Special Topic 33(6) 769­–782
© 2013 The American Society for
Aesthetic Plastic Surgery, Inc.
Retaining Ligaments of the Face: Review of Reprints and permission:
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DOI: 10.1177/1090820X13495405
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Mohammed Alghoul, MD; and Mark A. Codner, MD

Abstract
The retaining ligaments of the face are important in understanding concepts of facial aging and rejuvenation. They are located in constant anatomic
locations where they separate facial spaces and compartments. Their superficial extensions form subcutaneous septa that separate facial fat compartments.
Their main significance relates to their surgical release in order to achieve the desired aesthetic outcome. Furthermore, they have a sentinel role in their
anatomic relationship to facial nerve branches. When performing facial aesthetic surgery, plastic surgeons should select a plane of dissection, release the
appropriate ligaments depending on the desired aesthetic goals, and avoid nerve injury by using the ligaments as anatomic landmarks. Descriptions of the
retaining ligaments are variable in the literature; due to different interpretations of anatomy, several classifications, locations, and nomenclature systems
have been proposed. This article will review and clarify the anatomy of the retaining ligaments of the face, including the cheek, mandible, temporal, and
periorbital areas.

Keywords
retaining ligaments, SMAS, facial compartments, facial nerve, facial surgery, anatomy

Accepted for publication February 12, 2013.

A thorough knowledge of the layers, planes, and structures
of facial anatomy is critical when performing aesthetic
surgery. The retaining ligaments of the face represent an
additional dimension of this anatomy and are important in
understanding concepts of facial aging and rejuvenation.
Since Mitz and Peyronie’s description of the superficial
musculoaponeurotic system (SMAS) in 1976,1 numerous
studies have focused on further clarifying the anatomy of
the SMAS and its use as a vehicle in facial rejuvenation.2-11
Plastic surgeons—including Bosse, Papillon, and Furnas—
logically realized the importance of the ligamentous
attachments of the SMAS to the facial skeleton and deep
fascia.3,12 These ligaments are consistent anatomic struc-
tures and are therefore present in predictable locations.
The main significance relates to the surgical release of
these ligaments to achieve the desired aesthetic out-
come.11-16 Furthermore, they are useful landmarks because
of their intimate relationship with branches of the facial
nerve.11,12,14,15,17-23 Significant research describing the
retaining ligaments of the face has advanced our knowl-
edge in this field. However, these consistent retaining
ligaments have been inconsistently named by different
investigators due to subjective interpretation. As a result,
ligaments were discovered and named, then rediscovered
and renamed, which has led to some confusion (Table
1).11,12,14-16,18,24,25 Perhaps the tedious dissection required
to identify the ligaments has contributed to these varia-
tions, as well. The purpose of this article is
to review and clarify the anatomy of the retaining liga-
ments of the face, including their different descriptions,
nomenclature, and clinical significance in facial aesthetic
surgery.
Dr Alghoul is Assistant Professor in the Division of Plastic Surgery
at Northwestern University Feinberg School of Medicine, Chicago,
Illinois. Dr Codner is Clinical Assistant Professor of Plastic Surgery
at Emory University, Atlanta, Georgia.
Corresponding Author:
Dr Mark A. Codner, 1800 Howell Mill Road, Suite 140, Atlanta, GA
30318, USA.
E-mail: macodner@gmail.com
770 Aesthetic Surgery Journal 33(6)

Table 1. Nomenclature of Facial Ligaments in the Literaturea
Orbitomalar ligament (Kikkawa et al25)
Superficial lateral canthal tendon (Knize24)
Zone of adhesion (Knize24)
24
Orbital ligament (Knize )
Orbicularis-temporal ligament (Knize24)
Orbicularis retaining ligament (Muzaffar
et al16)
Lateral orbital thickening (Muzaffar
et al16)
Superior temporal septum (Moss et al)
Temporal ligamentous adhesion (Moss
et al)
Inferior temporal septum (Moss et al18)
Knize24 and Moss et al18 considered a true retaining liga-
ment to be a cylindrical arrangement of fibrous tissue that
meets the above-mentioned microscopic criteria and inserts
directly into the dermis. Examples of true retaining liga-
ments, per this definition, are the zygomatic and masse-
teric retaining ligaments. Moss et al described other forms
of ligamentous attachments, mainly in the temporal and
periorbital area, in the form of septa and adhesions.
According to Knize and Moss, septa and adhesions are not
considered true retaining ligaments since they do not insert
directly onto the dermis; instead, the septa exert a direct
effect on the SMAS and an indirect effect on the dermis

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Anterior platysma-cutaneous ligament Masseteric cutaneous ligament (Stuzin
(Furnas12) et al11)
Platysma-auricular ligament (Furnas12) Parotid cutaneous ligament (Stuzin et al11)
Platysma-auricular fascia
(Mendelson14,15)
a
Note that the nomenclature in each row describes ligamentous structures that occupy the
same anatomic location but were given different names by various authors.
Definition and Classification
The retaining ligaments of the face are strong and deep
fibrous attachments that originate from the periosteum or
deep facial fascia and travel perpendicularly through facial
layers to insert onto the dermis.11,12,14 These ligaments act
as anchor points, retaining and stabilizing the skin and
superficial fascia (SMAS) to the underlying deep fascia
and facial skeleton in defined anatomic locations (Figure
1). Furnas is credited for first using this retaining ligament
terminology when he described the retaining ligaments of
the cheek.12 Microscopically, each ligament is rooted in a
tree-like distribution as a periosteal or deep fascial thick-
ening that divides as it approaches the SMAS into numer-
ous branches, which insert onto the dermis as described
by Mendelson.14 This branching network of fibers is called
the retinacular cutis, which is part of a larger complex
system of fibrous septa in the subcutaneous layer, described
by Gosain et al2 as the “fascial fatty layer” of the face. It is
likely that the superficial extensions of the retaining
ligaments into the subcutaneous layer (retinacular cutis)
contribute to the formation of septa that divide this layer
into the fat compartments of the face.26,27 This theory is
supported by the fact that some of these subcutaneous
septal boundaries overlap with the location of the deeply
seated retaining ligaments. Together, both the retaining
ligaments and the subcutaneous fibrous septa create zones
of adhesion and divide the face into superficial and deep
compartments.
Stuzin et al11,28 classified the retaining ligaments as (1)
osteocutaneous ligaments originating from the periosteum,
such as the zygomatic and mandibular cutaneous liga-
ments, and (2) fasciocutaneous ligaments, which coalesce
between the superficial and deep fasciae of the face, as
with the masseteric and parotid cutaneous ligaments.
through the retinacular cutis. The authors suggested using
a broader term—ligaments of the superficial tissues—to
include these other forms of attachments, instead of refer-
ring to the entire group as retaining ligaments.18
This classification system (which, again, includes liga-
ments, septa, and adhesions), while sound from the mor-
phological and structural standpoints, is not without
flaws. The orbitomalar ligament, also known as the
orbicularis retaining ligament, is morphologically a septal
structure, but it should be considered a true ligament
according to the Moss et al18 classification since it does
attach directly to the dermis.25,29 The zygomatic cutaneous
ligaments located posteriorly along the zygomatic arch
take a septal form,28,30 while the anterior ones over the
junction of the arch and body of the zygoma take a more
cylindrical form.14,18 Despite this, these structures are still
considered true retaining ligaments in the Moss et al clas-
sification. Mendelson et al17 indicated that the retinacular
cutis could not be seen in the area of the zygomatic cuta-
neous ligaments medial to the zygomaticus major muscle,
which means that direct dermal attachment was not histo-
logically proven; however, the zygomatic cutaneous liga-
ments are considered true retaining ligaments. Finally, the
lateral temporal-cheek fat compartment described by
Rohrich and Pessa26 has both the superior and inferior
temporal septa as its boundaries (Figure 2), which means
that both of these septa should have a superficial exten-
sion connecting the superficial temporal fascia to the der-
mis (ie, they should connect directly to the dermis).
Therefore, we prefer using the term retaining ligaments of
the face to describe all the above-mentioned ligamentous
attachments of the face.
Anatomy
Retaining Ligaments of the Temporal Area
There is no consensus in the literature on the accurate
description and nomenclature of the retaining ligaments
of the temporal area.18,24,31-33 There is agreement, however,
on the general location of these ligaments. Knize24,32,33
described a zone of adhesion (also called the zone of fixa-
tion) as a 6-mm-wide zone located immediately medial to
the superior temporal fusion line where the galea and the
periosteum are fixed to bone. At the distal end of the zone
of adhesion on the supraorbital rim is a strong ligament,
which he named the orbital ligament. He also described a
Alghoul and Codner
Figure 1. Anatomic locations of the retaining ligaments of the face.
narrow band of fusion between the superficial and deep
temporal fasciae, which he named the orbicularis-temporal
ligament.24 Moss et al18 divided the ligamentous attach-
ments of the temporal area into septa, ligamentous adhe-
sions, and areas of thickening around the orbital rim, which
they referred to as thickenings of the periorbital septum.
They also divided the temporal fusion line and zone of
adhesion described by Knize into a superior septum (supe-
rior temporal septum) and a caudal adhesion (temporal
ligamentous adhesion) (Figure 3). Although the temporal
ligament described by Moss et al is synonymous with
Knize’s orbital ligament, they each had a slightly different
location. The temporal ligament, or temporal ligamentous
adhesion, was described as a 15 × 20-mm area of adhesion
located 10 mm cephalad to the orbital rim, while the orbital
ligament was described as a ligament located on the orbital
rim.18,24 Moss et al described the temporal ligament as the
keystone area for its communication with 3 ligaments: the
superior temporal septum superiorly, the inferior temporal
septum laterally, and the supraorbital ligamentous adhesion
medially (Figure 3). The inferior temporal septum is roughly
similar in location to what was described by Knize24,33 as
the orbicularis-temporal ligament (Table 1).
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Similarly, the presence of ligaments in the forehead
area is controversial. Some authors considered the fore-
head devoid of named ligaments and instead as being
stabilized by the supraorbital and supratrochlear neuro-
vascular bundles, which act as retaining ligaments.24
Others described ligamentous attachments such as the
supraorbital ligamentous adhesion and superolateral,
superomedial, and inferomedial ligaments.18,34 Moss et
al18 considered the supraorbital ligamentous adhesion to
be the same area that Knize24,32,33 described as zone B of
the forehead (the lower 2 cm of the forehead), where
the deepest layer of the deep galea is adherent to the
periosteum and where periosteal elevation is particularly
difficult.
Retaining Ligaments of the Periorbital Area
The orbicularis retaining ligament, also known in the ocu-
loplastic literature as the orbitomalar ligament, is the main
periorbital retaining ligament. It is an osteocutaneous liga-
ment that originates from the periosteum of the orbital
rim, traversing the orbicularis oculi muscle and inserting
into the skin of the lid-cheek junction (Figure 1).25,29 In
1963, Hagriss35 described a fascial extension that passed
772 Aesthetic Surgery Journal 33(6)
Figure 2. Superficial facial fat compartments and their relationship to the retaining ligaments.
from the orbital rim to the orbicularis muscle and skin.
Kikkawa et al25 was the first to describe this ligament ana-
tomically and histologically, and they named it the orbito-
malar ligament. Histological analysis showed that the
ligament “fanned out” in a lamellar fashion as it traveled
through the orbicularis oculi and the SMAS to the skin,
similar to the retinacular cutis.25,36
Muzaffar et al16 detailed the anatomic description of
this ligament and renamed it the orbicularis retaining liga-
ment. His characterization of this retaining ligament was
conceptually similar to that by Kikkawa et al25; they said
that the ligament is a septal structure originating from the
periosteum just outside the inferior orbital rim, in close
proximity to the septum orbitale, and inserting on the
deep-surface orbicularis oculi muscle. The ligament is ill-
defined at the medial origin of the orbicularis, where the
muscle fibers are tightly adherent to the orbital rim perios-
teum to the level of the medial corneoscleral limbus.
Lateral to this point, the muscle separates anteriorly from
the rim periosteum and becomes attached to it through the
septum-like orbicularis retaining ligament.16 In a recent
anatomic study that included 48 hemifaces, Wong et al29
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confirmed the presence of a well-defined ligament in this
medial adherent area of the orbicularis, which they named
the tear trough ligament. This ligament originates from the
maxillary periosteum immediately inferior to the orbital
rim, sandwiched between and separating the origins of the
palpebral and orbital portions of the medial orbicularis
oculi muscle. It terminates at the medial corneoscleral
limbus, where it becomes continuous with the orbicularis
retaining ligament.29 The orbicularis retaining ligament
then lengthens in an anterior-posterior dimension to a
maximum length of 10 to 20 mm16,29 and then shortens
until it reaches the lateral orbital rim, where it terminates
in an area of fibrous thickening called the lateral orbital
thickening.16,18 The importance of the lateral orbital thick-
ening area, also known as the “superficial lateral canthal
tendon,”37 is that it indirectly connects the orbicularis
retaining ligament to the lateral canthal tendon through
the orbicularis deep fascia (septum orbitale) and the tarsal
plate, forming a single anatomic unit.16,37 Ghavami et al38
confirmed the circumferential nature of the orbicularis
retaining ligament in a cadaver study using an operating
microscope. The ligament was noted to be present over
Alghoul and Codner
Figure 3. Retaining ligaments of the temporal area as described by Knize24,32,33 and Moss et al.18 The overlap of color codes
suggests similarity in location, despite different nomenclature.
the superior orbital rim as a distinct structure, separate
from the septum orbitale.36,38 Wong et al29 named this
superior portion of the orbicularis retaining ligament the
periorbital septum of the upper orbit.18
Retaining Ligaments of the Cheek and Mandible
Furnas12 was the first to describe the anatomy of the
retaining ligaments of the cheek. His description included
the zygomatic, anterior platysma-cutaneous, mandibular,
and platysma-auricular ligaments. Stuzin et al11,28 refined
our knowledge of the ligaments and renamed the platysma-
cutaneous ligaments as the masseteric ligaments. Most of
the work to define the anatomy of the zygomatic and mas-
seteric cutaneous ligaments—championed by Stuzin,
Mendelson, and others—was done alongside their attempts
to describe the surgical anatomy of the extended SMAS
facelift for correction of the nasolabial fold.11,13-15,28,39-41
Despite the variation in published descriptions, the zygo-
matic ligaments occupied a predictable anatomic location
given their relationship to the body and arch of the
zygoma. The masseteric ligaments, on the other hand,
were less predictable and varied in location given the fact
that they are condensations of the deep fascia.11,13,15,30,39
Zygomatic and masseteric ligaments. The zygomatic cuta-
neous ligaments are strong fibers that originate at the
inferior border of the zygomatic arch and extend anteriorly
to the junction of the arch and body of the zygoma.11,12,13,30
773
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These ligaments can take the form of fibrous septa, mainly
posteriorly along the arch, and can have a cylindrical
shape closer to the origin of the zygomaticus major muscle.
The zygomatic ligaments are considered true ligaments
due to their direct attachments to dermis. This is mani-
fested by skin dimpling that occurs when the surgeon pulls
on the cutaneous end of the cut ligament.12
Mendelson et al17,41,42 described zygomatic ligaments
medial to the junction of the arch and body, located along
the origins of the facial expression muscles (the zygo-
maticus major, zygomaticus minor, and levator labii supe-
rioris). These ligaments are weaker and often can be
disrupted by blunt finger dissection. The masseteric cuta-
neous ligaments arise from the masseteric fascia over the
masseter muscle.11,28 Their relationship to the muscle is
controversial. While some anatomic studies have shown
the ligaments arising along the anterior border of the mas-
seter,11,28,39 others have shown them to arise 1 to 2 cm
posterior to the anterior border14 and even from the mid-
dle portion of the muscle.13 Owsley39 described the mas-
seteric ligaments as a vertical septum, while other authors,
although they did not directly address the morphology or
structure, seemed to address them as individual liga-
ments.11,13,14,17,28,30 As the zygomatic and masseteric liga-
ments were often described together, Mendelson41,42 stated
that they take an inverted L shape, with the horizontal
limb extending medially across the origin of the muscles
of facial expression and the vertical limb formed by the
774 Aesthetic Surgery Journal 33(6)
masseteric ligaments. The main zygomatic ligament is
located at the angle of the “L,” just lateral to the zygo-
maticus major muscle. Stuzin et al28 differed in what they
considered a particularly stout zygomatic ligament, which
they indicated is located just medial to the zygomaticus
minor muscle. Looking at the various illustrations and
considering the zygomatic ligaments along the arch, it
seems that both zygomatic and masseteric ligaments form,
roughly, a T-configuration. The junction of the “T” is near
the origin of the zygomaticus major muscle, where both
zygomatic ligaments (main zygomatic) and masseteric
ligaments (upper masseteric) are stronger (Figure 1).
Several studies have attempted to provide measurements
for the dimensions and location of the zygomatic ligaments
in relationship to different reference points.12,13,30,43 However,
it was not always clear which of the zygomatic ligaments
were represented by these measurements. Furnas,12 for
example, provided measurements for a typical bundle of
zygomatic ligaments 3 mm in width and 0.5 mm in thick-
ness located 4.5 cm anterior to the tragus. Özdemir et al13
measured the “zygomatic ligament” dimensions at 1.8 to
3.4 cm × 0.29 to 0.34 cm in men and 1.6 to 3.0 cm × 0.27
to 0.33 cm in women and said that these were located 3.9
to 4.8 cm anterior to the tragus. Alghoul et al30 provided
measurements for the main zygomatic ligament, which
they defined as the largest ligament in close proximity to
the origin of the zygomaticus major muscle, as 1.45 ×
0.27 cm in dimension and located at a mean of 4.49 cm
from the tragus. They also confirmed that men had larger
ligaments than women.
McGregor’s patch. The term McGregor’s patch has been
used in the literature to describe the zygomatic ligaments.
Kaye44 referred to the McGregor’s patch as an adherent
area over the malar eminence. Furnas12 used the term syn-
onymously with zygomatic ligaments, and so did other
authors.11,13,19,28,40 Stuzin et al28 used the term to describe
the fibers comprising the zygomatic ligament extending
through the malar fat pad, which they also named a
“fibrous McGregor’s patch.” Owsley40 described the
McGregor’s patch as dense fascial septi that extends from
the zygoma, penetrates the superficial fascia, and inserts
into the dermis. Later in his article, he mentioned 3 struc-
tures—the transverse facial artery, parotid duct, and
zygomatic branch of the facial nerve—traveling deep to
the parotid-masseteric fascia and penetrating it in the
region of McGregor’s cutaneous ligaments. However, he
subsequently mentioned that those structures run superfi-
cial to the buccal fat pad. Furnas quoted Dr Mar McGregor
verbatim in “The Retaining Ligaments of the Cheek,”
saying the following of the patch bearing the original
author’s name: “It is the area of fibrous attachment
between the anterior edge of the parotid fascia and the
dermis of the skin of the cheek.” He also added, “In doing
a facelift procedure, if it is not necessary to extend your
undermining beyond this patch, you are safer to stop
before cutting through,” and “If in order to obtain good
skin drapage it is necessary to cut through the fibrous
attachment, you must be aware that you will cut a blood
vessel which should be cauterized on the skin side and on
the parotid fascia side.”12 The blood vessel to which
McGregor referred is most likely a perforator off the trans-
verse facial artery, which many surgeons use as a clinical
landmark to identify this patch. McGregor then added, “As
soon as you cut through this patch, you lose the protection
of the parotid fascia on your deep side and you will see
loose fat with branches of the facial nerve looking at you,
hopefully intact . . . running through the loose fat, a little
deeper and a little caudad, is the parotid duct . . . as stated
above, I have for years emphasized that this patch is a
warning sign asking the surgeon to be aware of the road
ahead.”12 The description of “loose fat with branches of
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facial nerve” seems to resemble the buccal fat pad, which
is located anterior and inferior to the zygomatic cutaneous
ligaments. The buccal fat pad is more anatomically related
to the masseteric cutaneous ligaments, which guard its
anterior border. It is therefore unclear from McGregor’s
description of the patch that bears his name whether he
was describing the zygomatic cutaneous ligaments or
more inferiorly located ligaments such as the upper mas-
seteric or the masseterics. It should be noted that when
McGregor described this “patch,” none of the retaining
ligaments of the face had been discovered or named. In
addition, a “patch” configuration of the retaining liga-
ments of the cheek is not commonly found. On the basis of
these facts, we recommend that the term McGregor’s patch,
other than having a historical significance, should have no
place in the modern anatomic terminology of the retaining
ligaments of the face.
Platysma auricular ligament/fascia. Furnas described the
platysma-auricular ligament as arising from the parotid fascia
and anchoring the posterior border of the platysma to the
anterior inferior preauricular skin (Figure 1). According to the
classification by Stuzin et al,11,28 this ligament is considered a
parotid cutaneous ligament. It is the first ligament encoun-
tered during a facelift procedure. The other parotid cutaneous
ligaments arise from the parotid fascia over the parotid gland
and vary in size, density, and configuration depending on the
size and extent of the parotid gland.45 Mendelson46 expanded
the description of the platysma-auricular ligament to include
an area of adhesion over the parotid gland extending just
anterior to the ear cartilage for 25 to 30 mm. He named this
area the platysma auricular fascia.
Mandibular ligament. The mandibular ligament is an oste-
ocutaneous ligament that arises from the anterior third of
the mandible and inserts directly into the dermis.11-13 Its
fibers penetrate the inferior portion of the depressor anguli
oris muscle.47 Furnas12 described 2 tiers of linear series of
parallel fibers 2 to 3 mm from each other, located 1 cm
from the inferior border of the mandible. Özdemir et al13
confirmed the presence of 2 distinct fibrous attachments
and confirmed histologically the connection between the
periosteum and overlying skin. Langevin et al47 reported
on the dimensions of the mandibular ligaments measuring
2 cm horizontally × 1.2 cm vertically and located 4.5 cm
anterior to the angle of the mandible. Reece et al48 identi-
fied another osteocutaneous ligamentous structure that
travels as a posterior extension of the mandibular ligament
Alghoul and Codner
originating 1 cm superior to the border of the mandible.
They named this structure the mandibular septum. This
septum extends from the mandibular ligament anteriorly
and ends abruptly posteriorly at another vertical septum
that forms the anterior border of the lateral temporal–
cheek fat compartment (Figure 1).
Facial Compartments
As stated earlier, the retaining ligaments of the face are
present in certain locations over the facial skeleton to
stabilize the soft tissue planes. They extend through all
the concentric layers and bind them together in fixed
immobile points. The areas in between the ligaments are
spaces and compartments where facial movements take
place.17,18,49,50 The diversion of the ligaments into the reti-
nacular cutis in the subcutaneous layer connects the super-
ficial fascia (SMAS or its equivalent) to the dermis and
enables these layers to move as a single unit during facial
expression.2,14 As the ligaments divide the sub-SMAS plane
into deep facial compartments, the retinacular cutis, with
their fibrous septa, divide the pre-SMAS plane, which is the
subcutaneous layer, into fat compartments.
Knowledge of the deep facial spaces and compartments
is important during facial rejuvenation, since they influ-
ence the type and level of dissection performed. Dissection
through a space in a sub-SMAS plane can be performed in
a blunt fashion, while dissection through the boundaries
of the space (the retaining ligaments) requires sharp dis-
section. Also, the level and difficulty of dissection may
differ between compartments; for example, a dissection
plane is often transitioned from a sub-SMAS plane in the
temporal compartment to a subperiosteal plane in the
forehead compartment. These 2 compartments are sepa-
rated by the zone of adhesion, per Knize’s description,24,32
or the superior temporal septum and temporal ligamen-
tous adhesion, per Moss et al.18 Similarly, the superior
temporal septum and the inferior temporal septum divide
the temporal space into 2 compartments, the upper and
lower temporal compartments. The upper temporal com-
partment is bounded superiorly by the superior temporal
septum and inferiorly by the inferior temporal septum. No
important structures pass through this compartment, and
dissection can proceed bluntly through the loose areolar
tissue. The inferior temporal compartment, on the other
hand, is bounded superiorly by the inferior temporal sep-
tum and inferiorly by the zygomatic cutaneous ligaments
overlying the zygomatic arch, and it contains important
anatomic structures such as the temporal branches of the
facial nerve, the sentinel vessels, and branches of the
zygomaticotemporal nerve.18 Careful dissection should be
performed when entering the inferior temporal compart-
ment to protect these “at-risk” structures.
The orbicularis retaining ligaments form the superior and
inferior boundaries of the orbital compartments of the upper
and lower lid, respectively—also called the preseptal
space.16,17,26 The orbicularis retaining ligament of the lower
eyelid also forms the superior border of the prezygomatic
space, while the inferior border is formed by the medial
zygomatic cutaneous ligaments.17,51 The lateral zygomatic
cutaneous ligaments over the zygomatic arch, on the other
775
hand, separate the temporal space from the lateral cheek
compartment. The masseteric cutaneous ligaments separate
the lateral cheek compartment and premasseter space over
the lower masseter from the masticator space containing the
buccal fat pad.49,50 Similarly, the location of the retaining
ligaments overlaps with some of the boundaries of the super-
ficial fat compartments of the face described by Rohrich and
Pessa.26,27 The orbicularis retaining ligament forms the supe-
rior border of the nasolabial and medial fat compartments.
These 2 compartments combine to form the malar fat pad,
an important structure in midfacial aging.52 Elevation and
repositioning of the malar fat pad has been described for
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midface aesthetic enhancement.40,53,54 The zygomatic liga-
ments overlap with the more superficial superior cheek sep-
tum, separating the lateral orbital compartment from the
middle fat compartment. The masseteric cutaneous liga-
ments overlap with the septum, separating the middle and
medial fat compartments. The temporal portion of the lateral
temporal–cheek fat compartment is bounded superiorly by
the superior temporal septum and inferiorly by the inferior
temporal septum, while the lateral orbital compartment is
sandwiched between the inferior temporal septum superiorly
and the superior cheek septum inferiorly. The platysma-
auricular ligament corresponds to the plane between the
lateral temporal cheek compartment and the postauricular fat
compartment.26,27 Finally, the mandibular ligament forms the
anterior border of the inferior jowl fat compartment, while
the mandibular septum separates both the superior and infe-
rior jowl fat compartments superiorly from the submandibu-
lar jowl-fat compartment inferiorly48 (Figure 2).
Relationship of the Retaining Ligaments
to Nerve Branches
One of the most fascinating aspects of the anatomy of the
retaining ligaments of the face is their spatial relationship
to facial nerve branches (Figure 4).* Since the ligaments
can be used as landmarks to navigate facial nerve and
sensory branches, knowledge of this relationship is critical
for safe release of the ligaments while avoiding nerve
injury. The inferior temporal septum is a landmark for the
temporal branches of the facial nerve that pass just medial
and parallel.18,24 These branches travel in close proximity
to the undersurface of the superficial temporal fascia and
are elevated with the flap.18-23 Approaching and releasing
the inferior temporal septum should be a warning sign for
the surgeon to slow down and perform careful dissection,
making sure to “stay down” on the deep temporal fascia.
The orbitomalar ligament has an intimate relationship to
the zygomaticofacial nerve branches located just inferior to
the lateral aspect of the ligament. However, these branches
can be compromised without any consequence.55 The zygo-
matic retaining ligaments are landmarks for the zygomatic
facial nerve branches.11-15,28,30 Furnas12 was the first to show
that a zygomatic branch passes in a deep plane just inferior
to the zygomatic ligament. Other authors considered the
area immediately inferior to the zygomatic ligament to be a
danger zone due to the proximity of zygomatic nerve
*References 11, 12, 14, 15, 17-20, 24, 28, 30, 47.
776 Aesthetic Surgery Journal 33(6)
Figure 4. Relationship of the retaining ligaments of the face to facial nerve branches.
branches.11,14,15,28 A recent study showed that the main zygo-
matic and upper masseteric retaining ligaments, located at a
mean of 11 mm from each other, create a pathway where an
upper zygomatic nerve passes in a deep plane, 4 mm deep to
the deep fascia. A lower zygomatic nerve passes just inferior
to or penetrates the upper masseteric ligament at a more
superficial level, 1 mm deep to the deep fascia, and pierces
the deep fascia just distal to the ligament.30 The authors of
that study concluded that the area (approximately 1 cm)
immediately inferior to the main zygomatic ligament is rela-
tively safe, except in 5% to 9% of cases, in which the upper
zygomatic nerve gives off a more superficial branch that
travels superficial to the zygomaticus major muscle.28,30
Another important observation is that facial nerve branches
often penetrate the ligaments. This incidence was reported to
be 27% for the zygomatic ligaments and 66% for the mas-
seteric ligaments.19,30
The masseteric ligaments are important landmarks for the
buccal facial nerve branches. These ligaments guard the
nerves, which penetrate the deep fascia and become superfi-
cial on top of the buccal fat pad, just distal to the masseteric
ligaments.14,15 In other words, releasing the masseteric retain-
ing ligaments in a sub-SMAS plane may cause herniation and
exposure of the buccal fat pad, with the buccal facial
branches lying superficial to it. Langevin et al47 described
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the relationship of the marginal mandibular nerve to the
mandibular ligaments. In 20 hemifaces, the nerve was found
to run just posterior to the mandibular ligament. Finally, the
great auricular nerve is anatomically related to the subcuta-
neous extension of the platysma-auricular ligament. This
septal extension separates the lateral temporal–cheek fat
compartment from the postauricular compartment, and the
great auricular nerve travels through this septum.26,27
Clinical Significance
Retaining Ligaments and Facial Aging
Facial aging results from a combination of soft tissue descent
and volumetric deflation.10,11,15,25,56,57 The loss of tissue elas-
ticity combined with repetitive motion from muscle contrac-
tion and gravity is believed to cause tissue descent.25 The role
of the retaining ligaments in this process is not well defined.
Some authors believe that laxity of the retaining ligaments
results in laxity and descent of the soft tissue they sup-
port.11,13,28,34,40,48 Another school of thought suggests that the
ligaments remain relatively strong while the unsupported
tissue in between (in the spaces and compartments) descends
with time. This phenomenon is responsible for the “stig-
mata” of facial aging, manifested in bulges and grooves.49,50,58
Alghoul and Codner
Figure 5. Stigmata of facial aging as they relate to retaining ligaments of the face in the form of grooves.
The location of the retaining ligaments is where these
grooves show. Perhaps one of the most notable signs of aging
is the nasojugal groove and its lateral extension, the palpe-
bromalar groove. These grooves correspond to the location
of the tear trough ligament and orbicularis retaining liga-
ment, respectively, and mark the location of the lid-cheek
junction.17,18,36,38,51
As the orbital septum attenuates with age, the periorbi-
tal fat bulges anteriorly against the septum and inferiorly
against the orbicularis retaining ligament. The formation
of this bulge, combined with volumetric deflation in the
upper cheek, leads to accentuation and visibility of the
orbicularis retaining ligament at the lid-cheek junction.16,29
Kikkawa et al25 suggested that the orbitomalar ligament,
or orbicularis retaining ligament, distends and stretches
with aging, which would theoretically lower the lid-cheek
junction.59,60 This, however, contradicts Lambros’s find-
ings56,57 that the lid-cheek junction is remarkably stable in
position over time. The ligament’s V-shape is due to non-
uniform length (distance from the orbital rim to muscle
insertion), which allows the longest portion at the apex
of the “V” to distend more.16,29,36,51 Similarly, the medial
limb of the zygomatic cutaneous ligaments, described by
777
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Mendelson et al, contributes to the formation of the mid-
cheek grove through the cutaneous extensions.17,49,58 The
prezygomatic space is bounded superiorly by the orbicula-
ris retaining ligament and inferiorly by the medial limb of
the zygomatic ligaments. Bulging and ptosis of this space
with age form malar bags and festoons.17
Another classic stigmata of facial aging is formation of
jowls, formed by the descent of the premasseteric space,
which overlies the lower portion of the masseter.15,49,50
According to Reece et al,48 the superior and inferior jowl fat
compartments descend, secondary to attenuation of the man-
dibular septum. Either way, as the jowl forms, its anterior
extension is limited by the mandibular ligament. The groove
that forms just anterior to the jowl corresponds to the man-
dibular ligament. Another unique aspect of the mandibular
ligament is that its subcutaneous extension (retinacular cutis)
can cause skin indentation with aging. Failure to recognize
and correct this deformity by subcutaneous release can lead
to patient dissatisfaction after facelift surgery (Figure 5).
Concepts of Release and Redraping
Any facial rejuvenation procedure that undermines
a superficial fascial flap (SMAS, superficial temporal
778 Aesthetic Surgery Journal 33(6)

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Figure 6. Concepts for release of the retaining ligaments and redraping of the skin and superficial musculoaponeurotic system
(SMAS). Point A is where the dissection starts, and point B is the area of the face that needs to be lifted or tightened. A′ and
B′ are locations of points A and B, respectively, after the skin or SMAS flap is pulled. I, subcutaneous facelift; II, SMAS facelift;
III, deep plane and composite facelift; and IV, SMAS plication.

fascia, or platysma) will require release of the retaining
ligaments to allow unrestricted mobilization and redrap-
ing of the flap. Dividing the ligaments in the sub-SMAS
plane will eliminate the restraining effect of the ligament
on the flap. By releasing the tethered portion of the
SMAS, the surgeon can effect a change in an area distal
to this tethered point. Imagine that point A is the area
where the flap was raised and where a pulling force will
ultimately be applied to redrape the flap, and point B is the
ptotic area in the face that needs to be lifted (Figure 6). If
Alghoul and Codner
the tethering ligament in between is not released, exces-
sive force will need to be applied on point A to effect
some change in point B. This excessive tension can com-
promise the flap and produce unnaturally tight results. If
flap elevation is not performed and plication is planned
instead, knowledge of the location of the retaining liga-
ment will help in carefully choosing the areas of plication
to achieve maximum results.
The retaining ligaments can be divided at different
levels depending on the plane of dissection. In the subcu-
taneous plane, the surgeon will encounter numerous
fibrous septa that need to be divided sharply. In the sub-
SMAS plane, the main trunk of the ligament is encoun-
tered and should also be divided sharply, paying close
attention to the location of the facial nerve branches. In
the temporal area, remaining on the deep temporal fascia
when dividing the ligamentous attachments (the inferior
temporal septum or orbicularis-temporal ligament) will
protect the frontal branches of the facial nerve. On the
contrary, the zygomatic and masseteric ligaments in the
cheek should be divided as close as possible to the SMAS,
away from the deep fascia, to avoid injuring the zygo-
matic and buccal branches. In the subperiosteal plane,
the ligament should be lifted with the periosteum using
blunt dissection.
When applying this concept to browlifting, point A is
the incision site and point B is the brow. The superficial
temporal fascia slides over the deep temporal fascia, con-
tributing to brow ptosis.24,32 When performing a browlift,
a composite flap is raised in the subperiosteal and sub-
galeal planes, medial and lateral to the temporal fusion
line, respectively. To achieve adequate mobilization of the
lateral brow, the intervening ligamentous attachments
should be divided.18,24,32-34 In addition to the ligaments,
periosteal release should be performed as close as possible
to the orbital rim, to avoid inadvertent trauma to the fron-
tal facial nerve branches.
Similarly, in the case of the orbicularis retaining ligament,
point A is the area of the lower lid subciliary or conjunctival
incision, and point B is the area below the lid-cheek junction.
Dividing the ligament will facilitate release and redraping of
the orbicularis oculi muscle in cosmetic blepharoplasty.61,62 It
also allows access through the lower lid for midface lifting63-65
and cheek skin recruitment for lower lid reconstruction.
Another important clinical application for the release of the
orbitomalar ligament is treating a tear trough deformity and
blending the lid-cheek junction with fat transposition across
the anatomic area of the ligament66-71 or placement of orbital
rim implants.72,73 Other reported clinical uses for the orbicu-
laris retaining ligament include its suspension for midface
lifting59 and ectropion repair.74
The same concepts apply in facelift procedures regard-
less of the technique. In a subcutaneous facelift with or
without SMAS plication, the ligaments are divided in the
subcutaneous plane, while in a deep plane and composite
facelifts, the ligaments are divided in the sub-SMAS
plane.75 The parotid cutaneous ligaments or platysma-
auricular fascia will be first encountered if the sub-SMAS
779
dissection is started in the preauricular area. If the preau-
ricular area is considered point A, then it seems logical
that the release of platysma-auricular fascia would improve
the jowl to a greater degree. However, some surgeons do
not advocate releasing this adherent area of platysma-
auricular fascia, instead starting their dissection superiorly
and anteriorly, completely bypassing it.14,15 If a sub-SMAS
dissection is not performed, then plicating the mobile
SMAS anterior to these ligaments can be as effective.76
To mobilize the SMAS flap in a superior lateral vector,
the surgeon should divide the zygomatic retaining liga-
ments along the inferior border of the arch. However, lift-
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ing the midface from a preauricular incision will require
the release of the main zygomatic and upper masseteric
cutaneous ligaments.† Releasing the lower masseteric liga-
ments is usually unnecessary and often leads to the her-
niation of the buccal fat pad with the overlying buccal
nerve branches. The release of the mandibular retaining
ligament in a sub-SMAS plane is unnecessary and could
be dangerous since it is located distal, or anterior, to point
B (the jowl, in this case) and has an intimate relationship
with the marginal mandibular nerve. We hypothesize that
in some patients, the cutaneous extension of the mandibu-
lar ligament produces a visible indentation at the caudal
extension of the marionette line. Dividing the ligament in
a subcutaneous plane, at the level of the retinacular cutis,
can improve the aesthetic appearance of this area (Figure
7). It should be noted that the shape, density, and distribu-
tion of the retaining ligaments of the cheek can be variable
among different faces, and each person can have unique
ligament topography. Despite this variability, there are
some more constant and predictable anatomic locations
and relationships such as the zygomaticus major muscle,
main zygomatic, and upper masseteric ligaments and their
relationship to the zygomatic nerve branches.30 This ana-
tomic variability should be recognized when performing a
sub-SMAS dissection.
Conclusions
The retaining ligaments of the face are important land-
marks that occupy predictable anatomic locations. When
performing facial aesthetic surgery, plastic surgeons
should decide on a plane of dissection, release the appro-
priate ligaments depending on the desired aesthetic goals,
and avoid nerve injury by using the ligaments as anatomic
landmarks. Clarification of the anatomic definitions of the
facial retaining ligaments and knowledge of their location,
function, and proximity to the SMAS and facial nerves
should add to the safety and efficacy of facial aesthetic
surgery. Anatomists should be aware of, respect, and
acknowledge the anatomic descriptions of the facial retain-
ing ligaments to avoid confusion of complex facial ana-
tomic structures.
†
References 14, 15, 28, 40, 42, 49, 75, 77.
780 Aesthetic Surgery Journal 33(6)

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Figure 7. (A) This 54-year-old woman presented with a prominent mandibular cutaneous ligament and underwent facelift
surgery (superficial musculoaponeurotic system plication) and upper and lower blepharoplasty. There was no skin resurfacing
performed. Note the circular indentation resulting from subcutaneous extension of the mandibular ligament. (B) The same
patient had a facelift and was unhappy with the area caudal to the marionette line. She underwent revision surgery, and the
subcutaneous undermining was extended to release the mandibular ligament. The skin was then redraped, achieving the final
result shown 6 months postoperatively in this photograph.

Disclosures
Dr Mohammed Alghoul declared no potential conflicts of
interest with respect to the research, authorship, and publica-
tion of this article. Dr Mark Codner is a paid consultant for
Mentor Corp (Santa Barbara, California) and Syneron Corp
(Irvine, California) and receives royalties for books published
by Quality Medical Publishing (St Louis, Missouri) and Else-
vier (New York, New York).
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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