FREQUENTLY CONFUSED TERMINOLOGY REGARDING THE CHEEK LIGAMENTS
Subcutaneous ligamentous attachments
Many articles published after Furnas challenged his concept, offering alternative
nomenclature of their own for the retaining ligaments, which has provoked confusion
in the use and categorization of the retaining ligaments in the face ever since. The
terminology used for the retaining ligaments of the cheek vary in the literature due
to the use of terms named for different interpretations of the anatomy, or by its
location ([Table 1 ]) [1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[12 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
[21 ]
[22 ]
[23 ]
[24 ]
[25 ]
[26 ]
[27 ].
Table 1.
Confused nomenclatures of the retaining ligaments of the cheek
Cheek ligaments
Presumed synonym
Retaining ligaments of the cheek are presented in variable ways in the literature
due to terminology based on different interpretations of the anatomy, or by their
location.
=, identical nomenclature or in the same location addressed by the original namer;
≒, difference in nomenclature at a similar location to that addressed by the original
namer; >, including the region described by the original namer.
Malar area
Malar area
McGregor’s patch (1959) [[1 ]
[2 ]]
= Zygomatic ligament (Furnas 1989 [[3 ]])
= Zygomatic cutaneous ligament (Özdemir 2002 [[12 ]])
Peri-auricular area
Platysma auricular ligament (Furnas 1989 [[3 ]])
= Auricle-platysma ligament (Botti 2012 [[16 ]])
Parotid cutaneous ligament (Stuzin 1992 [[5 ]])
= Platysma auricular fascia (Furnas 1994 [[4 ]
[17 ]
[18 ]])
≒Preauricular parotid cutaneous ligament (Özdemir 2002 [[12 ]])
Platysma auricular fascia (PAF, Mendelson 2008 [[19 ]
[20 ]])
> Platysma auricular ligament (Furnas 1989 [[3 ]])
> Parotid cutaneous ligament (Stuzin 1992 [[5 ]])
> Platysma auricular fascia (Furnas 1994 [[4 ]
[17 ]
[18 ]])
> Auricle-platysma ligament (Botti 2012 [[16 ]])
> Preauricular parotid cutaneous ligaments (Özdemir 2002 [[12 ]])
> Lore’s fascia (Labbé 2006 [[21 ]
[22 ]
[23 ]])
Temporoparotid fascia (Lore 1973 [[24 ]
[25 ]])
= Lore’s fascia (Labbé 2006 [[21 ]
[22 ]
[23 ]])
= Tympanoparotid fascia (Labbé 2006 [[21 ]
[26 ]])
Peri-masseteric area
Anterior Platysma-cutaneous ligament (Furnas 1989 [[3 ]])
≒Masseteric cutaneous ligament (Stuzin 1992 [[5 ]])
≒Parotidomasseteric cutaneous ligament (Özdemir 2002 [[12 ]])
Platysma cutaneous ligament (Özdemir 2002 [[12 ]])
≒Mandibular septum (Pessa 2008 [[27 ]])
The most confusing perspective arises from the subcutaneous ligamentous attachments.
Furnas [3 ] and Stuzin [5 ]
[8 ] rejected the term ‘cutaneous’ to describe the retaining ligaments with subcutaneous
ligamentous attachments with a skeletal origin. On the other hand, Özdemir et al.
[12 ] adopted the term “cutaneous” generally for ligamentous cutaneous attachments, regardless
of their origin. However, Özdemir did not use ‘cutaneous’ for the mandibular ligament,
which seems inconsistent. Mendelson (2000) created his own terminology categorizing
the retaining ligaments of the face as adhesion, septum, and true ligaments, and did
not utilize the term ‘cutaneous’ at all [10 ]
[20 ]
[28 ].
Somewhat different names for identical retaining ligaments have arisen because of
the intended purpose for categorizing the ligamentous attachment, as in the case of
Mendelson, or due to the individual variability of the appearance of the ligamentous
attachments found in the clinical setting or in cadaver specimens.
McGregor’s patch [1 ]
[2 ]
‘McGregor’s patch’ had been used synonymously with the zygomatic cutaneous ligament
or the zygomatic ligament [3 ]
[5 ]
[7 ]
[11 ]
[29 ].
The original description of the ‘McGregor’s patch’ presented in 1959 referred to “an
area of fibrous attachment between the anterior edge of the parotid fascia and the
dermis of the skin of the cheek” [1 ] ([Fig. 1A ], [B ]). The definition was meant to emphasize the warning that this patch is a necessity
and that in making cuts to obtain good skin drapage, there is a risk of injuring the
parotid fascia. The idea was to raise awareness of the existence of the facial nerve
branches and parotid duct running underneath [3 ].
Fig. 1. McGregor’s patch(A) Schematic illustration of McGregor’s patch. This patch is composed
of a perforator of the transverse facial artery running towards the malar area, zygomatic
ligaments, and upper masseteric ligaments. (B) A fresh frozen cadaveric dissection
shows the condensed fibrotic tissue between the superficial musculoaponeurotic system
(SMAS) and the skin in the zygoma. Red circle, McGregor’s patch; Heart, skin flap;
Clover, SMAS. (C) McGregor’s patch contains zygomatic and masseteric ligaments. The
perforating vessels are present. Yellow diamond, Zygomatic cutaneous ligament; Blue
diamonds, Masseteric ligaments; Green arrow heads, perforators of the facial artery;
Heart, skin flap; Clover, SMAS.
Alghoul and Codner [30 ] also emphasized that finding this patch, which is believed to be the perforator
of the transverse facial artery, during exploration alerts the surgeon to the presence
of blood vessels ahead ([Fig. 1B ]). Upon finding McGregor’s cutaneous ligaments, they mentioned 3 nearby structures
of importance: the transverse facial artery, parotid duct, and zygomatic branch of
the facial nerve that penetrates the parotid-masseteric fascia in that region. However,
the specific extent of McGregor’s patch itself is not described definitively; it is
unclear whether it solely refers to the zygomatic cutaneous ligaments or, in addition,
includes the masseteric ligaments. In that sense, we agree with the idea of Alghoul
and Codner [30 ]. The extent of this region of McGregor’s patch extends from the point of appearance
of the perforating branch of the transverse facial artery to the area covering the
zygomatic cutaneous ligament and the upper masseteric cutaneous ligament ([Fig. 1C ]). Measurements of its dimensions are approximately 3 cm anterior to posterior, and
approximately 3.5 cm cephalic to caudal. Thereby, considering the level of dissection
and description, there is common agreement that it is tethering the malar fat pad
(malar superficial musculoaponeurotic system, SMAS) [3 ]
[29 ]
[30 ]. Release of the McGregor’s patch will result in freed mobility of the midfacial
skin, in which is an important technique in adopting malar SMAS dissection to performing
a subSMAS facelift surgery.
Platysma auricular ligament (Furnas [3 ]) and auricle-platysma ligament (Botti [16 ])
Furnas [3 ] reported 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”.
O’Brien et al. [31 ] has described the platysma-auricular ligament (PAL) as extending from the auricle
in an inferior direction along the posterior border of the platysma. A thorough description
by Botti [16 ] also presents 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.
Although Botti [16 ] named the structure with more emphasis on its origin and named it the auricle-platysma
ligament, it is identical to the structure initially indicated as the ‘platysma auricular
ligament’ by Furnas [3 ] in his illustration ([Fig. 2 ]).
Fig. 2. Platysma auricular ligament and auricle-platysma ligament(A) Schematic illustration
of the platysma auricular ligament and auricle-platysma ligament. (B) In fresh frozen
cadaveric dissection, the trapezoidal fibrous tissue exists between the ear lobe and
the posterior border of the platysma muscle. Diamond: platysma auricular ligament
(auricle-platysma ligament). Heart, parotid masseteric fascia (deep fascia); Clovers,
The superficial musculoaponeurotic system is reflected.
Fresh frozen cadaver dissection performed by the authors has confirmed a trapezoidal
shape of a deep fibrotic expansion located at the superficial layer, extending from
the dermis of the inferior auricular region to the lateral border of the platysma.
We observed that as it completes its course with the insertion to the lateral border
of the platysma, the distribution and the morphology of the platysma auricular ligament
(auricle-platysma ligament) differs according to the shape of the platysma.
During the fresh frozen cadaver dissection, we also learned that the tension applied
to the platysma auricular ligament transmits such that it shifts the ear axis in the
anteroinferior direction.
However, several observations reveal that the platysma auricular ligament is obviously
a different structure from the parotic masseteric fascia (deep fascia).
The parotid cutaneous ligament (Stuzin et al. [5 ]), platysma auricular fascia (Furnas [4 ]
[17 ]
[18 ]) and preauricular parotid cutaneous ligament (Özdemir [12 ])
Nevertheless, back in 1989, aside from the illustration, Furnas [3 ] did not make mention of the direct relevance of the platysma auricular ligament
to the parotid fascia. Then, later in 1994, he discovered that the fascial condensation
actually originates from the parotid fascia and he renamed it the platysma auricular
fascia [4 ]
[17 ]
[18 ]. Furnas’s transition from considering the part to be a ligamentous structure to
thinking of it as a fascial condensation, and moreover, equating the term with Stuzin’s
‘parotid cutaneous ligament’ (1992) [5 ] and Özdemir’s [12 ] ‘preauricular parotid cutaneous ligament’ (2002), can be interpreted as indicating
that Furnas had conceptualized a broader range of fibrous connective tissue in the
preauricular area in describing the platysma auricular fascia ([Fig. 3 ]).
Fig. 3. The ligamentous structure of the preauricular area(A) Schematic illustration of the
parotid cutaneous ligament, platysma auricular fascia, and preauricular parotid cutaneous
ligament. ‘Parotid cutaneous ligament’ (Stuzin 1992), ‘platysma auricular fascia’
(Furnas 1994) and ‘preauricular parotid cutaneous ligament’ (Özdemir 2002) are terms
that have been used to denote a broad range of fibrous connective tissue in the preauricular
area. (B) Fresh frozen cadaver dissection reveals that upon cutting open the platysma
auricular ligament, the parotid cutaneous ligaments are exposed at the preauricular
area. Diamonds, parotid cutaneous ligaments; Heart, skin flap; Clover, superficial
musculoaponeurotic system.
Alghoul and Codner [30 ]
[32 ] suggested that the ligaments or the fascia in relation to the parotid gland have
structural variation in accordance to the parotid fascia over the parotid gland and
vary in size, density, and configuration depending on the size and extent of the parotid
gland.
Less well-known anatomic variation of the platysma muscle may add another element
of confusion. The classification of the platysma muscle presented by Bae et al. [33 ] reveals a better understanding of the variability in the location and direction
of the posterior fiber of the platysma, where the ligamentous attachment should be
located.
Platysma Auricular Fascia (PAF, Mendelson [19 ]
[20 ])
Alghoul and Codner [30 ] mistakenly noted in their article that Mendelson coined the term ‘platysma auricular
fascia’ (PAF). In reality, Furnas [17 ] named the platysma auricular fascia [4 ]
[17 ]
[18 ], and even in the article, Mendelson reported that the PAF combines the part of the
SMAS layer between the ear cartilage and the posterior edge of the platysma [19 ]
[20 ]
[34 ] ([Fig. 4 ]). In other words, Mendelson believes that the platysma auricular ligament by Furnas
(1989) is synonymous to the parotid cutaneous ligament by Stuzin (1992), and that
indicates of it to be a lower portion of the PAF [20 ].
Fig. 4. Platysma auricular fascia (PAF, Mendelson [2008 ])Schematic illustration of the boundary of the platysma auricular fascia (PAF, Mendelson).
In the lateral face, immediately in front of the ear, extending 25–30 mm forward of
the ear cartilage to the posterior border of the platysma is a diffuse area of ligamentous
attachment.
Conceptual arguments about the independence of the platysma auricular fascia are related
to where it originates. In contradiction to Mendelson’s suggestion of an auricular
cartilaginous origin, our cadaveric findings revealed a superficial nature with fibrous
connection with the dermis of the inferior earlobe and obvious structural differentiation
from the deep fascia, which support the notion that the PAF is a component of the
SMAS layer.
Temporoparotid fascia (Lore 1973 [24 ]
[25 ]), Lore’s fascia (Labbé 2006 [21 ]
[22 ]
[23 ]) and tympanoparotid fascia (Labbé 2006 [21 ]
[26 ])
Gray’s anatomy describes the parotid fascia as thick and broad anteriorly and thin
and translucent membranous posteriorly [35 ]. Lore [24 ] named the fascial structure in front of the tragus the ‘temporoparotid fascia’,
and Labbé [21 ] gave this structure a different name, the ‘tympanoparotid fascia’ (Lore’s fascia).
In 2006, Labbé et al. reported that the tympanoparotid fascia originates from the
tympanomastoid fissure [26 ].
The definition of the tympanoparotid fascia is also controversial. Mendelson [19 ] denied the isolated concept of Lore’s fascia and regarded it as a portion of the
PAF immediately in front of the lower tragus [20 ]. O’Brien et al. [31 ] asserted that, actually, Lore’s fascia was a completely different structure from
the platysma auricular ligament.
We believe that the tympanoparotid fascia is a dense fibrous tissue that covers the
parotid gland, located deeper than the PAF and the SMAS. As it originates from the
tympanomastoid fissure, it becomes dense and coarse as it approaches the inferior
tragus. The extent of the tympanomastoid fascia arises from the tympanomastoid fissure
and covers the ear cartilage superiorly and the parotid fascia anteriorly. As you
see in the figure, it is obviously a distinct structure compared to the platysma auricular
ligament ([Fig. 5 ]).
Fig. 5. Cadaveric dissection of the preauricular areaThe tympanoparotid fascia is a separate
layer from the platysma auricular ligament. red arrow, tympanoparotid fascia; blue
arrow, parotid masseteric fascia (deep fascia); white arrow, platysma auricular ligament;
heart, skin flap; clover, superficial musculoaponeurotic system.
Ligamentous structures found between the anterior border of the parotid gland and
the anterior border of the masseter muscle
Furnas [3 ] observed that aponeurotic connections were sometimes seen between the anterior platysma
and the skin of the middle and anterior cheek ([Fig. 6 ]). Attaching a fibrous connection to the platysma means that it has a septal form
rather than a significant ligamentous form. Observing what was previously called the
anterior platysma cutaneous ligament by Furnas [3 ], originating along the anterior border of the masseter, Stuzin [5 ] proposed the term ‘masseteric cutaneous ligament’ [8 ]. Reports differ with regard to the origin of the masseteric cutaneous ligament:
whether it arises along the anterior border of the masseter muscle [5 ]
[8 ]
[36 ] ([Fig. 7 ]), 1–2 cm posterior to the anterior border [6 ], or even from the middle portion of the muscle (Özdemir) ([Fig. 8 ]) [12 ]. The excursion of the origin definitely has to be closely related to the structural
variation in accordance to the intersecting area of the masseteric fascia and the
parotid fascia in relation to the size of the parotid gland [25 ]
[30 ]
[32 ]
[37 ]. Thus, each authors have suggested different nomenclature for the masseteric cutaneous
ligament or describe it with different anatomic locations ([Figs. 6 ]
[Figs. 7 ]
[8 ]) [3 ]
[5 ]
[12 ].
Fig. 6. The anterior platysma-cutaneous ligament (Furnas [1989 ])(A) Schematic illustration of the anterior platysma-cutaneous ligament. The aponeurotic
connections can be seen between the anterior platysma and the skin of the middle and
anterior cheek. (B) Fresh frozen cadaveric dissection over the preparotid region shows
that aponeurotic connections exist between the SMAS and the skin. Diamond, anterior
platysma-cutaneous ligament; Heart, skin flap; Clover, superficial musculoaponeurotic
system (SMAS); Spade, zygomatic arch.
Fig. 7. The masseteric cutaneous ligament (Stuzin [1992 ])(A) Schematic illustration of the masseteric cutaneous ligament. This ligament exists
along the anterior border of the masseter muscle. (B) Fresh frozen cadaveric dissection
shows the fibrous condensation along the anterior border of the masseter muscle, connecting
the skin flap and the SMAS flap. Diamonds, masseteric cutaneous ligaments; Heart,
skin flap; Clover, superficial musculoaponeurotic system (SMAS).
Fig. 8. The parotid masseteric cutaneous ligament (Özdemir [2002 ])(A) Schematic illustration of the parotid masseteric cutaneous ligament. This ligament
exists at a location where the anterior parotid makes the transition onto the fascia
of the masseter muscle. (B) The parotid masseteric ligament is 1–2 cm posterior to
the anterior border or can even originate from the middle portion of the muscle. Diamond,
parotid masseteric ligament; Black asterisk, parotid gland; Blue asterisk, masseter
muscle.
The masseteric cutaneous ligaments were previously thought to arise from the masseteric
fascia, but it was recently revealed that the upper masseteric ligament originates
from the maxillary buttress [15 ].
Platysma cutaneous ligament (Özdemir [12 ])
Özdemir et al. [12 ] observed a septal form of adhesion at the anterior platysma, and at the mandibular
body and angle, and they called it the platysma cutaneous ligament ([Fig. 9 ]). The platysma cutaneous ligament by Özdemir et al. (2002) indicates the mandibular
septum along the mandibular border, which is a completely different structure from
the anterior platysma cutaneous ligament by Furnas. Reece et al. [27 ] also made use of the term “platysma cutaneous ligament” and classified the mandibular
septum as an irrelevant structure in relation to the fat compartments, but the location
and description match, indicating the same structure.
Fig. 9. The platysma cutaneous ligament (Özdemir [2002 ])A schematic illustration of the platysma cutaneous ligament (Özdemir [2002 ]) describes its location long the mandibular border.
The extent of the zygomatic ligament
The zygomatic ligament travels from the zygomatic bone to the dermis, and it would
assist in a better surgical understanding in two different, subcutaneous layers and
subSMAS level dissection. The actual subcutaneous findings of the zygomatic cutaneous
ligament can be described as firm fibrous structures existing along the border of
the zygomatic arch, initiating from just in front of the tragus ([Fig. 10 ]).
Several studies have made their investigation under different reference points. The
subSMAS level dissection setting, collecting measurements of taut and dense attachments
of the zygomatic ligaments, may offer quite a difference range of measurements taken
from the bone or the subcutaneous level [3 ]
[12 ]
[13 ]
[14 ].
There is variability in the difference in measurements. For example, Furnas [3 ] provided measurements for a typical bundle of the zygomatic ligament 3 mm in width
and 0.5 mm in thickness located 4.5 cm anterior to the tragus. On the other hand,
Özdemir et al. [12 ] measured the zygomatic ligament dimensions at 1.8–3.4×0.29–0.34 cm in men and 1.6–3.0×0.27–0.33
cm in women and reported that it was located 3.9–4.8 cm anterior to the tragus.
The latter group with larger surface measurements of the zygomatic ligament must have
adopted more cutaneous and histologic evaluation compared to the previous study by
Furnas. Presenting the range in measurements shows that the structure may vary according
to individual variation of the cadaver subjects, but it is also important to consider
how to acquire more consistent reference points for more comparable measurements.
However, most papers offering definitions of the zygomatic ligament still choose to
state that it is approximately 4 cm from the tragus [3 ]
[12 ]
[14 ], limited only to a bony attachment area to the subcutaneous portion of the zygomatic
ligament. Investigation of the subcutaneous ligamentous attachment of the zygomatic
ligament would also be worthwhile.
Subcutaneous findings of the zygomatic cutaneous ligament can be described as firm
fibrous structures existing along the lower and/or upper border of the zygomatic arch,
initiating from just in front of the tragus where the zygomatic arch starts ([Fig. 10 ]).
Fig. 10. Zygomatic cutaneous ligaments on the zygomatic archZygomatic cutaneous ligaments
are found along the zygomatic arch, initiating in front of the tragus and found above
and/or below the zygomatic arch. Diamonds, zygomatic cutaneous ligaments; blue diamond,
anterior platysma cutaneous ligament (Furnas [1989 ]); asterisk, zygomatic arch; heart, skin flap; clover, superficial musculoaponeurotic
system.
There also exists a distinct variation in the extent of the zygomatic ligament at
the subSMAS level. Alghoul et al. [14 ] divides it into two groups, observing the main zygomatic ligament approximately
4 cm from the tragus, and the minor zygomatic ligaments arising 2 cm away. Stuzin
[5 ] noted a particularly stout ligament originating along the most medial portion of
the zygoma, medial to the zygomatic minor ([Fig. 11 ]).
Fig. 11. The area of the zygomaticus major and minor is dissected in a fresh frozen cadaverEasily
observed in the fresh frozen cadaver dissection, zygomatic ligaments are found extending
further medially along the zygomaticus minor muscle. Diamonds, zygomatic ligaments;
black asterisk, zygomaticus major; red asterisk, zygomaticus minor; black asterisk,
zygomaticus major; blue asterisk, orbicularis oculi muscle; clovers, reflected superficial
musculoaponeurotic system flap.
The zygomatic ligament described by Mendelson takes its course along the origins of
the facial expression muscles; the zygomaticus major, the zygomaticus minor, and the
levator labii superioris muscle. He also stated that the particularly strong main
zygomatic ligament originates from the lateral portion of the zygomaticus major muscle
[9 ]
[11 ]
[28 ].
DISCUSSION
Reasons for confusion
Advances in anatomical evaluation of the retaining ligaments, and information provided
by detailed histologic sections, are offering more specific classifications of what
was previously considered the same retaining ligament. Varying concepts applied to
each retaining ligament for each specified purpose and targeted surgical techniques
have influenced the naming of the retaining ligaments in the face.
We believe that since the time the ‘fibrous attachment’ was described by Furnas, there
has been no extraordinary discovery of a new retaining ligament in the cheek. However,
the introduction of new nomenclature for the retaining ligaments has resulted from
different dissection or surgical techniques which identify different reference points.
Similar location but different nomenclature
An identical anatomic structure can logically be described utilizing similar but different
anatomic structures [3 ]
[5 ]
[12 ]. Many have previously adopted the platysma as an emphasized landmark for description,
but this was later substituted with the parotid fascia or the muscle fascia for its
relevance as a point of origin.
Confusion in classification
We can easily find different classification systems for facial retaining ligaments.
Stuzin (1992), as well as Furnas, largely classified the ligaments into two categories:
the osteocutaneous ligament, which keeps its origin at the bone and the other, a supporting
ligament that arises from the superficial and deep fascia (Two supporting ligaments
mentioned are the parotidocutaneous ligament and masseteric ligament) [3 ]
[5 ]
[8 ]. Moss et al. [10 ] presented a revised classification based on a gross morphology of the ‘true ligaments’
([Table 2 ]).
Table 2.
Different classifications of the retaining ligament of the cheek
Furnas (bone & platysma)
Stuzin 1992 (bone & fascia)
Mendelson (Morphologic characteristics)
The retaining ligaments of the cheek have been described with varying nomenclature
systems due to different classification schemes by each namer. Furnas and Stuzin use
a similar bone origin, but differ in their opinion about the soft tissue origin. Mendelson
developed his own classification according to the morphology of the fibrous attachments.
Although various papers have applied individual rationales in naming the facial retaining
ligaments, the consistency among authors in using the terms ‘zygomatic,’ ‘mandibular,’
and ‘masseteric’ has confused the issue.
Bone origin
Zygomatic lig
True osterocutaneous
Zygomatic
True ligaments
Zygomatic
Mandibular lig
Mandibular
Masseteric
Platysma origin
Platysma auricular
Superificial & deep fascia origin (supporting ligament)
Parotid cutaneous
Mandibular
Anterior platysma-cutaneous
Masseteric cutaneous
Conceptual confusion
Before the time when Furnas (1989) adopted the term ‘ligament’ to describe these tissues
in the face, Bosse and Papillon [38 ] stated, “at the malar eminence we have found [the SMAS] to be quite solidly bound
to the malar bone by vertical fibrous septa”, and Owsley [36 ] also used the term ‘vertical septum’.
Varying descriptions of commonly understood fibrous attachments—patch [1 ], ligament [3 ]
[5 ]
[12 ], fascia [17 ]
[19 ], septum [10 ]
[28 ]
[36 ]
[38 ] etc.—can be another reason for confusion.
The generally accepted concept limits the use of the term ‘ligament’ to structures
with a full interconnection between the bone and the skin, whereas ‘fascia’ is used
when it is related to the parotid fascia or the masseteric fascia.
Moreover, the relatively loose and linear pattern of the septal formation is widely
accepted as a ‘septum’. Although the word, ‘septal boundary’, confined to refer to
the facial fat compartment by Reece et al. [27 ], Rohrich, and Pessa [39 ], is a different use of the same term.
We believe that the facial ligaments are limited to playing a role as a uniform dense
fibrotic tissue in offering safe passage for the vessel and nerve to traverse. The
zygomatic, upper and mid-masseteric and mandibular ligaments are good examples. Besides
these, any ligamentous structure in the face that does not convey vessels or nerves
is more suitably described as a ‘fibrous attachment’. Such structures include the
platysma auricular ligament and Lore’s fascia. Any septum in the face should be defined
as a boundary between one area and another, which interconnects the overlying facial
muscles to the underlying tissue.
McGregor was the first and the only one to mention the term ‘patch’, and it has never
been used since.
Confusion according to the intention of naming
Included in this type of confusion is reading too much or differently into what was
phrased by the author who named a structure, giving diametrically different descriptions,
or giving what is thought to be a different but more accurate version of the nomenclature.
When Furnas and many other authors stated their opinion that McGregor’s patch is synonymous
to the zygomatic ligament, or when some equated the platysma auricular ligament (Furnas
1989) and the parotid cutaneous ligament (Stuzin 1992) with the platysma auricular
fascia (Mendelson 2008), these distinctions are owing to a discrepancy in interpretation.
Variations in the subject
Advances in anatomy should take statistical variation of the cadaver subject into
account. It is widely accepted that the parotid fascia is of critical relevance as
a rule of origin in relation to the size and location of the parotid gland or the
direction of the platysma muscle fibers. For these reasons, the origins of the retaining
ligaments between the fascia of the platysma can be confusing.
Variation caused by the surgical technique [8 ]
[20 ]
[40 ]
[41 ]
[42 ]
For specific techniques requiring little skin undermining with a similar vector pulling
the deep and superficial tissue lifting, mentioning the subcutaneous ligamentous attachments
is unimportant. But when undermining of the skin flap is separate from deep tissue
dissection, or when the vectors differ for pulling superficial and deep tissues, the
surgical technique needed for a good outcome is intimately related to a thorough understanding
of the subcutaneous ligamentous attachments.
The spatial concept of Mendelson’s ‘composite facelift’ technique coincided with his
anatomic categorization of the facial retaining ligaments as adhesion, septum, and
space [41 ]. Minimal skin dissection performed in his technique also left out the subcutaneous
concept in his studies, producing a conflicting concept when applied to the previously
described conventional retaining ligament.
