How can I confirm that I am in the pre‑maxillary and pre‑zygomatic spaces and that the tear‑trough retaining ligament and orbicularis retaining ligaments have been fully released during a trans‑conjunctival lower eyelid procedure?

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Last updated: February 28, 2026 • View editorial policy

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Confirming Anatomical Planes and Ligament Release in Trans-Conjunctival Lower Eyelid Surgery

To confirm you are in the pre-maxillary and pre-zygomatic spaces during trans-conjunctival lower eyelid procedures, you must dissect inferiorly until you reach the junction of the orbital rim and floor, as failing to fully dissect to this level creates blind spots that impede complete membrane detachment and increase perforation risk. 1

Anatomical Plane Confirmation

Pre-Maxillary Space Identification

  • Dissect through the orbital septum and identify the pre-maxillary fat pad, which sits anterior to the maxillary bone and posterior to the orbicularis oculi muscle
  • The pre-maxillary space is bounded superiorly by the orbital rim and inferiorly extends to the maxillary bone surface
  • Visual confirmation occurs when you see the smooth periosteal surface of the maxilla after releasing overlying soft tissue attachments

Pre-Zygomatic Space Identification

  • The pre-zygomatic space lies lateral to the orbital rim, anterior to the zygomatic bone
  • Palpate the zygomatic arch and body to orient yourself - the space should be directly anterior to this bony prominence
  • You should be able to visualize the periosteum of the zygomatic bone once properly positioned

Critical Dissection Technique

Avoiding Incomplete Release

  • Residual bone at the orbital rim-floor junction is the most common cause of inadequate dissection 1
  • Dissect inferiorly with a periosteal elevator until you clearly identify the transition from vertical orbital rim to horizontal orbital floor
  • The dissection must extend at least to the inferior orbital fissure to ensure complete access to the subperiosteal plane

Confirming Ligament Release

Tear Trough Ligament (Orbicularis Retaining Ligament)

  • The tear trough ligament runs from the arcus marginalis (orbital rim periosteum) to the overlying orbicularis muscle and skin
  • Confirmation of release: You should be able to freely elevate the orbicularis muscle away from the orbital rim without resistance
  • Test by gently pulling the lower lid tissues superiorly - if the tear trough depression persists, the ligament remains partially attached
  • Complete release is confirmed when the suborbicularis oculi fat (SOOF) can be mobilized freely without tethering

Orbicularis Retaining Ligament

  • This ligament attaches the orbicularis to the periosteum along the inferior orbital rim
  • Release is confirmed by the ability to separate the orbicularis muscle from the underlying orbital septum and periosteum without encountering fibrous bands
  • After release, the lower lid should have increased mobility and the pre-septal tissues should move independently from the deeper orbital structures

Common Pitfalls to Avoid

Inadequate Fat Handling

  • Inadvertent entrapment or adhesion of orbital fat can lead to restrictive strabismus, a rare but serious complication 2
  • Avoid aggressive manipulation or cautery of orbital fat that could cause scarring and adhesions
  • Meticulous fat handling techniques are essential - use gentle traction and avoid excessive thermal injury 3

Incomplete Inferior Dissection

  • Stopping dissection before reaching the rim-floor junction leaves residual attachments that prevent proper repositioning 1
  • Always verify you have reached the horizontal orbital floor by direct visualization and palpation with your instrument
  • The periosteum should be completely elevated from bone in your working area

Verification During Surgery

  • Use gentle traction on the lower lid to assess mobility - properly released tissues should move freely without dimpling or tethering
  • Palpate the orbital rim with your instrument to confirm you are on bone, not in soft tissue planes
  • The pre-maxillary and pre-zygomatic spaces should communicate freely once properly developed - you should be able to pass your instrument between these spaces without obstruction

References

1
Guideline

Risks of Inadequate Inferior Dissection in Orbital Floor Surgery

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Risk of Restrictive Strabismus from Fat Entrapment in Lower Lid Blepharoplasty

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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