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Clinical Anatomy

Critical review

The zygomatic ligament of the face: a critical review

P Rossell-Perry*

Abstract branches of the facial nerve and the histological description. He consid-
Introduction zygomaticofacial nerve. The main ered the face ligaments as a reminis-
The soft tissue of the face covers application of the zygomatic liga- cent of the retaining ligaments of the
the underlying bony structures ment is in cosmetic surgery. Further finger. It was found that these liga-
and is supported by ligaments that studies are necessary to establish ments stabilise the skin of the fingers
run from deep within the dermis relationships between the zygomatic in order to allow better tactile func-
to the overlying layers of the skin, ligament and variables such as age, tion3. Similar descriptions have been
serving as anchoring units for the sex, race and other such factors. presented with regard to the tissues
face. The zygomatic ligament of the of the breast and feet4. The concepts
face is an osteocutaneous ligament Introduction described by Furnas were further

All authors contributed to the concepƟon, design, and preparaƟon of the manuscript, as well as read and approved the final manuscript.
that originates from the periosteum The zygomatic ligament was initially elucidated by Stuzin et al. in 19925.
of the zygoma and/or the ante- described by McGregor in 19591. Stuzin et al.5,6 described the zygo-
rior and lateral border of the zygo- He described this anatomical struc- matic and mandibular ligaments as
matic arch (posterior to the origin ture in relation to his surgical tech- being osteocutaneous (i.e. originating
of the zygomaticus minor muscle). niques for facial rejuvenation during from the periosteum and inserting
It is found inserted into the super- the Annual Meeting of the Cali- directly into the dermis). The other
ficial muscular aponeurotic system fornia Society of Plastic Surgeons in supporting ligaments are formed as
which is connected to the dermis of Yosemite, California1. However, Mrs. a coalescence that occurs between
the cheek. This ligament restrains Rosebud Preddy, a medical artist at the superficial and deep facial fascia
the facial skin against gravitational the Letterman General Hospital in in certain regions of the face, e.g. the
changes and delineates the anterior San Francisco, California, denomi- masseteric ligament. Owsley7 and
border of the cheeks. Attenuation of nated the ligament as ‘McGregor’s Kaye8 provided a brief description of
support from this ligament is respon- patch’ when she prepared a slide the zygomatic ligament as, ‘a vertical
sible for many changes that occur presentation for Dr. Mar McGregor2. septum between the masseteric
during facial aging. The main appli- This denomination has persisted fascia and SMAS’ and ‘an adherent
cation of this anatomical structure since. McGregor described the liga- area over the malar eminence’, during

All authors abide by the AssociaƟon for Medical Ethics (AME) ethical rules of disclosure.
is in cosmetic surgery. The surgical ment as, ‘An area of fibrous attach- facelift procedures. The ligaments
correction of the retaining ligaments ment between the anterior edge of of the face have been classified by
of the face, plication of the superficial the parotid fascia and the dermis of Moss et al.9 as true ligaments, septa
muscular aponeurotic system and the skin of the cheek’1. His facelift and adhesions. The zygomatic and
repositioning the soft tissues of the procedure did not recommend exten- masseteric ligaments are considered
CompeƟng interests: none declared. Conflict of Interests: none declared.
face, are all common techniques used sion of the undermining skin beyond as true ligaments. A true ligament is
in the rejuvenation of the face. An this patch. Plastic surgeons have a discrete cylindrical arrangement of
overview of the literature regarding mainly contributed in the study of fibrous tissue that is surrounded by
the location of the zygomatic liga- the zygomatic ligament. Most of their fatty tissue. Microscopic examination
ment, its important relations and publications are descriptive studies of these ligaments showed bands of
clinical applications are reviewed in (outcome studies).The first good dense connective tissue. These liga-
this article. description of the anatomy of face ments are known to arise from the
Conclusion ligaments was provided by Furnas in deep fascia or periosteum and cross
The zygomatic ligament consists of 1989 2. The zygomatic ligament was the sub superficial muscular aponeu-
the prezygotmatic space, zygomatic described as, ‘a bundle of white firm rotic system (SMAS) plane and the
fibres, 3 mm in width and 0.5 mm in SMAS, where they divide into several
thickness, located 4.5 cm in front of branches which distribute the attach-
the tragus’. He also described that ment of the ligament to the dermis.
‘the ligament is 6 to 8 mm in length, Rossell-Perry et al.10 conducted a
* Corresponding author travelling directly from the zygomatic recent study to understand the liga-
E-mail: [email protected] bone to the dermis’2. The article was mentous attachments of the face and
San Martin de Porres University, Schell St No limited in its analysis of the anatom- found both types of ligament struc-
120 Apt., 1503 Miraflores, Lima, Peru ical relations of the ligament and its tures for the masseteric ligament

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F : Rossell-Perry P. The zygomatic ligament of the face: a critical review. OA Anatomy 2013
Feb 06;1(1):3.
Page 2 of 5

Critical review

Figure 2: The zygomatic ligament of Figure 3: The zygomatic ligament of

the face and its relations. the face and the prezygomatic space.
Figure 1: Location of the main re-
1: Zygomatic ligaments; 2: Orbicularis 1: Zygomatic ligaments; 2: Zygo-
taining ligaments of the face.
retaining ligament; 3: Sub orbicularis matic major muscle; 3: Orbicularis

All authors contributed to the concepƟon, design, and preparaƟon of the manuscript, as well as read and approved the final manuscript.
1: Orbital rim; 2: Zygomatic ligaments; oculi fat pad; 4: Orbicularis oculi retaining ligament; 4: Orbital rim;
3: Masseteric ligaments; 4: Mandibu- muscle; 5: Zygomatic major muscle; 5: Zygoma; 6: Orbicularis oculi mus-
lar ligament; 5: Gonion; 6: Menton; 6: Facial artery; 7: Facial vein; cle and sub orbicularis oculi fat pad;
7: Tragus; 8: Malar fat pad; 9: Mas- 8: Buccal branch to the orbicularis 7: Cutaneous flap; 8: Bichat´s fat pad;
seter muscle; 10: Zygomatic arch; oculi muscle from the facial nerve; 9: Malar fat pad.
11: Superficial muscular aponeurotic 9: Eyelid. Black arrow: entrance to the prezy-
system (SMAS).
Black arrow: entrance to the prezy- gomatic space.
Black arrow: entrance to the prezy- gomatic space.
gomatic space.
conducted in accordance with the
ligament (above), orbicularis oculi Declaration of Helsinki (1964) and
(true ligament and septa). Ozdemir the protocols of these studies have
muscle and sub orbicularis oculi fa
et al.11 and Rohrich et al.12 conducted been approved by the relevant ethics
tpad (anterior), the zygomatic liga-
histological studies of the facial liga- committees related to the institution
ments (below),the zygoma and
ments. The length of the ligament in which they were performed. All
preperiosteal fat (posterior) and the
ranged from 7 mm to10 mm between human subjects, in these referenced
lower temple (laterally). Recent

All authors abide by the AssociaƟon for Medical Ethics (AME) ethical rules of disclosure.
the skin and the zygoma and had studies, gave informed consent to
studies about the zygomatic
significant collagenised connective participate in these studies.
ligament have described its
tissue formation as described by
anatomy, functional characteristics
histological examination. Rohrich et
and biomechanical properties17,18.
al.12 also described subcutaneous fat
Brandt et al.17 showed that the
compartments in the face, limited by
CompeƟng interests: none declared. Conflict of interests: none declared.
Descriptive anatomy
zygomatic ligament is the strongest
‘septa’ originating from the under- There are four main ligaments in
and stiffest retaining structure in the
lying fascia and inserting into the the face: zygomatic, masseteric (or
face. In addition, they did not find
dermis of the skin. Histological parotidomasseteric), mandibular
any variations in the dimensions and
examination of the area between the and platysmaauricular2,5 (Figure 1).
biophysical properties of the
nasolabial fold and the medial cheek Other minor structures in the face are
ligament in relation with hemiface,
showed a fibrous structure that the preauricular parotid, SMAS malar
age or sex. This critical review
inserts into the dermis of the skin. and the anterior platysma cutaneous
discusses the anatomy and the
This structure is termed by these ligaments11. The soft tissue of the
reconstructive applications of the
authors as the ‘middle cheek septum’. face is supported over the under-
zygomatic ligament.
A good description of the location and lying bony structures by these liga-
relations of the zygomatic ligaments ments that run from deep within the
has been published by Mendelson et dermis to the overlying layers of the
al.13-16. They described the prezygo- skin through the retinacula cutis,
matic space, an important area of Discussion fixing facial structures and serving
the midface. The author has referenced some of as anchoring units for the face. The
This space is a junction area its own studies in this review. These retinacula cutis is a connective tissue
between the orbicularis retaining referenced studies have been composed of numerous small fibrous

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F : Rossell-Perry P. The zygomatic ligament of the face: a critical review. OA Anatomy 2013
Feb 06;1(1):3.
Page 3 of 5

Critical review

Figure 6: Structures below the zygo-

Figure 5: Relations between the matic ligaments.
Figure 4: Structures above the zygo- zygomatic ligament and branches of 1: Location of the zygomatic liga-
matic ligament. the facial nerve. ment; 2: Zygomatic major muscle;
1: Zygomatic ligaments; 2: Cutane- 1: Zygomatic ligament; 2: Zygomatic 3: Auricular temporal nerve; 4: Tem-

All authors contributed to the concepƟon, design, and preparaƟon of the manuscript, as well as read and approved the final manuscript.
ous flap; 3: Orbicularis oculi muscle; minor muscle; 3: Zygomatic major poral division of the facial nerve;
4: Lateral canthal tendon; 5: Lateral muscle; 4: Orbicularis oculi muscle 5: Parotid duct; 6: Cervical division of
orbital rim; 6: Zygomatic arch; 7: Zy- and sub orbicularis oculi fat pad; the facial nerve; 7: Masseter muscle;
gomatic orbital artery; 8: Frontal 5: Zygomatic branches of the facial 8: Risorius; 9: Marginal branch of the
branches of the facial nerve; 9: Su- nerve; 6: Bichat´s fat pad; 7: Zygoma; facial nerve; 10: Facial vein; 11: Facial
perficial temporal fascia (divided); 8: Malar fat pad; 9: Buccal branch artery; 12: Depressor angularis oris
10: Deep temporal fascia (divided); of the facial nerve;10: Orbicularis muscle; 13: Malar fat pad; 14: Modi-
11: Temporal muscle; 12: Superficial retaining ligament; 11: Facial vein. olus; 15: Bichat´s fat pad; 16: Zygo-
muscle aponeurotic system (SMAS); Black arrow: entrance to the prezy- matic branch of the facial nerve;
13: Orbicularis retaining ligament; gomatic space. 17: Cervical branch of the facial
14: Malar fat pad. nerve; 18: Parotid gland (retracted).
Black arrow: entrance to the prezy- Superficial Anatomy
gomatic space. Furnas described the location of the
zygomatic ligaments as being 4.5 cm
in front of the tragus2. In a recent
publication, Rossell-Perry et al.10 Relations
strands that extend through the

All authors abide by the AssociaƟon for Medical Ethics (AME) ethical rules of disclosure.
found the location of the zygomatic The most important relations of the
superficial fascia, attaching the deep
ligament to be 4.3 cm to 5.5 cm in zygomatic ligaments are: 1) above,
surface of the dermis to the under-
front of the tragus (average: 5.0 +/− the prezygomatic space and the zygo-
lying deep fascia, determining the
0.336). Ozdemir et al.11 found the maticofacial nerve, a branch of the
mobility of the skin over the deep
location of the zygomatic ligament maxillary division of the trigeminal
structures4,19. The zygomatic liga-
nerve (Figures 3 and 4); 2) medi-
ment, as described by Stuzin et al., is to be 4.2 cm to 4.8 cm in front of
ally, buccal branch of the facial nerve CompeƟng interests: none declared. Conflict of Interests: none declared.
not a single structure5,6. The original the tragus in men and 3.9 cm to 4.5
cm in women. This is less evident in to the orbicularis oculi muscle, the
description of the ‘McGregor patch’
younger people and more obvious infraorbitary nerve and the malar fat
refers to the main component of
in the elderly. The proximal inser- pad (Figure 2); 3) below, the upper
these series of fibrous tissues that
tion is usually not related to the age, zygomatic branch of the facial nerve,
begin laterally where the zygomatic
as described by Furnas, and remains zygomatic muscles, transverse facial
arch joins the body of the zygoma.
unchanged during the process of artery, parotid duct, Bichat´s fat pad
This main structure extends through
aging21. Raksin et al.22 observed and masseteric ligaments (Figures 5,
the malar fat pad and inserts into
that the location of the zygomatic 6 and 7) and 4) laterally, the lower
the overlying malar skin2,20. An
temple.
isolated structure originates along ligaments was mildly affected by
the most medial portion of the age. The localisation of the zygo- Function
zygoma near the zygomaticomaxilla- matic ligaments may vary depending The importance of the zygomatic
ry suture5 (Figure 2). These septa on age (distal insertion only), sex, ligament lies in its ability to suspend
form an interconnecting framework race and populations. There are no malar soft tissue over the zygomatic
that limits shearing forces on the fa- studies describing the anatomic vari- eminence. The ligament efficiency
ce. This framework provides a ‘re- ations of the zygomatic ligament for depends on the width of its attach-
taining system’ for the human face12. these variables. ments to the skin and if small, the

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F : Rossell-Perry P. The zygomatic ligament of the face: a critical review. OA Anatomy 2013
Feb 06;1(1):3.
Page 4 of 5

Critical review

drainage is carried out through mended to improve our under-

the venous plexus formed mainly standing of the relationship between
by transverse facial vein and facial the zygomatic ligament and variables
(angular) vein. such as age, sex, race or other such
factors.
Clinical applications
The main application of these
anatomical structures is in cosmetic Abbreviations list
surgery. The surgical correction of SMAS, superficial muscular aponeu-
the retaining ligaments of the face, rotic system.
plication of the SMAS and reposi-
Figure 7: Relations of the masseteric
tioning the soft tissues of the face References
ligament.
that have descended with gravita- 1. McGregor M. Face Lift Techniques.
1: Location of the zygomatic ligaments;
tion, are common techniques used in Presented to the Annual Meeting of the
2: Masseteric ligament; 3: Cutaneous California Society of Plastic Surgeons.
rejuvenation of the face. Management
flap; 4: Buccal branch of the facial Yosemite, California, 1959.
of facial aging of the nasolabial folds

All authors contributed to the concepƟon, design, and preparaƟon of the manuscript, as well as read and approved the final manuscript.
nerve; 5: Masseter muscle; 6: Facial 2. Furnas DW. The retaining ligaments
should be carried out by restoration
vein; 7: Bichat´s fat pad; 8: Zygomatic of the cheek. Plast Reconstr Surg. 1989
of the malar soft tissue, by repo-
major muscle; 9: Facial artery. Jan;83(1):11–16.
sitioning the tissue to its previous
3. Grayson J. The cutaneous ligaments of
position. Improvements in the the digits. J Anat. 1941 Jan;75(Pt 2):164–5.
aging of the face, based on ligamen- 4. Nash LG, Phillips MN, Nicholson H,
ligament can stretch in time. The tary suspension of the soft tissues, Barnett R, Zhang M. Skin ligaments: regional
downward movement of the malar has been described by Aufricht27, distribution and variation in morphology.
fat pad mainly results from lack of Stuzin6, Muzzafar et al.24, Mendelson Clin Anat. 2004 May;17(4):287–93.
ligament support, which is one of et al.15,28, Ozdemir et al.11 and other 5. Stuzin JM, Baker TJ, Gordon HL. The
the main reasons for an aging face. plastic surgeons. These authors have relationship of the superficial and deep
described the importance of the facial fascias: relevance to rhytidectomy
The malar fat pad protects the thin
surgical anatomy of the retaining liga- and aging. Plast Reconstr Surg. 1992
anterior wall of the maxilla and the Mar;89(3):441–9.
maxillary sinus against traumas23. ments of the face and its importance
6. Stuzin JM. Face lifting. Plast Reconstr
Rohrich et al.12 suggested that in facelift surgery. Aston29 described
Surg. 2008 Jan;121(1 Suppl):1–19.
these septa and ligaments stabilise a technique for midface elevation and 7. Owsley JQ Jr. Platysma-fascial rhyt-
the blood supply to the skin. The suspension based on fingertip dissec- idectomy: a preliminary report. Plast

All authors abide by the AssociaƟon for Medical Ethics (AME) ethical rules of disclosure.
septal membranes are located in the tion of the malar fat pad through Reconstr Surg. 1977 Dec; 60(6):843–50.
vascular zones that occur between the prezygomatic space. Recently, 8. Kaye BL. The extended face-lift with
the anatomical compartments. This Rossell-Perry et al. published a tech- ancillary procedures. Ann Plast Surg.
is particularly evident in the medial nique describing SMAS plication 1981 May;6(5):335–46.
face, where perforators from the to facial ligaments which is used to 9. Moss CJ, Mendelson BC, Taylor GI.

CompeƟng interests: none declared. Conflict of interests: none declared.

improve aging of the nasolabial folds Surgical anatomy of the ligamentous
transverse facial artery and angular
and neck10. attachments in the temple and perior-
artery are found. In addition, the bital regions. Plast Reconstr Surg. 2000
zygomatic ligaments may aid in the Apr;105(4):1475–90.
prevention of the lower eyelid ectro- Conclusion 10. Rossell-Perry P, Paredes-Leandro P.
pion24,25. Defects of the midface with The zygomatic ligament is not a Anatomic study of the retaining liga-
absence of the zygomatic ligament single structure. The original descrip- ments of the face and applications for
and repaired with flaps may develop tion of the ‘McGregor patch’ refers to facial rejuvenation. Aesthetic Plast Surg.
lower eyelid ectropion26. the main component of these series 2012 Oct.
of fibrous tissues that begin later- 11. Ozdemir R, Kilinç H, Unlü RE, Uysal
Innervation AC, Sensöz O, Baran CN. Anatomicohisto-
ally where the zygomatic arch joins
Branches from the zygomaticofacial logic study of the retaining ligaments of
the body of the zygoma. The most
nerve and infraorbital nerve provide the face and use in facelift: retaining liga-
important relations of this structure
sensation to the zygomatic ligaments. ment correction and SMAS plication. Plast
are the prezygomatic space, the zygo- Reconstr Surg. 2002 Sep;110(4):1134–47.
Blood supply matic branches of the facial nerve 12. Rohrich RJ, Pessa JE. The retaining
Branches from the transverse facial and the zygomaticofacial nerve. The system of the face: histologic evaluation
artery, angular artery and infraor- main application of these anatomical of the septal boundaries of the subcuta-
bital artery provide blood supply structures is in cosmetic surgeries neous fat compartments. Plast Reconstr
to the zygomatic ligaments. Venous (facelift). Further studies are recom- Surg. 2008 May;121(5):1804–9.

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F : Rossell-Perry P. The zygomatic ligament of the face: a critical review. OA Anatomy 2013
Feb 06;1(1):3.
Page 5 of 5

Critical review

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All authors abide by the AssociaƟon for Medical Ethics (AME) ethical rules of disclosure.
CompeƟng interests: none declared. Conflict of Interests: none declared.

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F : Rossell-Perry P. The zygomatic ligament of the face: a critical review. OA Anatomy 2013
Feb 06;1(1):3.