Can A Custom Infraorbital-Maxillary-Malar Implant be Put In Through Lower Eyelid Incisions?

Q: Dr. Eppley, Overall, I am looking for sharp angular model-like features.

As in the custom jawline implant design: 

1) Is the chin square? 

2) I am unsure of the exact terms to describe the features I am looking for, but I would like the resultant jaw to be square, sharp, and chiseled. 

3) I would like this sort of square jaw angle if possible/suitable.

As in the custom infraorbital-malar-maxillary implant:

4) I would like a bottom part to the implant covering the area to make it into a full mask implant in order to get as much forward maxilla/midface projection as possible (within your guided measurements) to get that Lefort effect. Such as in these examples:

5) I just wanted to make sure the zygomatic arch part of the model cheekbone is included as there are different lengths on different skulls shown on the website. Not sure if there is any difference on the lengths and the cheekbone effect. 

6) I would like zygos/cheekbones with both forward and lateral projection meaning I would like to add slightly more forward projection to the zygomatic area (if possible/appropriate). 

7) I have concerns about removing a Negative Orbital Vector and negative canthal tilt, just wanted to ensure that the implant will tackle this. 

8) As I believe the custom midface implant is going to be inserted through the eyelids and closed using a lateral canthopexy and we are using spacer grafts to lift the bottom eyelid – is it possible to change the outer corner of my eyes slightly to fix their asymmetry and eliminate excessive scleral show and to give the eyes a slightly positive canthal tilt or “as almond as possible”? 

9) Reading anecdotes from others who have gotten infraorbital rim implants is that though the support under the eye is a significant improvement but there is still a bit of hollowing due to the lack of fat under the eyes – is there a solution to this such as under eye fat bag repositioning or fat pocket transfer? Is it possible to do it at the same time as adding the spacer grafts? Should it be done post implant healing? Could it be recycled fat from the buccal liposuction? 

10) I would like to get my whole mouth area improved – this includes mouth widening, lip corner and lip projection. I asked you asked about this via email and you said I would need to wait a minimum of three months post jaw surgery. As I believe this can be done under local anesthetic, I believe seeing you in person will be the best gage on what to do with that. Same thing with a possible fat transfer to the upper eyelid area. I’m not sure if I have Ptosis of the eyelids or not – can this be evaluated in person and done under local anaesthetic at another point in time as well? 

11) In case there is emergency, should I have a local surgeon kept in the loop about the surgery before I go to the states?

12) What should I do in case I believe there is an infection or something wrong? 

13) Do I need to clean shave for surgery or is having a light beard okay?

A: In answer to your custom infraorbital-malar-maxillary and jawline implants:

  1. The current design of the custom jawline implant has a square chin. Whether it should be more sharply square in the design can be debated.

2)  The ability of any custom facial implants design to show through depends on the thickness of the overlying tissues. Thinner facial tissues allow these designs to show their defined designs, thicker facial tissues do not. So the patient has to appreciate what is possible within the limits of their own facial tissues.

3) The squareness of the jaw angle design must be considered very carefully. If it is over squared on the design the implant can protrude beyond the posterior edge of the masseter muscle causing what is known as implant reveal, an aesthetic deformity.

4) A midface mask implant design can replicate a LeFort-like effect but a more complete one.

5) A zygomatic arch component can be added to the design to go back as far along the arch as aesthetically desired.

6) Forward and lateral projection at the zygomatic area is common in these implant designs.

7) A custom infraorbital-malar implant is the most effective approach to correction of the negative orbital vector and negative canthal tilt.

8)  Such an infraorbital-malar-maxillary implant can NOT be solely inserted through just the lower eyelid incisions. This will need to be combined with intraoral incisions as well. In addition, while the implant may be designed as one-piece, it can neither be manufactured as one piece nor inserted as one piece. There would be a split in the implant design at the level of the infraorbital-malar and maxillary portions to allow both manufacture and surgical placement. But it will fit together int surgery like a puzzle piece.

9) Recycing the fat from buccal lipectomies for additional volume augmentation over the infraorbital area can be done at the same time. But the risk of infection is increased since the vascular fat grafts are placed on top of an avascular implant surface.

10) With the stretch on the lips from the surgery delicate soft tissue procedures such as mouth widening are not advised at the same time. Postoperative facial swelling will adversely affect the appearance of the resultant lip/mouth scars.

11) There really won’t be an emergency per se.

12) Infection is the only real semi-emergency. But that is treated initially with oral antibiotics to get it under control which gives us time to decide how to further manage it if needed.

13) You will need to be clean shaven the day of surgery.

Dr. Barry Eppley

Indianapolis, Indiana