Can I Get A Custom Lateral Orbital Rim Implant To Fix Overdone Shaving?

Q: Dr. Eppley, I had surgery last year which included a brow lift and midfacelift, as well as shaving of the orbital rim. While I’m very happy with most of the results, I wanted to inquire about an implant to restore the orbital rim to my prior shape. 

I feel the doctor shaved off too much and it gave me a very unnatural appearance. The eye is no longer framed by the bone and looks too lifted. 

I tried facial filler to replace the volume, and was successfully able to restore it to its prior appearance. But I wanted to look into more permanent options, and can dissolve the facial filler prior to surgery. 

I did speak with the previous doctor about my revision options, and his recommendation was a fat Transfer. However, I am apprehensive about this option because I’ve read that the results do not always heal evenly and I’d rather have something that will not change overtime with a density closer to bone. 

Does the doctor offer any 3D imaging in which we can get an idea of the outcome of the custom implant? 

A: Thank you for your inquiry, sending your facial pictures as well as detailing your surgical history and postoperative efforts. While I don’t know exactly the orbit rim area that was reduced. I am going to assume it was the lateral orbital rim based upon your circled areas. I could easily imagine that with a lateral orbital rim reduction, and then the lifting of the mid face tissues further up onto the cheekbone, this would create a lateral rim deficiency or indent. The lift magnifies the lateral orbitakl rim reduction not helps it.

Based on your successful improvement with injectable filler treatments of the indented area, a more permanent volume addition should be successful. The question then becomes how to augment that area. While it is always hard to argue with making a custom implant design, the lateral orbital rim is not a dimensionally complex area and very likely the reduction was no more than 2 to 3 mm in depth. On a 3-D CT scan the area of orbital rim reduction could likely be visualized by its altered appearance.

That being said, there are two approaches to treating your lateral orbital rim deficiency. Go the ideal route of making a custom lateral orbital rim implant or use an older, but sometimes very effective historic approach of hand making an implant designj during surgery. A 2mm sheet or block of ePTFE is hand fashioned in surgery to the rim defect and secured like a custom implant design with a small micro screw.

Normally, I wouldn’t recommend the more historic custom implant design approach, but the simplicity of the orbital rim anatomy can make that a very viable option. Quite frankly, the decision between the two is primarily an economic one… meaning true custom implants cost more but they do provide the patient with preoperative knowledge of the defect and the exact implant design to treat it.

One caveat about custom implant designs that I would mention based on a comment/question you made in your inquiry is that you cannot design an implant and then paint the patient’s soft tissue back over it to see what it looks like. That technology in any accurate way does not yet exist. Custom implant designs remain an approximation or a guess as to what is going to best address the patient’s problem. In your case, that is a lot easier than most because the defect is small and likely can be well visiualized in a 3D scan. What you really wanting to do is to fill a bone defect rather than creating a true augmentation on a normal bone. Returning a bone to a normal shape is a lot more predictable than changing the shape of a normal bone to a supernormal one in terms of outcome.

Dr. Barry Eppley

World-Renowned Plastic Surgeon