Custom Midface Implants

Q: Dr. Eppley, I am interested in custom midface implants.  I am 28 years old. Before double jaw surgery, I was diagnosed with Class III malocclusion. I underwent a Lefort 1, BSSO of the mandible and genioplasty involving advancement and rotation. What I noticed after double jaw surgery was that the rest of my midface was ‘left behind’ by the procedure, and appeared sunken and unnatural. 

So the following year I got a zygomatic sandwich osteotomy for anterior projection of the cheeks which managed to make a huge difference and restored some balance. However the result still looked odd, mainly because the orbital region was left behind which made my eyes appear somewhat bulgy. So towards the end of last year I got orbital rim implants that extended out laterally to cover the bone to the outside corner of the eye. Again this made a big difference to my sunken under eye area, but it didn’t reduce the appearance of prominent eyes at all. I was confused for a while after this, but then I realized that perhaps the reason why the implants didn’t help the bulginess at all was because they were placed in front of the infraorbital bone. Visualizing it, I imagined that the implant needed to be placed on top of the orbital rim, pointing upward and forward rather than just forward. This thought came to me after thinking about the counter clockwise rotation that I received. I went on to think that maybe I should have got ‘counter clockwise rotation’ of the area around the orbital rims just like I did for the lower part of the midface. It wouldn’t be true counter-clockwise rotation of course, but the effects of the implant would mimic that in the sense of pulling the infraorbital margin upwards and forwards, rather than just providing more volume to the front of the upper midface. 

The other issue I noticed only after going through double jaw surgery and the orbital rim implants was that the ‘inner’ part of the upper midface still appeared recessed. By this I mean the position of the junction between the ‘flat’ part of the midface and the nose itself, stretching from the medial side of the eye, all the way down to the base of the nose. I did a bit of research on this and found out that the Lefort 2 osteotomy is equipped to mobilize the nose including the nasal bone and the frontal process of the maxilla in addition to the lower maxillary region. In other words, the junction I am referring to is the groove at which the frontal process of the maxilla sharply changes direction to form the top part of the nose. This ‘groove’ or ‘junction’ sits too far back into my face, giving a flat appearance to my midface, only the lower part of that groove was fixed with the Le fort 1. 

So there are two questions that I have about the issues I have discussed:

1) Whether an infraorbital implant can be custom made to give upward and forward projection from the infraorbital margin, and whether you think that this is a better option to fix the appearance of bulging eyes than just a standard orbital rim implant design

2 – Whether any sort of custom made implant can be placed around the area of the groove between the nose and the horizontal part of the midface, running all the way up the midface, to simulate the effect of a Lefort 2 osteotomy. I noticed in some of your posts that implants can be fashioned to replicate the movements of a Lefort 3 osteotomy, so if there are any ways to move the area mentioned forwards, I would be eager to go through with it with you.

Thanks so much for your time Dr. Eppley.

A: Thank you for your inquiry and detailed description of your facial surgery history and anatomic concerns.. In summary you have done a variety of procedures that have been chipping away at a total midface advancement. Custom midface implants can be designed just about anyway one wants based on the soft tissue stretch and tolerance of the tissues. Whether it is to raise up the infraorbital rim or fill in the paranasal-maxillary region, they can be so designed to do so. A 3D CT scan would show exactly the positive augmentative midface changes you have accomplished as well as the parts of the midface that have been left ‘behind’.

Dr. Barry Eppley

Indianapolis, Indiana