How Is Lateral Orbital Rim Reduction Done?

Q: Dr. Eppley, I wanted to address three outstanding concerns.

1. I understand the Superolateral OR forms the top and side protrusion of the brow bone. However, I wanted to ensure that this top area would remain untouched, as the concern is not so much brow protrusion, but rather the thickness along the side and at the base of this (near the zygomaticofacial foramen) to provide the angularity desired. In fact, I would rather appreciate having has much “side brow protrusion” as possible, so I wouldn’t want this “top” area reduced. I attach a picture (skull) to illustrate this concern: I would rather leave the protrusion provided by the superolateral rim alone (region A) and rather focus on shaping the angularity of the circled region. Perhaps you could provide some clarity on this.

2. Another issue of great concern is the procedure itself. Is it truly necessary to peel forward the face to achieve the aesthetic result? It seems this is drastic (in terms of exposure of the surface area, infection risks associated, shaving the head, healing time, among many others) and I was hoping there would be an endoscopic alternative or lateral incisions that could be made along the temporal region or at the base of/along the rim itself.

3. Finally, I wanted to make sure that we were in agreement with regards to the aesthetic result. I would like to ensure that the cheekbone area/zygoma remain intact in its width and protrusion. The simple changes I wish to make are essentially a small indentation along the temporal region (see attached photo face example, region A) to result in an indentation between the brow and zygoma (region B). I do not wish to drastically change my face by any means. It is important for me to know if you believe from your professional perspective if this procedure will produce a significantly aesthetically pleasing result in terms of facial balance and angularity, or if you believe this would simply satisfy a request to change a proposed anatomical irregularity. I attach two final photos (a before and after) with an example of the intended aesthetic result. I am interested in what you think. 

Many thanks for all.

A: In answer to your questions:

1) The zone of bone reduction is decided and marked before surgery so there is not confusion as to where to go and not to go.. I think as you have described it is pretty clear that any aspect of the brow bone is not part of the lateral orbital rim.

2) While perhaps a full coronal incision does make it a bit easier to do, I would need think that effort and scar tradeoff would justify that approach. This leaves us with three incisional options, either alone of done in time combination, upper eyelid, lower eyelid and intraoral. The outer half of the upper eyelid incision would be the most practical with possibly an intraoral component as well.

3) You are specifically referring to a lateral orbital rim reduction, which lies between the tail of the brow bone superiorly and the main body of the cheek (zygoma) inferiorly. That would create an indentation between the brow and cheek bones. As for the anesthetic outcome I can only comment on its aesthetic effectiveness based on your own description and imaged illustrations…if that is what looks good to you then can say this procedure is what can do it.

Dr. Barry Eppley

Indianapolis, Indiana