Your Questions

Q: Dr. Eppley, I have a severe tear trough deformity and am interested in the implant procedure. However there does not seem to be anyone in my area that will use implants for correction????

A: Thank you for your inquiry and seconding your picture. I think you are referring to a complete infraorbital rim implant not just a tear trough implant which just covers the inner half of the orbital tim. While most plastic surgeons prefer fat injection grafting for a deficient infraorbital rim, I prefer an implant rim augmentation technique which produces a more reliable, smooth and permanent result. This is a vey rare type of facial implant that is used only by experienced facial implant surgeons. While the technique to place them is the same (lower eyelid incision), the design of the infraorbital rim implant varies. It can be made as a custom implant from the patient’s 3D CT scan or can be used as a ‘semi-custom’ type implant which is a derivative from prior custom implant patients. (infraorbital rim anatomy/shape is not that different amongst most patients) There are no performed or standard off-the-shelf infraorbital rim implants for use…which is also why there are so few surgeons that use or have any knowledge about them.

When in doubt about using infraorbital rim implants, one should always try fat grafting first. There usually is little to lose by doing so as fat often completely resorbs in the infraorbital area. If it is overdone and too much fat persists then infraorbital rim implants can be placed and the extra fat removed at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I underwent upper and lower jaw surgery over one year ago. The surgeon did a fairly good job advancing my lower and upper jaw, however, it has (if anything) accentuated the deficiency around my orbital area. I have very deepset eyes, which could pose a challenge with this sort of procedure. What are your initial thoughts – and do you have a lot of experience with infraorbital rim implants?

A: It would not be rare to develop an infraorbital rim deficiency after a lower maxillary/mandibular orthognathic surgery procedure. As the bones are moved below the orbital rim, how that area looks will be affected based on the lower facial skeletal movements. Infraorbital rim augmentation can certainly be done but the relevant question, as you have pointed out, is how will that affect the already appearance of deep set eyes. Will doing so be an aesthetic improvement or not? I have performed numerous orbital rim augmentations either alone or as part of custom malar-infraorbial rim implants. There are different styles/shapes between preformed off-the-shelf and custom infraorbital implants. Off the shelf infraorbital rim implants are designed to augment the front edge of the rim (sit in front of the orbital rim) and, in deep set eyes, such isolated horizontal augmentation may make the eyes look more deep set. In more custom designs, the infraorbital rim augmentation sits more on the top of the orbital rim with some slight overhang, causing a slightly different and more natural effect in my opinion and one that is less likely to cause an adverse effect on your eye appearance. These custom designs also flow into the cheek area with a smooth transition, providing as much augmentation effect in this area as the patient prefers. (or prefers not to have) As an initial thought on what make happen with infraorbital rim augmentation, I will do some computer imaging and get that back to you later today. At this point, I could not tell you whether this would be a favorable facial skeletal change or not.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know I want infraorbital rim implants but an additional concern is the changes in the skin under my eyes that I have noticed in the last three to four years.  I have attached a PDF of some of my eye pictures.  They shows the bunching up and “crepey” skin that tends to exacerbate my undereye issues and tired appearance.  Even though the lower photos are the effect with an extreme smile, this tends to occur even with a mild smile, and really affects my self-esteem.  I was wondering how infraorbital implants and/or fat relocation will ameliorate these folds.  Though I had a series of three micro laser peels this last year, they did little to address this issue.  I just would like to be realistic as possible in terms of the outcome of this procedure.

A: The smile animation ‘deformity’ around the lower eyelids (under eye wrinkles) is a tough one since it is a muscular action effect and not a structural problem. No amount of static skin resurfacing will help a dynamic movement issue. The  infraorbital rim implants will make some improvement in it due to volume expansion and some diminution of muscular excursion but ultimately animation wrinkle deformities respond best to Botox injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if the implants that you use to replenish the infraorbital eyelids are the same used for the cheeks or are this special for this area? Last year I had put some implants under my eye this were the regular implants for the cheek but the doctor cut them to reduce them. My problem is that my skin is very thin under the eye and the implant shows the edges and feels hard so it looks and feels unnatural. Please tell me if there is a remedy. Maybe the implants you use look more natural.

A: One of the important issues with infraorbital rim implants is their positioning along the inferior orbital rim. Depending upon the aesthetic purpose, they may be used to provide more horizontal projection to the bony rim but still stay below the edge of the bone or they may be used to treat under eye hollows and are raised above the level of the bony rim. Depending upon their size and shape of the implant there is the risk of palpability of the implant edge. More uncommonly there is also the potential for actually being able to see the implant edge through the thin skin of the lower eyelid. I don’t know what type of implants you had placed (Medpor vs silicone) or exactly where on the bone they are located. If standard cheek implants were used and then modified for the infraorbital rim area, it would be unlikely they would have perfectly smooth edges. Based on just your question alone, the remedy may be to have implants that are actually made for that facial bony area.

It would be helpful to have some more information, such as a picture of you showing exactly where the edge of the orbital rim implants are that you feel.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve read online that you do infraorbital rim implants. I’m really sorry to trouble you, but I have a concern regarding my upcoming procedure with these implants. Basically, my doctor has informed me that he will be using an intraoral approach for the Medpor Extended Orbital Rim implants, but every resource I’ve seen has said that the implants are placed through an eyelid incision. Do you think an intraoral approach is possible, and will the results be affected by using it? Should I at all be concerned that he isn’t going to use the eyelid incision?

A: The placement of infraorbital rim implants can be done either through an eyelid or an intraoral approach. Both are acceptable approaches and which one is done is based on surgeon preference. It is a little easier to assure good implant position on the bone from above (eyelid incision) as one does not have to work around the large infraorbital nerve. But an infraorbital implant can be effectively placed from inside the mouth, it is just a little more technically challenging to do so and the risk of some protracted lip numbness from infraorbital nerve traction will occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really need your advice, I have a problems with my eyes. There are very round, there are always dry and the corner of my eyes there is no fullness. (no arch shape) . My questions is are infraorbital rim implants right for me? Should a midface lift be done with the infraorbital implants? Please send info to my email please get back to me if you can.

A: To best answer your questions, I would need to see some pictures of your orbital/facial area. Round eyes with too much scleral show can be improved by tightening  procedures at the corners (canthopexy) which may alone offer an improvement. In some cases of round eyes, there is laxity and/or a lower eyelid malposition contributed to by a lack of underlying skeletal support. That is where infraorbital rim implants can be helpful. By providing skeletal augmentation and a push upward to the lower eyelids, lower eyelid tightening procedures can be more effective and the lower eyelid position better maintained in its new position. This is also the role of a midface lift, to provide soft tissue support to the lower eyelid. By definition, infraorbital-malar implants produce a midface lift by the displacement of the soft tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about 4 years ago upon a surgeons recommendation, I got infraorbital implants. Shortly afterward, I noticed a “bulge” underneath my eyes. I am not sure if the implants need to be removed or if this is a case of my cheeks dropping and my own bones would have produced the same appearance. I believe the implants were placed close to the lower lid. (I have attached  a picture of where they are placed ) I am not sure exactly what they are made out of.  When I went to the web-site, it just said a porous material. I believe that they were placed from inside the mouth.

A: Based on that information, you have Medpor implants placed through the mouth. This means they are actually a combined infraorbital rim/malar type implant. The bulge to which you refer, given that it appeared shortly after surgery, is undoubtably that of the implant and not your natural bone. As the tissues eventually contract and shrink around the implants, their outline and placement become fully evident.

The good question now is what to do with them. The only way to get rid of the bulge is to remove the implants. The interesting question is what will happen to the soft tissues that have been expanded because of them. It may be that is largely a non-issue or it may be that it will cause some soft tissue sagging over the cheek afterwards. It is hard for me to tell the likelihood of either just based on one single photo. However, knowing their location, size (bulge) and that they are a Medpor material (which means they will be harder to remove), that all suggests that there may be some additional cheek sagging afterwards. An alternative approach to removal is to feather the edges of the implant so that a bulge no longer is seen, but keeping the implant volume in place.

Dr. Barry Eppley

Indianapolis, Indiana