Your Questions

Q: Dr. Eppley, I want to get orbital rim implants to correct my negative vector (it bothers me a lot), and being that it’s an obscure procedure (I’ve only found you and one other doctor that performs it), my biggest concern is the implants’ safety, considering their proximity to the eyeball, and chance of migration. I also wanted to correct a nasal tip deformity that happened as a result of an initial rhinoplasty five years ago. Thank you, Doctor.

A: Orbital rim implants are one of the most uncommon facial implants as there are no preformed implants for this facial skeletal area. The best way to create orbital rim implants is to have them made in a custom fashion for each patient off of a 3D CT scan. That way they will fit the bone precisely which, when combined with microscrew fixation, assures their long-term stability. These implants are very safe and pose no threat to the eye when out in by a surgeon skilled in working in this area. Orbital rim implants are very effective at achieving exactly your concern…eliminating tear troughs and a negative orbital vector.

As for your nose, what I see is an entire deviated nasal axis to the right and tip cartilages that deviate to the left. The deviation appears to not be just restricted to the tip of the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What can be the most likely solution to my bulging eyes? You can see in my pictures that my eyes stick out. They have been this way since I was little girl. 

A: Thank you for sending your pictures. The first question to answer is whether this is exophthalmos due to a medical condition such as hyperthyroidism. But since your eyes have always been ‘buggy’ it would be reasonable to assume that this is their natural appearance. It looks like you have what is known as pseudoproptosis. (appears like eye bulging when in fact it is not) This is due to a lack of bony rim/fullness around the eye particularly in the superior and lateral orbital rim areas. When the bony rims are recessed or not adequately projected the eyeball will look like it is sticking out when in fact its position is normal within the orbital box. The fact that they have been this way your whole life would support that this is just the way your face developed. Placing custom made superior and lateral orbital rim implants through an eyelid incision or doing it from above through a scalp incision would be the only way to improve this bulging eye appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim implants. I am 23 years old with severe depressions under my eyes. I’ve had them since I can remember. I’ve tried everything. Special vitamins, creams, makeup, nothing works. I also have dark colors as well. I am more concerned with the depressions though. You can cover up color, but not hollowness. I went to see a local plastic surgeon and he basically told me nothing could be done. “Try our cream, and makeup” is basically all they said is necessary. I am tired of looking this way. How much does the implant surgery cost? I am so desperate. Thank you.

A: When it comes to infraorbital hollowness/tear troughs, this is an anatomic problem of either lack of soft tissue volume or inadequate bone projection.  These are most commonly treated today through the use of temporary injectable fillers. In my opinion, however, these should only be used a trial method to see if soft tissue voluminazation would be effective. They are certainly not a long term strategy particularly when ine is very young and this is a congenital anatomic issue.

Longer-term surgical treatment options would be either the use of injectable fat grafting or infraorbital rim implants. (sometimes called tear trough implants although these are not necessarily the same) Each has their role and the choice between the two would depend on what your depressions under the eyes look like. I would need to see some pictures of your eyes to make a more definitive recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim and brow bone implants. I have a sunken eye area and eyes that seem to bulge out with droopy eyelids and bags under the eyes. What combination of procedures would produce the best results based on my overall appearance? I’ve also attached a picture of an actor whom I want similar features to.

A: While orbital and brow bone implants may be what is ultimately needed, that is not the first place to start. I would have fat injections done first to both the brows and the entire infraorbital area first. This would be initially done for three reasons; 1) To try and rid some of the hyperpigmentation of the lower eyelids. This is going to be a chronic skin color disorder which is both common with your ethnicity and may be unimproveable. 2) To improve the quality of the tissues particularly that of the lower eyelids if eventual implant surgery is desired and 3) it is possible that enough fat may be retained that implants may not be needed.

While orbital rim and brow bone implants can help make more deep set eyes when done together, they do require scalp and lower eyelid incisions to place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking of getting orbital rim implants to improve my lower eye hollows socket area and mainly to raise my lower eyelids so less scleral show is showing…

Can cheek implants placed very high have the same effect of pushing up lower eyelids? Give a less round eye look?

Also will there be lower eyelid retraction after orbital rim implants?

A: It is important to understand that neither orbital rim or cheek implants is going to drive up the lower eyelids to improve scleral show and give the eye less of a rounded eye look. In fact, one of the potential side effects of these implant procedures when done through a lower eyelid approach is lower eyelid retraction. If technically done well and orbicularis muscle resuspension and lateral canthopexies are performed with closure, lower eyelid retraction can be prevented and may even help with less scleral show. But bone-based implants can not push up on the lower eyelid and improve the level of the lash line across the eyeball. The bone levels lie well below the lash line of the eyelid. This is a common misconception which can be verified by pushing up on he cheek tissues and you will see that it does not change the position of the lower eyelid. (unless you really push up far which is not a realistic surgical effect)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital rim  implants. Are they dangerous? I know you do them. I have three questions: 1) Are they effective? Can they diminish hollow eyes and give them a better aesthetic look? 2) Will they cause retraction of lower eyelid? 3) Can you go blind?

A: In answer to your questions about orbital rim implants:

1) With proper design and placement they can be very effective at improving bony recession of the infraorbital rim and tear trough areas. They often, however, need to be supplemented with fat grafts in the lower eyelids to balance out the entire lower eyelid area.

2) With good surgical technique and resuspension of the lower eyelid, no. In some cases they are placed through an intraoral approach where there is no risk of lower eyelid problems at all.

3) Blindness is NOT a risk of orbital rim implants. This is a surgery that is not done on the inside of the orbital rim and would not cause any increase in intraocular pressure or injury to the optic nerve. Other than lower eyelid retraction, the biggest risk to the eye is that of a corneal abrasion if corneal protectors are not used. Or in some cases could even occur if they were used as a result of placing and removing the corneal protectors.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my question is if one wants to raise the lower eyelids, instead of doing a canthopexy/canthplasty (as I am only 24 years old) can one do a orbital rim implant and still raise the lower eyelid to decrease scleral show?

I’m guessing this would push the lower eyelids up, remove the hollows and possibly increase cheek projection?

One doctor I spoke to said that placing orbital rim implants through the lower eyelids is the worst surgery as you have to cut everything up and then put the implants in and then reattach everything. He would stick a cheek implant through mouth all the way near the rim of eye and get the same result.

A: Orbital rim implants can potentially have a minor influence in some patients on pushing up the lower eyelids with the potential for decreased scleral show.  But it is important to remember that the implants are on the inferior orbital rim bone which is below the actual lower eyelid. So I think this potential effect is more theoretical than actual in most cases.

When it comes to the incisional method for the placement of orbital rim implants, any doctor’s opinion will be colored by their experience. When a doctor has no experience doing this surgery through the lower eyelid approach, then for that doctor it is the ‘worst’ surgery. But in experienced hands the lower eyelid approach for orbital rim implants is both safe and effective.

Depending upon the design of the cheek/orbital rim implants, it is possible in some cases to go through the mouth for implant placement. But in many cases the orbital result may not be the same as with the lower eyelid approach. It is all about getting the implants in the right anatomic position.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Two years ago I got lateral supraorbital rim implants made of Medpor.There is only one design of supraorbital rim implants available from this company (Porex/Stryker). They were placed through the upper lid crease. About 4 weeks after surgery the implant on the left side got infected. The pus was drained through a small incision in the lid crease, the wound has been daily cleansed and I have been on Rifampicin and Ciprofloxacin for two months. Because of the incision for the draining, about 2 mm oft the implant surface became visible, but the hole closed soon after the infection subsided. Although since then I have never got any symptoms of infection like swelling, discharge, pus, warming or pain, there is still a quite visible red patch where the pus had been drained. This patch is 7 mm long and 3 mm broad and very adherent to the underlying implant surface… that means it doesn´t move with the upper eyelid. Fortunately it is no problem to close my eyelids. From time to time a thick layer of keratin forms on this patch. Do you think this could still be some kind of infection or could this be a chronic inflammation due to the mechanical friction? What would you advise me to do?

A: What you have is a healed sinus or fistula tract and the local sequelae when that occurs in thin tissue. When the implant was infected, the accumulated pus had to go somewhere and it usually goes to the path of least resistance. (along the incision line) This draining tract was a ‘hole’ in the tissues that, once the infection was resolved, collapsed and healed with scar tissue. This scar tissue is thinner and less stable than the normal eyelid tissues. This is why it is adherent, red and undergoes intermittent effort sat re-epithelization. (thick keratin patch)In short, this is not normal skin.

If this is bothersome what I would do is excise the scar, place a small fat graft underneath (to fill in the missing tissue and prevent recontracture of the skin down to the implant) and close the skin over it. This is a scar contracture issue not a chronic implant infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his  face and skull. My friend found your contact details in the Internet. I have a few questions to you:

1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the  maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?

2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?

3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.

4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?

Thank you so much for your reply.

A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.

While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.

From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.

From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.

The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been told by another physician that infraorbital rim implants would benefit me.  I have dark circles that have really been developing a lot under my eyes and have had Restylane with little effect (just one treatment).  I am hoping for a more permanent solution.  Do you agree it could benefit me?  Can this procedure be done under local anesthesia?  What is the approximate cost of this procedure?  I have attached my photos.

A: I would agree that you are a good candidate for combined infraorbital rim-malar implants given your anatomy and the lack of success with injectable fillers. Both your cheeks and your lower orbital rims are retrusive in position. From the side view you have a negative vector, meaning the cornea of your eye sticks out further than the cheek-lower eye socket bone. This is an anatomic sign that bony augmentation may be aesthetically beneficial. The placement of orbital rim implants can be done in two ways, either through a lower eyelid incision (preferred) or from an intraoral approach. Better implant placement and less risk of injury to the infraorbital nerve is ore assured with a lower eyelid approach. Either way the procedure can NOT be done under local anesthesia under any circumstances. The approximate total cost of the procedure is around $6500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m considering cheek implants to address the following problem. I have a wide round face with a flat midface and I want to avoid implants that make my face look wider or rounder. Should I go for malars without edges (so ones that only address the cheekbone) what part of the cheek contributes the most at creating forward projection? My main goal is to achieve a less wide face with more projection. Thank you so much!

A: When it comes to increasing midface projection without making the face wider, all implants have to remain inside of a vertical line drawn down from outside of the lateral orbital rim. This means the options of using orbital rim implants with small malar extensions relegated to the anterior cheekbone surface, paranasal, and premaxillary implants. These are the implants that can increase midfacial projection without creating width.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a step-down of about 3-4mm from the rim of the orbital bone under my eyes straight down to the eyeball. There is no fat. Post after blepharoplasty about 6 years ago. I don’t like the look. Any help available? I am 56 years old and healthy with good skin. Thank you.

A: With the loss of fat, either through surgical removal, aging or a combination the edge of the lower orbital rim is now skeletonized. There are three approaches to consider for obliteration of this orbital rim step-off with the underlying theme that they all add volume but do it in different ways. I will first mention synthetic injectable fillers but this is not really on my list of sustainable long-term approaches.

Replacing what has been lost, fat, constitutes two of the orbital rim augmentation approaches. Fat injections are a well known option which is principally marred by the unpredictability of such fat grafts. It is however the simplest and least invasive approach. The other way to add fat is through dermal fat grafts, like a natural implant, placed along the inside of the orbital rims done through your existing blepharoplasty scars. These fat grafts take remarkably well but do require an open approach and a harvest site which is usually from the abdomen or from any existing scar that you may have on your body.

The other implant options are synthetic orbital rim implants that are made for exactly this area. Like a dermal-fat graft, they are placed through a lower eyelid incision and are secured to the bone with 1mm small screws.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wrote you about orbital rim implants some time ago. I am 42 years old and am interested in rim implants or canthopey or both. Do you see any problem in having only canthopexy to reduce scleral show and slightly tilt the eyes? The thing is when I tried fillers (which didnt change my problem much at all to be honest) the surgeon said that permanenet implants feel rigid that you can feel them all the time? I really would like to simply narrow and sharpen my eye shape, just concerned that a lot of people get either a “stretched look” or nothing at all?

A: When it comes to lifting up the lower eyelid to reduce scleral/orbital show, lateral tendon procedures are not going to shorten the ‘clothesline’ and lift the lower lid margin. That is simply asking too much of the procedure. There is a good correlation between the lower eyelid margin and the underlying bone support. The lower the bony orbital rim, the more likely the lid margin may also be lower or at least have less support. Therein lies the value of orbital rim implants, raising the bony rim and helping to push up the eyelid. and its lid margin. Lateral canthopexy has as role in the placement of orbital rim implants by providing suture support to the closure of the lower eyelid incision to decrease the potential of postoperatve ectropion.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Here you will find attached some crude pictures of myself on the webcam. They are not the highest resolution but it might give you a first impression. I personally think that the overall look of my eyes and eyebrows is a bit sad or tired. I thought of rim implants to push forward and fill a bit the depression  and also maybe reduce the scleral show? Not really sure if  its possible or if I will go for a tilt of my eyelids as I think that a simple narrowing will do. I was also curious about what a jaw angle implant could do for me even though some how I’m not so concerned about it overall. Please feel free to comment. For me this is more of a structural improvement rather than an anti aging procedure I am seeking as look younger than my actual age. Any procedure that you think could be beneficial to make me look more handsome without obvious work being done is welcome. Thank you for your advice and time.

A: Thank you for sending the detailed pictures. It shows that you have a recessive infraorbital rim-malar region which you already know. This is why you have undereye hollowing and weak lower eyelid support with some mild scleral show. Orbital rim implants do add volume in this area and can provide a bit of an upward push to improve lower eyelid support and position. This may provide a bit of decreased scleral show in which  a lateral canthal tightening or adjustment is a good combination with them.

While jaw angle implants can provide some significant lower facial changes, you do not consider them on a casual basis. They are the most difficult of all facial implants to undergo and recover from so you have to be really motivated to undergo their placement. Since you are not concerned about the jaw angle at all, this is not a procedure to consider for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could my prominent, asymmetrical eyes be corrected with fillers? A nurse told me that the bones in one eye socket are further apart causing that eye to be able to stick out further. Could they be made even and the bulging eliminated? They are quite “bug eyed” to me which is just genetic. All the women in my family have these eyes. Also, the wrinkles beneath my lower lid when I smile– will the increased volume in that area from the filler eliminate them? Will it also correct the dark skin/shadow under my eye?  I think they really age my face. But I think it’s lack of volume that causes it.  How much would something like this cost in total? Do u use Restylane for this? I really appreciate your time.

A: In looking at your pictures, injectable fillers under the eyes is NOT going to correct you eye concerns. What you have is what is known as pseudoptosis. The eyes bulge out, not because they are too far forward, but because the bone around them (orbital rims) is recessive or deficient. You are not going to lift up the lower eyelid by placing injectable fillers underneath it, that simply will not work. What you need is to have the orbital rims built up with an implant material. For the lower eyelids this would be infraorbital rim implants. For the upper eye area, this would be brow bone augmentation. Understand that the problem is a bone deficiency of which it requires surgical augmentation not injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 42 years old and i have just one concern about my eyes showing a bit too much sclera and lack of support of lower eye lids…i had fillers injected but I must say that the improvemnet was mild to non existant and did little for the scleral show even if the lateral volume was improved. Also fillers tend to be pulled by gravity and the infraorbital fillers the shifts and becomes more of a feminized cheek implant. I was imagining that infraorbital rims will be more precise and long lasting. Also I was wondering if the rim itself will push the lower eyelid enough to show les sclera or if it would be better to tighten up the sides as well. I always found that I look much better when I squint slightly which makes me believe this is what i need…how natural doesthis procedure look? is it a spectacular change? Do rim implants shift as easily as jaw angles? Thank you

A: The position of the lower eyelid is affected by many factors but one of the most significant is the amount of bony support from the lower orbital rim. Adding permanent volume through an implant is a logical choice. The amount of volume added is dependent on the style and size of the infraorbital rim implant. Regardless of the implant, tightening the lower lid through a lateral canthoplasty is always advised/done. Moving the level of the lower eyelid up is never an easy task but the combination of infraorbital rim implants and canthoplasties gives the best chance for that to occur. Since I always screw the orbital rim implants in, like all facial implants, I have never seen implant shifting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have very dark circles under my eyes that bothers me a great deal. I have tried all sorts of creams and lotions without any improvement. Are there any more result-oriented surgical approaches that will work?

A:Some of the best results for dark circles improvement is based on volume addition, either using injectable fillers or surgically done with orbital rim implants.  (synthetic implants or dermal grafts) The cause for the appearance of dark circles in some patients is that the orbital rims (lower eyelid socket) is weak or underdeveloped. This causes the lower eyelid tissues to lack support so they fall inward, creating both a trough or depression whcih is also prone to looking darker due to shadowing. It is easy to see whom may have orbital rim hypoplasia by a side view. If the front part of the eye (cornea) sticks out further than the lower orbital rims one has lower eye socket hypoplasia.

The success of orbital rim implants can be predicted by initially using injectable fillers. Injectable fillers are both a diagnostic test and a treatment. Unlike the lips or nasolabial folds, which are exposed to a lot of muscle movement, the tear trough and lower eyelid area is not so injectable fillers can last a much longer time in this area.

Since any form of orbital rim implant must be put in through a lower eyelid incision, this also gives the opportunity to do a little skkin removal and tightening which can also help improve the dark circle appearance.

I would have to see pictures of one’s anatomy to determine if orbital rim hypoplasia is making a major contribution to one’s dark circle appearance.

Dr. Barry Eppley

Indianapolis Indiana

Q: I would like to know more about the transconjunctival approach referring to orbital rim augmentation with medpor implants and subperiostal midface lifts. Because you are both a plastic surgeon and an oral an maxillofacial surgeon I´am sure you are very familiar with this kind of approach. Once I have read that the infection rate of medpor implants placed through an intraoral approach is a little bit higher, because the mouth can´t be completely disinfected. Is it the same with the transconjunctival approach or is the mucosa in the lower eyelid an area in the face that is usually very clean due to its special purpose? What are the common risks of a tranconjunctival approach? Is there any chance of getting blind after such an operation? If performed right, has the transconjunctival approach any risk of ectropion or entropion or an increase of scleral show? Thank you in advance for your reply.

A: Unfortunately, you have been misinformed about placing any type of orbital rim implant through a transconjunctival approach, regardless of the material type. That is simply not physically possible given the size of the implant and the very size of this inner eyelid incision. All orbital rim implants have to be done through an external or subciliary lowere eyelid incision. This is the only way to insert them and have them properly secured into place.

You are correct about the higher rate of infections with porous implants like Medpor when placed through an inside the mouth or mucosal incision. That has been my experience as well.

Dr. Barry Eppley

Indianapolis Indiana

Q:  I am asking about what to do with my under eye area.  I had a lower blepharoplasty 15 years ago. My undereye area is very sunken looking and there is a little darkness in the skin but that may be due to some shadowing as well. I am wondering if I need a redo with a canthoplasty/canthopexy and some orbital rim/tear duct/cheek implants. I have attached some photos of my eyes from different angles. I assume you can tell from photos I also had a cheek lift and other work.

A: Based on your photos, you have a significant volume loss of fat/tissue of the lower eyelids and over the lower orbital rims onto the cheeks. Whether that is due to your prior lower blepharoplasty with fat removal is speculative and irrelevant at this point. Because of the loss of lower eyelid/cheek volume and support, you also have increased scleral show. (pseudoectropion)

What you need is volume replacement of the lower eyelid and cheek. There are several different options to consider for this replacement. It fundamentally comes down to synthetic vs. autogenous graft materials. The synthetic approach is one you have already mentioned, that of an orbital rim/cheek implant either as a single piece or in two different segments. There are several different styles for this area. These have the advantage of an immediate augmentation that will be permanent. They are placed through your old blepharoplasty incision and a canthopexy would be done at the same time. The other option is that of fat injections to add volume or the placement of allogeneic dermal grafts. This approach has the advantage of not using an implant but the survival of fat is not assured and it may require more than one treatment session to get the best result.

There are advocates for either approach and it is not a proven matter than one method is better than the other. The use of implants has a more proven track history of use.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had inferior orbital rim implants done with a midface lift about 6 weeks ago. It has left me with upper lips on the right side that I cannot purse and numbness in my top front teeth and extending up my nose to my eyes. I am also numb above the implant on the right side. I also had a blepharoplasty. My muscles of my lip don’t function right so my lip hangs down a bit and I have to be careful not to bite it. I can’t spit or whistle right. The muscles that lift the right side of my nose and face don’t work right so one side goes up higher than the other. The implant was put in so that part of it sticks up like the screw wasn’t seated well so i can feel the edge and see its edge in the mirror. The surgeon says he’ll fix it but there is still so much trauma in my face that I don’t know if it will ever resolve and I don’t want to make it worse! I know you don’t know me but I need advice on how to proceed and if this teeth numbness, etc. is normal. Should I wait until my face settles down?

A: The combination of a midface lift, lower blepharoplasties, and orbital rim implants does impose a fair amount of trauma to the midfacial area. It does take more than a few weeks for the feeling and lip and nose movement to return to normal. If this was done in the usual fashion, the lower blepharoplasties was the route through which the orbital rim implants were placed and incisions were done inside the mouth under the upper lip to assist with the midface lift.

The combination of orbital rim implants and the intraoral dissection works around the infraorbital nerves which comes out just under the lower orbital rim. This nerve supplies the feeling to your lip, nose and cheek. It is normal for some temporary numbness to occur afterwards due to the trauma around it. It should be gradually improving and I would expect less numbness each and every week at this point. It should take no longer than three months or so to completely return. If the numbness is not improving by the week, there is the possibility that the implant may be impinging on the nerve. If the other side is completely different in the recovery and much further along, this becomes a real possibility.

Feeling the edge of the implant or the screw is not likely to become less noticeable with time. I believe this is the implant on the same side as the lip and nose numbness and movement concerns. The combination of the above suggests that orbital rim implant adjustment may be needed. Since this is done through the lower blepharoplasty incision, there would be no added trauma to the recovering area below the implant.

As a general philosophy, you wait on a revision when it appears that time is continuing to make progress. When time no longer is making any difference, and the operated area still has problems, then revisional surgery can proceed.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting some facial implant work done and was wondering if I can have wisdom teeth extraction done at the same time? I want to get orbital rim implants with a possible midface lift. Is there any reason why these two can not be done together? Will one potentially cause problems with the other or is it better to have them done separately, like a decreased risk of infection?

A: I see no reason why these two facial bone procedures can not be done at the same time. It is quite common to do multiple hard and soft tissue procedures of the face together. The face is tremendously well vascularized and very resistant to infection. (I didn’t say impossible just very resistant) While such a combination (facial implants and 3rd molar extraction) is unusual, it is by no means contraindicated. The hardest part is not the operation, but finding someone who is well qualified to do both at the same time.

Orbital rim augmentation and a midface lift is done from the outside through a lower blepharoplasty incision. Wisdom tooth or 3rd molar extraction is done intraorally from inside the mouth.  The two areas are not anatomically contiguous and would not connect, thus ensuring no risk of oral bacterial contamination coming in contact with any implanted material. Because of this risk, the orbital/midface procedure is done first so cross-contamination from instruments does not cause any inadvertent oral bacterial inoculation on the implant.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a tear trough and orbital deformity. One year ago I had surgery in which malar implants were placed. But it is too big and was the wrong choice for me. I only wanted to make my midface look healthy. I want make another surgery in 3 months and I now think an orbital rim implant is the right choice for me. Do you have experience with this type of facial implant and what are your feelings about it? Are the risks for an orbital rim implant surgery higher than a malar implant which I have now? Thank you very much.

A:  The use of malar vs. orbital rim implants are for completely different facial problems or concerns. Even though they are anatomically close and contiguous, what effects they have on facial structure is completely different. If a malar implant was used in the treatment of a tear trough (orbital) deformity, it would have likely made it look even worse.

The midface has  six structural components to it including the orbital rim, malar, lateral malar, submalar, paranasal and maxillary regions. The tear trough deformity represents a central and medial soft tissue recession even though the underlying bone deficiency may extend out into the malar area. Tear trough, also known as orbital rim, implants come in several different shapes and sizes which differ in the extent of the orbital rim that they cover and in how much projection they provide. It requires a careful assessment of the lower orbit and cheek to see which implant is best. Even with good implant selection, tailoring and shaping for fit is almost always required.

Unlike malar (cheek) implants, orbital rim implants must be placed through a lower eyelid (blepharoplasty) incision. This induces one potential risk that does not exist with an intraoral approach for malar implants, that of ectropion or lower eyelid retraction. Careful handling of the eyelid tissues and orbicularis muscle and canthal suspension are needed to avoid this potential problem.

Of all available facial implants, orbital rim implants are the most sensitive to size, placement and incisional access. To those with a lot of experience in maxillofacial trauma and craniofacial surgery, orbital manipulations is a comfortable place to work.  

Dr. Barry Eppley

Indianapolis, Indiana