Would Hydroxyapatite Granules Be A Good Choice To Correct A Negative Orbital Vector?

Q: Dr. Eppley, I have a receded jaw and because of this my cheekbone is behind the line of my eye. (negative orbital vector) This causes my cheeks to sag and I am developing sagging and dark under eyes. I am wanting cheekbone augmentation to correct this and stop the progressive sagging. I was lined up to see a local surgeon who has developed a surgery using a coral extract called hydroxyapatite that he uses to build up the bone structure by making an incision through the under eye. Once he has done this he also says he will remove some of my sagging under eye skin and seal it up. I was wondering if you have heard of this surgeon or procedure, whether you think it’s safe and what you would recommend to combat my condition?

A: The use of hydroxyapatite blocks and granules for facial bone augmentation have been around since the 1980s. There is nothing new or novel about its use or any surgeon that still uses it. Various HA granule concoctions have been used over the years with agents such as blood or PRP to turn it into a more workable putty or a semi-injectable material. While seemingly a great idea twenty five years ago because of its bone compatibility and bone ingrowth which does occur into it, it has almost completely fall out of favor because of contour problems and secondary revisional difficulties with it. Potential contour problems such as irregularities, lumps/bumps and lack of smoothness are all the result of the difficulty with creating an absolutely smooth contour with a material that is a collection of granules. I am certain any surgeon that still uses it will say that is not a problem with their technique but having treated numerous hydroxyapatite granules patients with inadequate results and secondary irregularities this is clearly not always the case.

While hydroxyapatite offers the most biocompatible material for facial bone augmentation, this biologically appealing feature is overshadowed by its aesthetic limitations. The same can be said today for hydroxyapatite cements which can be applied in a much smoother fashion but adequate and assured contouring of it requires good visualization like an open skull site not in the limited confines of the face where discrete incisions are used often remotely placed from the site of actual augmentation.

In short there are today far superior methods of precise facial bone augmentation that can be properly planned before surgery. Having the surgeon whip up a mixture of a material and place it using an eyeball technique is really outdated and almost of historic significance in my opinion. While no facial bone augmentation is perfect the unforgiving nature of the thin tissues of the eyelid and cheeks requires good preoperative planning (3D design) and a material which allows for a good fit to the bone, a smooth other surface and the desired amount of augmentation and contours.

Dr. Barry Eppley

Indianapolis, Indiana