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Dr. Barry Eppley

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Archive for the ‘orbital rim implants’ Category

Case Study: Implant Augmentation of Lower Eyelid Hollows/Tear Troughs

Sunday, May 12th, 2013


Background: The shape of the eyes is determined by many anatomic factors including the amount of fat under the eyelid skin. One undesired aesthetic look of the eyes is a deep depression underneath it. Known as lower eyelid hollows, this is when the lower eyelid skin indents beneath the lashline and lower lid margin. This creates a shadowing effect which lends to a tired or aged appearance.

Lower eyelid hollows are a reflection of the underlying anatomy. It could be due to a natural lack (congenital) of or age-related atrophy of fat, a weak or deficient infraorbital bony rim, a bulging eye (rare) or some combination. The most common cause of lower eyelid hollows, however, is almost always skeletal-based due to the projection of the lower bony rim. Fat deficiency may also be present but is not often the sole source of the problem.

Treatment of lower eyelid hollows requires augmentation which can be done by two basic approaches. The non-surgical injection approach is the simplest using either synthetic (hyaluronic acid-based) fillers or fat injections. A trial with synthetuc fillers is a good first step to confirm whether any type of augmentation will be effective. Fat injections offer a potential long-term solution but there is the risk of lumps or irregularities and its retention is not completely assured. Implants of the infraorbital rim offer an assured permanent solution but it is a surgery that is very technique-sensitive.

Case Study: This 47 year-old male did not like the appearance of his lower eyes. He felt they were sunken in, particularly in the tear trough area. He was not interested in fat injections and had had a prior experience with an injectable filler that left him bruised and irregular over a year ago. He not only wanted the bony rim built up but also wanted some malar augmentation as well.

Under general anesthesia, a lower blepharoplasty (subciliary and lateral canthal extension) incisional approach was used. The bony rim was exposed and subperiosteal elevation done from the medial edge of the rim to the cheek area. The infraorbital nerves were identified in the course of the dissection. Using Medpor infraorbital-malar implants, they were applied to both sides making sure there was not a elevated step-off in the tear trough area. The implants were secured with self-tapping 1.5mm screws into two locations for each implant. The lower blepharoplasty incisions were closed by orbicularius muscle suspension and lateral canthopexies.

His postoperative course had the usual amount of swelling of the lower eyelids and cheeks that took three weeks to completely go away. Despite the swelling, the lower eyelids never experienced any sag or ectropion. His final result as seen at 8 weeks after surgery showed elimination of the lower eyelid tear trough/hollows and some cheek augmentation as well. On his right side, he did have some cheek and upper lip numbness which had completely resolved by three months after surgery.

Synthetic implants can be successfully used for improvement of lower eyelid hollows, which is often deepest in the medial tear trough area. Their placement is just an extension of a lower blepharoplasty procedure which is very similar to the dissection needed for a midface lift. There are specific implants designed for this purpose that produces good results when properly placed.

Case Highlights:

1) Tear troughs or lower eyelid hollows can be permanently improved by orbital rim implants.

2) Orbital rim implants are placed through a lower eyelid (blepharoplasty) incision.

3) Precise placement of the implants on the infraorbital rim and secured by small screws is necessary to prevent implant migration and edge palpability.

Dr. Barry Eppley

Indianapolis, Indiana

Understanding the Zones of Midface Implants

Monday, June 14th, 2010

Facial implants have come a long way in the past two decades with the introduction of dozens of different styles. One of the expanding facial implant areas is that of the midface. Known commonly as the cheek, it has become recognized that its anatomy is more complex than a single implant design can adequately treat. With the numerous midface implants now available, more patients than ever are being implanted. With increasing numbers of midface augmentations comes complications. The vast majority of these complications are cosmetic in nature, meaning the final result was not what the patient had hoped.

Undesired midface implant results are usually the result of a mismatch between the patient’s aesthetic concerns and the implant type and size. The large number of implant options may seem confusing, but midface augmentation can be thought of as three zones or implant locations. These include the malar, submalar, and suborbital tear trough malar regions. There are more anatomic zones to the midface, but based on desireable facial changes, these three areas can be effectively enhanced.

The malar area is the most midface zone enhanced and makes up the major aspect of the zygomatic or malar bone. This extends from the infraorbital nerve to the middle third of the zygomatic arch. Malar implants create a high, strong cheekbone which is for men who want a more sculpted facial appearance or by younger women who want more of an exotic look.

The submalar area lies below the zygomatic bone. It actually sits on the top portion of the masseter muscle where it comes up and attaches to the underside of the zygomatic bone. This facial area has become recognized as significant because fat is lost in this area with aging. Submalar hollowing can also be created in the younger person with a fuller face by buccal fat pad removal. Augmenting the submalar area can help reestablish a more youthful appearance by building it out again. When introduced over a decade ago, the submalar implant was touted as a substitute for a midface lift by being able to lift up sagging cheek tissues. This probably overstates the effect that it actually does create.

The newest midface zone to be effectively implanted is the suborbital tear trough area. Extending from the medial canthus, over the top of the infraorbital nerve, and along the lateral orbital rim extending into the malar area, this implant fills out suborbital flattening and tear trough depressions. Because of its location, this implant must be inserted from a different direction than all midfacial implants…from above (through the eyelid) rather than from below. (through the mouth)

While these three types of midfacial implants augment areas in close proximity, their effects can produce dramatically different facial changes. Subtle changes in the midface are easily detectable because of their proximity to the eye, a visual focal point in all conversations. The rise in the number of midfacial implants has led to, not surprisingly, an increased rate of complications. Many times the correct zone is augmented but the implant is too big. It is always best to undersize a midfacial implant in most cases. Unless there is a significant facial bone deficiency (e.g., maxillary hypoplasia), large midfacial implants should not be used. What make look like a significant improvement on the operating table can look dramatic in real life afterwards. Other times, the effect the implant created was different than the patient expected. This is most commonly seen with the submalar implant when it is used for a cheek tissue lifting effect and all the patient sees afterwards is unnatural fullness.

The three primary midfacial implants add an effective arsenal to a variety of congenital and age-related midfacial changes. Complications can be avoided by an implant size and type that is suited to the patient’s aesthetic concern. While the midface is one of the hardest facial areas to accurately computer image, such analysis furthers the dialogue between patient and plastic surgeon.  

Dr. Barry Eppley

Indianapolis, Indiana

The Tear Trough Deformity: Surgical and Injectable Filler Treatment Options

Friday, February 19th, 2010

A very common patient concern is that of dark circles under the eyes. While patients frequently try a variety of creams to improve the dark discoloration that they see, they are usually chasing the wrong ‘rabbit’. Most dark circles problems are really a tear trough deformity, an indentation problem that is creating a shadow effect which casts an image of a tired and older lower eye appearance.


The tear trough affects the inner aspect of the lower eyelid and appears as a visible concavity or indentation. While associated usually with an early sign of aging, some patients have it naturally as a true anatomic ‘defect’. The tear trough is at the junction of the very thin lower eyelid skin with the thicker nasal skin superiorly and slants downward into the cheek area over the lower eye socket bone. Because herniated fat from the lower eyelid may and often exists above it, the tear trough can look quite deep in some patients. Women may often camouflage this area with make-up.


A key question is why does the tear trough exist? In an extremely insightful article in the February 2010 issue of the journal Plastic and Reconstructive Surgery, it is pointed out that volume loss is the primary reason. As the face ages, we lose fat and this facial area may be one of the very first to show it given its thin tissues and the lack of any significant fat between the skin and the underlying orbicularis muscles. For those with a more natural or congenital tear troughs, it may be how the complex array of underlying muscles merge and interdigitate that accounts for this triangular medial lower eyelid and cheek deformity.


From a surgical standpoint, this area can be improved by a lower blepharoplasty procedure that either places fat grafts underneath this area or even a medial orbital rim implant. I have done both successfully and the choice of either one is based on the depth of the tear trough. A standard lower blepharoplasty alone will usually not correct it and may make it look worse if significant lower eyelid fat is removed, creating a total lower eyelid hollowing effect. A blepharoplasty approach, even if just a transconjunctival one, is an ideal time to place a small composite or dermal-fat graft.


By far, however, injectable fillers remain the most common treatment method particularly in the younger patient. While many injectable fillers exist, the safest and most versatile are the hyalurons. (e.g., Restylane, Juvaderm, etc) These gels give good and easy flow and that is important when injecting into this thin and delicate area where bruising can easily occur. When  bruising occurs in the lower eyelid, it will likely be three weeks or so before it resolves.


One of the keys to tear trough injections is to not think that it is a ‘single shot’ injection that is placed just under the skin. That will undoubtably lead to both inadequate and poor results with a visible bulge. One has to think of going into and beyond the tear trough area as well as deep to the muscle. The material must go between the muscle and the bone. For this approach, one needs a local anesthetic block to have the patient be comfortable. Topical anesthetic is not enough. Multiple needle passes are needed followed by massage an filler manipulation. A smooth result must exist at the end of treatment.


Interestingly, the length of injection filler treatment of the tear trough is longer than what one experiences in the rest of the face. (e.g., lips or nasolabial folds) This must be related to the lack of any significant motion in this area. Many patients will experience at least a year of sustained improvement. 

Dr. Barry Eppley

Indianapolis Indiana

Orbital Rim Implants for Tear Troughs and Lower Eyelid Hollowing

Sunday, December 27th, 2009

The area around the eyes is known in plastic surgery as the periorbita or the periorbital region. It consists of the eyelids and cheek soft tissue which is supported underneath by the bones of the orbital rims and the zygoma. How this area appears externally, in both youth and as one ages, is highly influenced by the underlying bone structure that supports it.

In youth, the cheeks appear full and prominent and the lower eyelids are fairly smooth and tight.  The outer corner of the eye (where the upper and lower eyelids meet) is sharp. As one ages, the cheek soft tissue drops down, rounding out the corner of the outer eye, and the eyelids develop loose tissue and wrinkles. Often a groove develops at the junction of the lower eyelid and cheek across the lower rim of the eye. While most of this is caused by loose and sagging soft tissue, there is some contribution from the underlying bone as it slowly resorbs in some patients.

For some patients, the appearance and the aging of the periorbital region is worsened by their natural bony anatomy. Their cheek bones are flatter and the lower orbital rim is more recessed, creating what is known as a flatter face or lack of any facial convexity. (as viewed in profile) This is particularly evident in what is known as the orbital rim-eyeball relationship or vector. The position of the cheekbone in relation to the cornea of the eye is determined in a side view by dropping a perfectly straight  vertical line down from the cornea. If the cheek prominence extends beyond this corneal line, it is known as a positive vector. If it lies behind it, it is a negative vector. It is patients with a negative vector that are predisposed to looking older in the periorbital region earlier than those with a positive vector.

Using synthetic materials to treat the negative-vector patient is one of the newer and less common uses of facial implants. Orbital rim implants can be used to build-out this skeletally weak facial area. By changing the horizontal relationship of the orbital rim to the cornea, more midfacial convexity can be obtained. This provides greater support to the lower eyelid which can be a real asset when performing lower eyelid tucks (blepharoplasty) or correcting undesired lower eyelid sagging after such a procedure. It is also a great way  to rejuvenate a hollowed or sunken in look around the lower eyes.

Orbital rim implants are placed through a lower eyelid incision. It is  not possible to place a rim implant through an incision inside the mouth. Besides having to work around the large infraorbital nerve, one can not get on top of the rim where the implant needs to be. Certain manufacturers do make a series of orbital rim implants, one of which is just for the lower orbital rim. It is larger than what most patients need but it can be easily shaped to fit any patient’s rim anatomy.  They are always secured with titanium 1.5mm screws.

There are other implant type options for those patients with more minor bone deficiencies or who do not prefer the use of an implant material. Smaller amounts of orbital rim augmentation can be done by carving out Gore-ex blocks or sheets or using the larger tubes of Advanta implants which can be easily cut and adapted to the rim. Small 1mm titanium screws are used to secure them. A more natural alternative is to harvest and place dermal-fat grafts in strips. They are not as reliable in terms of volume or shape but I have found that much of what is implanted is retained.

Rejuvenation of the periorbital region may also require some additional procedures including lifting of the midfacial soft tissues and tightening of the corner of the eye. These are almost always used in the older patient. Younger patients require bone augmentation only.

These procedures do cause some significant swelling around the eyes for several weeks. It usually takes about three to four weeks until one looks fairly normal and the benefits can be fully realized.   

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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