The most effective method to treat undereye hollows and flat cheeks associated with a skeletal deficiency (as evidenced by a negative orbital vector) is with custom infraorbital-malar implants. By augmenting the associated and connected skeletal parts around the eye and out onto the cheek produces a smooth augmentation that can look natural because of the bony surface area that it covers.
There are many variations to the design of the custom infraorbital-malar implant in the extent of coverage and thicknesses along its arced-shape. One of these implant design elements is in how far along the medial infraorbital rim the implant should extend. To achieve maximal augmentation and correction of undereye hollowing the design would typically extend close to or right next to the naso-maxillary sutural junction.
But since many custom facial implant patients are younger it would not be uncommon for them to request and undergo a nose reshaping along with these facial implant procedures. In these cases it comes paramount to factor into the implant design where the osteotomy lines will be placed for the rhinoplasty.
Since the more sterile custom infraornital-malar implants will be placed first one would not want to perform either intranasal or external osteotomies which runs into the medial infraorbital implant section by the rhinoplasty performed immediately after. Besides potentially causing implant displacement it may also create the opportunity for implant infection by nasal bacterial contamination. This is most relevant when a low-to-low osteotomy is to be used.
This potential problem can be avoided in either the preoperative implant design or by intraoperative implant modification/reduction. In the design the medial infraorbital rim implant location should be moved more lateral than usual. If it is determined intraoperatively that the implant design may be too close it can be reduced by scalpel shaving reduction. In either case the aesthetic loss will be minimal and the intersection risk of these two procedures mitigated.
Dr. Barry Eppley