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Background:  The perception of one’s face is well known to be highly influenced by the appearance of the eyes. How the eyes appear is influenced by a large of bony and soft tissue elements that encase the colorful eyeballs that lie at the center of all of them. The foundation that encircles the eyeball and supports the soft tissue overlay are the bones around the eye. Known as the orbital rims there is a superior, lateral and inferior section. (there is no medial or inner orbital rim) While the inferior and lateral orbital rims retain their anatomic names, the supraorbital rim is usually referred to by its external appearance, the brow bones.

The forward development of the bones around the eyes is not historically thought of unless it is deficient. This presents as eyes that may be too prominent or buggy. The eyeball has a normal position but the bones around it are recessed. This is one indication for a ‘reconstructive’ periorbital augmentation. Using custom implant designs the three rim bones around the eye can be augmented. This would never be possible without custom implant designs based on the patient’s 3D CT scan.

An equally requested indication today is for aesthetic periorbital augmentation in the male who has a normal or near normal bony development around the eye but wants an even greater or more enhanced projection. More brow bone projection is a masculinizing feature and going all the way around the eye makes them appear more setback and creates a tighter or more narrow eye shape from the push of the overlying soft tissues forward. It is not thought as an aesthetic facial reshaping procedure because it is usually believed that it is not possible to do.        

Case Study: This male wanted periorbital augmentation for a more masculinizing and enhanced eye effect. He previously had standard infraorbital implants which he found unsatisfactory and were removed. Custom brow bone and infraorbital rim-alar implants were designed to create this effect.

A unique interlocking design between the brow bone implant and the inferior orbital-alar component at the lateral orbital rim area helps with placement of both implants and makes for a smooth connected implant augmentation around a circular area.

Like all custom facial implants they can be designed almost any way the patient or surgeon wants. But an equally important issue along with the design is what incisional access is going to be used to place them. 

Under general anesthesia the first implant placed was that of the brow bone. A small 3cm incision was made centrally behind the frontal hairline. Endoscopic dissection was done down to and around the brow bones with a subperiosteal release between the frontozygomatic sutures across the inferior edge of the brow bones. The implant was then inserted vertically to pass through the incision and turned back to horizontal orientation again once inside the pocket. It was slide down into position making sure the lateral legs of the implant went down along the lateral orbital rims.

The most important aspect of any brow bone implant is that it must be positioned low enough. Because of the tightness of the soft tissues along the brow bones there is always going to be recoil from them pushing the brow bone implant superiorly. Screw fixation to hold it down as it heals is critical. There are two techniques to do so. Bilateral screw fixation at the lateral orbital rim ends of the implant or a central screw placed at the frontonasal junction.

To place the inferior infraorbital-malar implants a standard lower eyelid incision was used. Part of making sure the interlocking implant areas was near the lower eyelid incision, it needed to be designed well below the frontozygomatic suture line. Once in good position and interlocked a screw was placed both above and below it. A protective lateral canthopexy was done on each eye closure during closure.

The term periorbital augmentation implies near circumferential augmentation around all bony rim surfaces that surround the eye. This is heretofore thought impossible or only achievable by moving the bones around the eye by osteotomy. A custom implant now allows it to be done both effectively and with minimal scarring to do so.

Case Highlights:

1) Augmentation around the eyes can be done to create a more masculine appearance and/or a more narrow or closed eye appearance.

2) The combination of custom brow bone and infraorbital-malar implants can encircle the bones around the eyes and are placed through a triangular incision pattern. (small scalp and lower eyelid incisions)

3)An interlocking design between the brow bone and the infraorbital implant aids in accurate placement of both implants.

Dr. Barry Eppley

Indianapolis, Indiana

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