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Background: The periorbital rim of bone around the eye can be aesthetically augmented but how it can be done is not well known. The only standard orbital rim implant is the tear trough implant, a limited spot implant of the infraorbital rim. Its original use was to treat an external indentation at the inner half of the infraorbital rim either from a congenital origin or from aging. The use of the tear trough implant, while still effective, has largely been supplanted today by either injection fat grafting or fat transposition during a lower blepharoplasty.

But this limited infraorbital rim implant doesn’t have a role to play when larger orbital rim augmentations are desired. More complete infraorbital rim augmentations are commonly done as part of a larger infraorbital-malar (IOM) implant that extends out onto the cheekbones. Superior orbital rim or brow bone augmentations are also commonly done through custom implant designs as well as no such standard brow bone implants are yet available.

But the rarest periorbital rim augmentation is the near circumferential or 270 degree ‘goggle’ implant design. This is used when one wants to bring out the entire orbital box for protruding eyes or when the upper face is very narrow. Placement of more complete periorbital implants are done through eyelid incisions, most commonly the lower eyelid supplemented with an upper eyelid incision as well. But once such a custom periorbital implant is placed can additional rim augmentation be added later?

Case Study: This male had a prior history of a staged periorbital augmentation using custom implants designs (graduated 3 step process) that eventually created a near 270 degree augmentation effect. As seen in his 3D CT scans it created a ‘goggle-like’ effect, sparing the medial brow-orbit-nasal area which naturally has a more anterior projection than the outer orbital box. 

He desired one last periorbital augmentation to create increased superolateral rim augmentation of a few more millimeters per side. Thin custom rim implants were designed to accomplish this last augmentation effect. (teal color) 

Under general anesthesia and through outer upper eyelid incisions, dissection was carried down to the existing implant capsule. The capsule was opened and the implants were placed on top of the existing implant and secured into position by a small microscrew.

The upper eyelid incision provides a convenient point of access for implant placement as well as an incision that will heal imperceptibly.

The superolateral portion of the orbit is a very visible facial edge seen in the oblique view. In fact it makes up the upper portion of the Ogee curve and can be augmented either in isolation or on top of an existing implant.

Key Points:

1) Custom periorbital implants are the only method to build up the bone around the eye to make it more prominent.

2) Secondary or tertiary periorbital augmentation can be done through a custom onlay implant approach.

3) The upper eyelid may be the preferential incisional approach for secondary onlay periorbital augmentation.

 Dr. Barry Eppley

World-Renowned Plastic Surgeon

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