Background: The bones around the eye consist of three rim segments, supraorbital, lateral orbital and infraorbital rims. The medial aspect of the orbital bone that completes its circumference is not a convex rim of bone but a concave surface. All of the orbital rims can be aesthetically augmented of which the brow bones (supraorbital rim) and the infraorbital rim are most well known although not commonly done.
Near circumferential orbital augmentation, which is virtually unheard of, is now possible because of 3D custom implant designing. In such designs the historically separate orbital rim segments can be combined into a composite implant that is designed and made in two pieces for placement. The key to such an implant placement is that they must be able to be placed through limited eyelid incisions.
Patients that may seek such near circumferential orbital augmentation are those that have bony deficiencies which are usually manifest by excessive globe exposure. In some parents this is obvious based on the relationship of the cornea of the globe which mat be close or actually protrude being a line drain between the upper and lower as well as the medial and lateral anterior bony points. In other patients the interpretation of excess globe exposure is an aesthetic based on how much one wants more deep set eyes.
Case Study: This male had a prior history of having custom infraorbital implants placed with a good aesthetic outcome. Thereafter he decided to pursue more superior augmentation with temporal implants. Only after having temporal implants did he come to the realization that what he was really needing was lateral brow and lateral orbital rim augmentation rather than temporal augmentation. He then had the temporal implants removes and custom supra lateral orbital rim implants designed.
Under general anesthesia the custom supralateral orbital rim implants were placed through lateral upper eyelid incisions. They were placed so that the inferior end of the implants abetted up against the indwelling infraorbital rim implants and secured with two microscrews.
A postop 3D CT scan showed good alignment of the new supra lateral rim implants up against the infraorbital rim implants which was in agreement with the preoperative design position.
1) Periorbital augmentation consists of near circumferential increased orbital rim projection.
2) A two-piece implant consisting of infraorbital and supra lateral orbital rim implants is used, done either together or separately.
3) The custom supralateral orbital rim implant is the most challenging to place through a lower eyelid incision because of its curved surface and lack of direct line of vision.
Dr. Barry Eppley