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Custom infraorbital-malar (IOM) implants have expanded the augmentation options for the midface. Creating an implant footprint from under the eye and out onto the zygomatic arch provides a horizontal line of augmentation that uniquely treats undereye and cheekbone deficiencies. It is also responsible for creating the popular high cheekbone look.

When placing custom IOM implants there are two different approaches, through the mouth (intraoral) and through the lower eyelid. Each approach has their advantages and disadvantages. My preference is almost always a transcutaneous lower eyelid incision as it provides the most assured placement of the implant, particularly if the design saddles the infraorbital rim area. (which most IOM implants do) Trying to negotiate around the infraorbital nerve makes placement difficult and will cause some prolonged infraorbital nerve dysesthesia.

But occasionally the sheer size of an IOM implant can make going through the lower eyelid seemingly impossible. When confronted with this implant placement problem there are two options. One approach is to separate the implant into two pieces through a geometric split technique. The two smaller half of the implant can then more easily pass through the incision and then be reassembled once inside the pocket.

The other approach is to use dual incisional access. This is where the pocket dissection is done through both intraoral and lower eyelid incisions. The lower eyelid incision can be used just to complete the dissection along the infraorbital rim and out not the zygomatic arch with direct horizontal access. The implant can be passed intraoral where its one piece size is much less of an issue. The lower eyelid incision is used to get good implant position along the infraorbital rim and where screw fixation can be placed. Such a dual approach allows very large implants to be placed that initially may seem impossible. This dual approach also allows the lower eyelid incision to be smaller in length, disrupting less orbicularis muscle.

While most custom infraorbital-malar implants can be placed exclusively through a lower eyelid incision without much difficulty, in the uncommon design which has a large malar component this does not work as well. More assured pocket dissection and implant insertion/placement can be done by coming from both above and below taking advantage of the benefits that each incisional access provides.

Dr. Barry Eppley

Indianapolis, Indiana

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